0:01

This was a three-month-old who was found to be unconscious

0:05

when the parents came back and found

0:09

the child with their caregiver.

0:12

The CT scan is remarkable for a large amount of hemorrhage

0:17

at the superior aspect of the brain.

0:20

This type of hemorrhage,

0:22

which is seen just at the subarachnoid

0:25

space and gray matter junction,

0:27

is not unusual in children who have had a

0:30

traumatic brain injury. As you can see,

0:32

this is a bilateral process which is just on the surface

0:35

of the brain extending into the subarachnoid space.

0:39

In addition,

0:41

you will note that the patient has a hemorrhage along

0:46

the posterior temporal lobe on the left side,

0:49

and it looks as if there is a low-density extra-axial

0:53

collection overlying the lateral aspect

0:56

of the left temporal lobe.

0:59

As well.

1:00

You also see a small amount of low-density fluid

1:04

overlying the frontal lobes. In addition,

1:07

one can see subarachnoid hemorrhage that is

1:10

present in the right frontal convexities.

1:15

When one has extra-axial collections

1:19

of multiple ages in a child,

1:23

one has to consider nonaccidental trauma or child abuse.

1:29

For this patient,

1:30

we want to be particularly aware

1:32

of the potential for fractures.

1:34

So we will look at the thin-section bone images.

1:37

We will reconstruct them into three

1:39

D to look for calvarial fractures.

1:42

If one has these multiple-aged hemorrhages in a child,

1:47

one usually will call the clinician and say that

1:50

you have a concern for nonaccidental trauma.

1:53

At that juncture,

1:54

the child will likely get a series of plain films to look

1:58

for rib fractures or metaphyseal fractures or

2:02

other signs of child abuse.

2:05

In this case,

2:06

the patient was doing much worse than was

2:09

apparent based on the initial CT scan.

2:13

If you look at the coronal reconstructions of the

2:16

axial CT data, you see what I was talking about,

2:20

where sometimes it's difficult to tell where this

2:22

hemorrhage is in the gray matter itself or just layering

2:26

along the surface of the brain in the subarachnoid space

2:31

or along the PIA. And this patient, as you can see,

2:35

has areas of sort of flame-shaped hemorrhage that's

2:38

going into the subarachnoid space as well as,

2:40

as I described previously, the low-density,

2:43

older extra-axial collections.

2:47

So an MRI scan was subsequently ordered.

2:51

This is the MRI scan of the same patient.

2:56

This is the flare image where we have dark signal.

3:00

Intensity CSF.

3:01

And you can see that there are low signal intensity

3:05

collections overlying the frontal lobes bilaterally

3:09

representing chronic subdural hematomas. In addition,

3:13

more superiorly,

3:14

you have the higher signal intensity blood products

3:17

along the high frontal convexities.

3:20

This is the T2-weight scan.

3:23

The T2-weight and again demonstrates

3:27

the extra-axial low density,

3:31

in this case, high signal intensity collections.

3:35

How do we know this is not the subarachnoid space?

3:37

If one sees that the Dura margin is displaced

3:41

inward or the vessels are displaced inward,

3:45

that implies that these are subdural collections.

3:48

So blood vessels displaced inward and not crossing the CSF

3:54

space suggests that these are chronic subdural hematomas

3:57

rather than just dilatation of the subarachnoid space

4:00

where the blood vessels would course freely

4:03

within the entire subarachnoid space.

4:06

Here you can see the acute blood products represented

4:09

by dark signal intensity on T2-weight imaging

4:12

overlying the high frontal convexities

4:15

as well as the parietal convexities.

4:21

The patient had a diffusion-weight scan as well,

4:28

and one sees that there does appear to be some

4:31

higher signal intensity posteriorly in the

4:36

subcortical white matter.

4:40

Here, on the gradient echo scans,

4:43

you see the blood products in the subarachnoid space

4:46

marked as the dark signal intensity overlying

4:49

both frontal and parietal convexities.

4:52

All this darker signal intensity representing blood

4:55

products in the cortex and the subarachnoid space.

4:59

You can also have a better appreciation

5:02

of the extra-axial collections

5:05

that are present.

5:10

There is an additional finding that

5:12

I would like to point out

5:14

that was present in this patient and that is

5:21

the finding associated with the retina.

5:28

This is

5:29

demonstrated.

5:31

I'm going to try to magnify here by the irregular

5:38

margination of the posterior globe membranes.

5:44

You can see that there are areas that are crenated

5:49

at the posterior portion of the globe.

5:56

These areas represent.

6:00

Retinal hemorrhages.

6:02

Retinal hemorrhage.

6:04

It is a very sensitive marker for nonaccidental

6:10

trauma or child abuse.

6:12

Finally,

6:13

I want to demonstrate one other finding in this patient

6:21

and that is the presence of high signal intensity

6:26

within the posterior portion of the brain.

6:31

And this

6:36

seemed best on one of these sequences,

6:39

which is the diffusion-weight imaging.

6:43

What can happen in a patient who has had nonaccidental

6:46

trauma is that you can have expression of Glutamate from

6:52

the injury to the brain from Shaken Baby Syndrome that

6:57

Glutamate expression is cytotoxic to the brain tissue as

7:04

it comes out of the neurotransmitter and

7:07

then leads to injury to the brain.

7:10

This then is yet another of the findings that can be seen

7:14

in a patient with nonaccidental trauma and that is diffuse

7:17

cerebral edema secondary to the expression of

7:21

Glutamate from the traumatized brain.