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This is a second example of a patient who was suspected

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of sustaining child abuse.

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Non-accidental trauma.

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On this case,

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one can see the presence of blood products

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along the right lateral temporal lobe,

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likely representing a subdural hematoma by virtue of the

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fact that it's crossing suture lines and coming

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along the middle cranial fossa floor.

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There also is blood products along

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the interhemispheric fissure.

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So intrahemispheric subdural hematomas in children

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is a marker for potential child abuse.

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You see that there's a collection overlying

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the right parietal region as well.

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One of the findings that was noted on this case also was the

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fact that there seemed to be some element of

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a loss of the gray-white differentiation.

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Doesn't seem like we can sort of separate good quality gray

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matter from the white matter and this had sort

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of a bland appearance to it.

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For that reason,

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the patient was recommended for MRI scanning.

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This is the MRI scan of the patient

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which was performed on the same day.

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Once again, we can see, as in the previous case,

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high signal intensity on T2-weighted scanning,

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which is extending into the occipital region and parietal

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region bilaterally and fairly symmetrically.

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The diffusion-weighted scan is even more striking in that we

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see Cortical high signal intensity on the diffusion-weight

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scan in the medial aspect of the occipital lobes

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as well as extending to the temporal lobes.

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And you also see bright signal intensity bilaterally

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in the thalami. This is symmetrical.

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This is high signal intensity also demonstrated in the

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frontal gray matter extending to the parietal lobe on the

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right side as well as to a lesser extent on the left side.

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This is confirmed on the ADC maps.

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The patient underwent MRI scanning of the spine to look for

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any additional areas of trauma which was not present.

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The abnormality that was demonstrated

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here on the T2-weighted scan,

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as well as the diffusion-weighted scan and confirmed on the

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ADC maps also represents another example of the diffuse

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injury to the brain that can occur with shaken baby

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syndrome. That is, there is diffuse shearing.

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Gray-white fiber tracts such that there is an outpouring

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of neurotransmitters. And as I mentioned previously,

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this is usually glutamate-based,

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and that leads to a diffuse injury to the brain.

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And this patient has a very, very poor prognosis.

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You see the large area of restricted diffusion

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on the ADC map affecting the thalamus,

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as well as all these gray matter areas which have been

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injured not so much by the initial trauma as much as the

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expression of the glutamate into the subarachnoid space,

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which is toxic to the brain cells

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and leads to the diffuse injury.

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The patient got a subsequent CT scan.

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Again,

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you note that there isn't all that much damage

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apparent on initial review of the CT scan.

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But you do see that absence of gray-white differentiation,

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which is implying that the patient has had a diffuse injury

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to the cortex as well as the underlying white matter

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as demonstrated by the diffusion-weighted scan.

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This patient's brain is edematous and swollen from that

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diffuse cytotoxic edema associated with shaken baby

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syndrome as an example of non-accidental trauma.