Abusive head trauma Part II: radiological aspects

Abstract

Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis.

Conclusion: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Fig. 1

A four-month-old boy with a linear skull fracture (arrow) after a 80 cm high fall on a hard surface

Fig. 2

a A two-month-old girl admitted because of abusive head trauma. The CT obtained at admission shows an overall decrease in density of brain tissue and a lack of grey–white matter differentiation. This is a sign of severe hypoxia of the brain and has a poor prognosis. b The skeletal survey shows a metaphyseal corner fracture of the distal tibia. This, in combination with the intracranial trauma, is highly indicative of abusive head trauma. c Five weeks after the initial CT scan, the girl has developed extensive diffuse multicystic encephalomalacia

Fig. 3

Cranial ultrasound of a four-month-old boy with a subdural collection due to BESS

Fig. 4

a A three-dimensional shaded surface display (3D-SSD) of a skull fracture in a six-week-old boy with no history of trauma. The 3D-SSD images can be used to display the lesions to lay persons, e.g., parents or in court. These images should always be interpreted in combination with the original axial source data in order not to miss small lesions, which can be obscured in the rendering process, giving false negative results. b CT shows a relative high density of the basal ganglia known as the reversal sign. This finding is a sign of diffuse, anoxic/ischaemic cerebral injury and carries a poor prognosis

Fig. 5

A three-year-old boy with a right-sided subdural haematoma (arrow) and a shift of the midline as a result of this subdural haematoma. Note the decrease in density of the white matter on the right side and the asymmetry of the ventricles

Fig. 6

a A two-year-old girl with a subdural haematoma along the left convexity (arrow) and diffuse ischaemia (asterisk) as a result of abusive head trauma. b Diffusion-weighted MRI, obtained on the same day as the MRI, shows extensive temporoparietal cytotoxic oedema as a result of disturbed perfusion (restricted diffusion). c Diffusion-weighted MRI (apparent diffusion coefficient) shows a corresponding decrease in signal intensity. d Blood clot in the subdural haematoma shown on the FLuid Attenuation Inversion Recovery (FLAIR) image. This sequence uses a long TI in order to suppress the effect of fluid on the images. It can be used to show lesions that are normally obscured by the high signal intensity of fluid. e Chest radiographs obtained 3 weeks after the incident shows a consolidating posterior ribfracture (see insert). This was not visible on the initial skeletal survey and this shows the importance of a repeat skeletal survey in case of inconclusive findings. f MRI obtained after 2 months of the incident shows extensive diffuse multicystic encephalomalacia and bilateral subdural hygromas (asterisk)