Interactive Transcript
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This was a three-month-old who was found to be unconscious
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when the parents came back and found
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the child with their caregiver.
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The CT scan is remarkable for a large amount of hemorrhage
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at the superior aspect of the brain.
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This type of hemorrhage,
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which is seen just at the subarachnoid
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space and gray matter junction,
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is not unusual in children who have had a
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traumatic brain injury. As you can see,
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this is a bilateral process which is just on the surface
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of the brain extending into the subarachnoid space.
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In addition,
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you will note that the patient has a hemorrhage along
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the posterior temporal lobe on the left side,
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and it looks as if there is a low-density extra-axial
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collection overlying the lateral aspect
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of the left temporal lobe.
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As well.
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You also see a small amount of low-density fluid
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overlying the frontal lobes. In addition,
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one can see subarachnoid hemorrhage that is
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present in the right frontal convexities.
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When one has extra-axial collections
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of multiple ages in a child,
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one has to consider nonaccidental trauma or child abuse.
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For this patient,
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we want to be particularly aware
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of the potential for fractures.
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So we will look at the thin-section bone images.
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We will reconstruct them into three
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D to look for calvarial fractures.
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If one has these multiple-aged hemorrhages in a child,
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one usually will call the clinician and say that
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you have a concern for nonaccidental trauma.
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At that juncture,
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the child will likely get a series of plain films to look
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for rib fractures or metaphyseal fractures or
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other signs of child abuse.
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In this case,
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the patient was doing much worse than was
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apparent based on the initial CT scan.
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If you look at the coronal reconstructions of the
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axial CT data, you see what I was talking about,
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where sometimes it's difficult to tell where this
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hemorrhage is in the gray matter itself or just layering
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along the surface of the brain in the subarachnoid space
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or along the PIA. And this patient, as you can see,
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has areas of sort of flame-shaped hemorrhage that's
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going into the subarachnoid space as well as,
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as I described previously, the low-density,
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older extra-axial collections.
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So an MRI scan was subsequently ordered.
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This is the MRI scan of the same patient.
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This is the flare image where we have dark signal.
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Intensity CSF.
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And you can see that there are low signal intensity
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collections overlying the frontal lobes bilaterally
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representing chronic subdural hematomas. In addition,
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more superiorly,
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you have the higher signal intensity blood products
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along the high frontal convexities.
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This is the T2-weight scan.
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The T2-weight and again demonstrates
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the extra-axial low density,
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in this case, high signal intensity collections.
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How do we know this is not the subarachnoid space?
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If one sees that the Dura margin is displaced
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inward or the vessels are displaced inward,
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that implies that these are subdural collections.
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So blood vessels displaced inward and not crossing the CSF
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space suggests that these are chronic subdural hematomas
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rather than just dilatation of the subarachnoid space
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where the blood vessels would course freely
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within the entire subarachnoid space.
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Here you can see the acute blood products represented
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by dark signal intensity on T2-weight imaging
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overlying the high frontal convexities
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as well as the parietal convexities.
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The patient had a diffusion-weight scan as well,
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and one sees that there does appear to be some
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higher signal intensity posteriorly in the
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subcortical white matter.
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Here, on the gradient echo scans,
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you see the blood products in the subarachnoid space
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marked as the dark signal intensity overlying
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both frontal and parietal convexities.
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All this darker signal intensity representing blood
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products in the cortex and the subarachnoid space.
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You can also have a better appreciation
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of the extra-axial collections
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that are present.
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There is an additional finding that
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I would like to point out
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that was present in this patient and that is
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the finding associated with the retina.
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This is
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demonstrated.
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I'm going to try to magnify here by the irregular
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margination of the posterior globe membranes.
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You can see that there are areas that are crenated
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at the posterior portion of the globe.
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These areas represent.
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Retinal hemorrhages.
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Retinal hemorrhage.
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It is a very sensitive marker for nonaccidental
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trauma or child abuse.
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Finally,
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I want to demonstrate one other finding in this patient
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and that is the presence of high signal intensity
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within the posterior portion of the brain.
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And this
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seemed best on one of these sequences,
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which is the diffusion-weight imaging.
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What can happen in a patient who has had nonaccidental
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trauma is that you can have expression of Glutamate from
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the injury to the brain from Shaken Baby Syndrome that
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Glutamate expression is cytotoxic to the brain tissue as
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it comes out of the neurotransmitter and
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then leads to injury to the brain.
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This then is yet another of the findings that can be seen
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in a patient with nonaccidental trauma and that is diffuse
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cerebral edema secondary to the expression of
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Glutamate from the traumatized brain.
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