Multicystic encephalomalacia as an end-stage finding in abusive head trauma

Abstract

Abusive head trauma (AHT) is one of the most severe forms of physical child abuse. If a child initially survives severe AHT the neurological outcome can be poor. In recent years several children were seen who developed multicystic encephalomalacia (MCE) after documented severe AHT. A search of the Netherlands Forensic Institute database in The Hague was performed. Inclusion criteria were cases of AHT between 1999 and 2010 where the child was under the age of 1 year old at the time of trauma. Trauma mechanism and radiological information were collected. Five children, three boys and two girls (mean age 57 days, range 8-142 days) who developed cystic encephalomalacia after inflicted traumatic brain injury were included. Survival ranged from 27 to 993 days. In all cases judicial autopsy was performed. All cases came before court and in each case child abuse was considered to be proven. In two cases the perpetrator confessed, during police interrogation, to shaking of the child only. Although a known serious outcome, this is one of the few reports on MCE as a result of AHT. In all cases the diagnosis was confirmed at autopsy.

Fig. 1

Cranial ultrasonography showed diffuse hyperechogeneity of the brain parenchyma with increased demarcation of the white matter—cortical border. Doppler US of the pericallosal artery shows diastolic flow reversal as a result of increased intracranial pressure

Fig. 2

Computed tomography showed diffuse severe ischemic brain injury with a white cerebellar sign

Fig. 3

Coronal T2 weighted MRI shows a subdural left sided effusion (asterisk) and diffuse cystic changes of the brain in keeping with multicystic encephalomalacia

Fig. 4

Computed tomography shows a subdural hematoma along the falx cerebri (arrow)

Fig. 5

Diffusion weighted MRI (a: DWI and b: ADC) shows restricted diffusion in keeping with cytotoxic edema as a result of hypoxia

Fig. 6

Gross pathology specimen, coronal section, shows diffuse subcortical necrosis and cystic encephalopathy

Fig. 7

CT shows wide subarachnoid spaces and a right occipital subdural hematoma (arrow)

Fig. 8

CT shows a fracture of the left orbit (arrow) as a result of impact trauma

Fig. 9

Coronal microscopic preparation of cerebral hemispheres (HE-stain). The preparation shows multiple diffuse cystic changes in keeping with cystic encephalomalacia

Fig. 10

Post mortem CT shows hydrocephalus (asterisk) and multicystic encephalomalacia (arrow)