0:00

In most academic centers, the evaluation

0:03

of children with trauma is being done more

0:08

and more with fast MRI scanning in order to

0:12

reduce the radiation exposure to children.

0:14

So this is part of the ALARA, as Low

0:18

as possible radiation dosage.

0:21

So in the— at Johns Hopkins, when a child comes in with

0:26

head trauma, they're getting fast spin-echo T2-weighted

0:30

scans rather than CT scans for their evaluation.

0:35

So this was a child who had head trauma, and a protocol

0:40

was performed for a traumatic brain injury in a child.

0:45

This consists of sagittal,

0:48

axial, and coronal HASTE images.

0:51

The HASTE pulse sequence is

0:53

unique in that it's very rapid.

0:55

It does sequential scanning rather

0:58

than a group of scanning, so it reduces

1:00

the possibility of motion artifact with

1:02

children moving around in the scanner.

1:05

And this is followed by diffusion-weighted imaging in

1:08

order to look for ischemic foci, susceptibility-weighted

1:12

scanning in order to look for hemorrhagic products.

1:16

And often, we do a black bone scan

1:20

in order to look for fractures.

1:22

Remember that fractures are not that important from

1:25

the standpoint of surgical intervention unless they're

1:28

depressed or open, which is usually obvious clinically.

1:33

So, MRI is now even being

1:36

used to look for fractured bones.

1:39

So here was a patient where the initial

1:41

HASTE image showed some prominence to the

1:46

high signal intensity anteriorly here.

1:49

And the interpretation here was: are these blood vessels

1:55

crossing the subarachnoid space, or are they not?

1:59

If they cross the subarachnoid space, then this

2:02

may be a young patient who has benign macrocephaly

2:06

of infancy with a dilated subarachnoid space.

2:10

Or, if the blood vessels are compressed inward,

2:14

these could be subdural hematomas chronic.

2:18

So, I thought that the diffusion-weighted

2:20

scan on this case was very helpful.

2:23

So here is our DWI scan, where it shows absence

2:29

of parenchymal cytotoxic edema, but up anteriorly—

2:34

I'm going to window this a little bit differently—

2:37

you can see that the collections anteriorly

2:40

are not isointense to cerebrospinal fluid.

2:46

They're different.

2:47

Here is the subjacent subarachnoid

2:50

space—cerebrospinal fluid.

2:51

Here is hyperintense—slightly hyperintense to CSF.

2:58

So that raises the suspicion that

3:00

this represents blood collections.

3:03

The next sequence in line is going

3:05

to be our susceptibility-weighted

3:06

scan, and this is pretty traumatic.

3:09

Notice that in the susceptibility-weighted scan,

3:13

there are areas here that are too thick to just be veins.

3:16

Obviously, the veins are black on SWI

3:19

because of the presence of deoxyhemoglobin.

3:21

But here, we're seeing blood products on

3:24

the surface of the brain that is too thick.

3:27

There's no vein that's going to be that thick.

3:29

And it's also present along the posterior falx here.

3:33

And anteriorly, now we see that there are actually

3:37

two different intensities of collection.

3:40

There is the darker area here, anteriorly,

3:45

and then a brighter area of signal

3:48

intensity just to the left of midline.

3:52

So, what I'm talking about is the brighter

3:54

area here is different than the lower

3:57

signal intensity collection here.

3:59

And these are collections.

4:01

So now we have subdural collections of different ages,

4:07

associated with some more diffuse hemorrhage over

4:12

the high convexities in the subarachnoid space.

4:16

This should alert you to non-accidental trauma.

4:20

There are lots of different names for non-accidental

4:23

trauma: child abuse, or shaken baby syndrome, etc.

4:27

But the bottom line is that this is not from

4:31

just a fall—this is likely multiple

4:35

aged hemorrhages from child abuse.

4:37

And this is something that you would

4:39

immediately alert the clinicians that you

4:42

raise the possibility of non-accidental trauma.

4:45

They will then get social services

4:47

involved to interview the family about the

4:51

circumstances surrounding this child's trauma.

4:54

Whenever I see this phenomenon, the next thing I

4:57

want to do is to look at the orbits carefully.

5:00

One of the findings associated with non-accidental

5:04

trauma in children is retinal hemorrhages.

5:08

And this is from the shaking or the

5:11

acceleration-deceleration injury.

5:13

So, if there's any type of blood product

5:15

that you can identify associated with the

5:18

retina, it's going to increase your certainty

5:21

that the patient has non-accidental trauma.