The Big Black Brain: Subdural Hemorrhage with Hemispheric Swelling and Low Attenuation

Abstract

The term "Big Black Brain" was first coined in 1993 to describe cases of abusive head trauma associated with subdural hematoma(s), brain swelling, and uni- or bilateral hypo-density involving the entire supratentorial compartment on CT scan imaging. This constellation of findings was invariably followed by extensive cerebral parenchymal destruction and a dismal neurological outcome or death. We describe two such cases and review the pathophysiology and differential diagnosis of this entity.

Keywords: Abusive head trauma; Big black brain; Brain damage; Cerebral edema; Cerebral hypodensity; Subdural hematoma.

Fig. 1

Unilateral big black brain in a 13-month-old AHT victim. CT: right-sided subdural hemorrhage with accompanying right brain swelling and hypo-density

Fig. 2

a–c. Unilateral big black brain in a 6-month old with AHT. a. Initial head CT scan demonstrates global left hemispheric hypo-density with loss of grey-white distinction and hemispheric swelling. b. Small posterior falx acute SDH and hypo-density of the left parietal-occipital brain. c. The next day the MRI demonstrates diffusion restriction involving the entire left hemisphere. Magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) failed to reveal vascular problems

Fig. 3

Sequelae of unilateral BBB

Fig. 4

a–c. Bilateral BBB. Initial CT scan findings in a 6-month-old infant with AHT. a. Marked left greater than right temporal lobe hypo-density with preservation of cerebellar and brain stem density and blood layering along the falx. b. At the level of the 3rd ventricle, subdural blood is present along the posterior falx. Cortical density is decreased with brain swelling and loss of grey-white distinction. c. At the level of the lateral ventricles, the brain is dense, with partial loss of grey-white distinction, mild left to right midline shift with falcine and left anterior subdural blood

Fig. 5

Bilateral BBB in a 6-month-old infant. Repeat Heat CT scan findings 13 h after initial presentation