A 4-month-old female was referred to the pediatric intensive care unit after she presented with 9 days of emesis. She initially began vomiting once per day but this increased to several times per day over 3-4 days.
She was seen by a local health care provider who admitted her locally. She improved with intravenous fluid by the next day and was discharged home.
Three days later she began to have emesis again and her mother noticed her crossing her eyes. She was again seen by her local health care provider who noticed a large fontanelle.
A computed tomography scan of her head revealed bilateral subdural hematomas and she was referred for neurosurgical care.
The past medical history revealed a healthy female who was born full-term by scheduled caesarean section because her mother had had a previous caesarean section.
She had been seen for normal health supervision visits and had her 2-month immunizations.
The family history was positive for heart disease and cancer, but not for blood dyscrasias, skeletal abnormalities, and children or infants who died young or who had congenital abnormalities.
The review of systems showed her to be fussier and crying more over the past 9 days also.
The pertinent physical exam showed an alert infant with normal vital signs. Head circumference was 44 cm (> 95%).
She was a fussy infant with bulging fontanelle that was tense. Pupils were 3-4 mm in diameter and reactive to light. Bilaterally eyes were adducted and did not appear to be able to full abduct.
She was not able to fixate on a light. Frenulae was intact. Lungs, chest, abdomen, genitourinary and skin examinations were normal.
Neurologically she had normal tone and strength in all extremities. All other cranial nerves were intact except the sixth nerve as noted.
The laboratory evaluation included complete blood count, liver and pancreatic function tests, chemistries, and coagulation studies including von Willibrand factor were normal.
She also had a urine and hair drug screen for potential substances of abuse which were normal. Urine organic acids were also normal.
The radiologic evaluation showed bilateral chronic subdural hematomas that also had newer blood within them.
The work-up included an ophthalmological examination and skeletal surveys (one on admission and a second skeletal survey 2 weeks later) that were normal.
The child protection team also evaluated the child and interviewed the family. The family members could not remember any trauma, even minor incidents, that could have produced the hematomas.
They also had no concerns about the childcare provider or family friends who had baby-sat for them.
The diagnosis of bilateral subdural hematomas of unknown cause with increased intracranial pressure was made.
The team also noted that under good constant supervision, which this infant needed because of her age, any significant trauma would be observed by a caretaker.
As there is no disclosure of any incident there was a concern for non-accidental head trauma.
The Department of Human Services was contacted when the infant was admitted and they investigated the social situation.
Over the next two weeks, the patient was transferred to the inpatient ward and the patient’s clinical course showed that she would have episodes of increasing head circumference and anterior fontanelle tension, followed by emesis. The neurosurgeons would then aspirate the subdural fluid through the anterior fontanelle with relief of the tension and stopping of the emesis.
The patient underwent 3 aspirations. She was discharged after 6 days when she had stable head circumference measurements, physical examinations of her fontanelle and eyes, and no emesis.
She was discharged to foster care along with her older sibling pending further investigation by the Department of Human Services and court action.
Figure 55 – Axial T1 (left), T2 (center) and FLAIR (right) weighted images from an MRI scan of the brain performed without intravenous contrast obtained at the same level as the previously performed CT scan of the brain better demonstrates the large, bilateral chronic subdural hematomas with the linear focus of acute subdural hematoma in the frontal aspect of the left chronic subdural hematoma. Note the appearance of the signal intensity of the CSF in the patient’s normal subarachnoid space on the T1, T2 and FLAIR weighted images which are the same signal intensity as the CSF in the ventricular system.
Figure 54 – Axial image of a CT scan of the brain performed without intravenous contrast shows large, bilateral, low density extraxial fluid collections that are subdural hematomas. In the frontal aspect of the left chronic subdural hematoma a linear focus of high density is seen and this represents an area of acute subdural hematoma within the chronic subdural hematoma. Another acute subdural hematoma was noted in the left posterior fossa (not pictured).
Accidentally injured children are usually brought to medical attention quickly by a supervising adult who gives a history that is consistent with the extent and proposed mechanism of the child’s injury; the story generally remains the same when re-told to multiple healthcare providers over time also.
Children who present to health care providers without a history of trauma, or with a trauma history that is not consistent with the extent of the child’s injury or proposed mechanism of injury or a history that changes during re-telling, should make a health care provider consider non-accidental trauma as a potential cause.
Birth trauma should be considered as a potential cause of subdural hematomas. Approximately 25% of normal, vaginally delivered, term infants have the potential of developing asymptomatic acute subdural hematoma that sometimes may evolve into chronic subdural hematomas.
This child was delivered by caesarean section and therefore this is not a possibility.
The absence of retinal hemorrhages in this child also does not necessarily rule out non-accidental head trauma because in mild to moderate cases of non-accidental head trauma up to 50% may not have retinal hemorrhages.
It is possible that this child was shaken or shaken and then slammed against a softer surface sometime in the past. At the time of injury, she might have had other signs of injury such as retinal hemorrhages or bruising of the skin that were not apparent when the subdural hematomas were identified.
Fractures, especially fractures at different stages of healing, posterior rib fractures and metaphyseal fractures are more likely to be associated with non-accidental trauma.
Incidental findings such as rib fractures can be the presentation of non-accidental trauma. A second skeletal survey was conducted to look for occult fractures that might have been missed on the original skeletal survey, which ruled out any skeletal injury in this child.
Timing of injuries may assist the health care providers treating the patient, e.g. knowing approximately when the maximum brain swelling should occur for acute head injuries.
Timing may also assists child protection legal system professionals such as social workers, police officers, lawyers and judges. However, in some cases, especially those presenting with chronic findings, it maybe difficult to precisely time injuries exactly owing to many factors.
Factors that can affect the imaging appearance include hemoglobin level at the time of bleeding, location of the bleeding (brain parenchymal versus extraaxial), oxygen status of hemoglobin, intracellular versus extracellular location of hemoglobin, single versus recurrent bleeding, operative intervention, and obviously time from injury to imaging, to name a few.
Because of this, timing of subdural hematomas should be done based on utilizing imagining findings combined with taking into consideration the onset, progression and severity of clinical findings.
There is little of reliable data for the dating of extraaxial hemorrhages such as subdural hemorrhages.
There is data on timing of brain parenchymal hemorrhages using magnetic resonance imaging. This is often grouped according to the following information below, but note timing in only approximate.
- Timing – < 24 hours
- Appearance – Oxyhemoglobin shows up hyperintense on T1 weighted images and hyperintense on T2 weighted images
- Timing – < 1 week
- Appearance – Deoxyhemoglobin shows up isointense/slightly hypointense to gray matter on T1 weighted images and hypointense to gray matter on T2 weighted images
- Timing – 1-3 weeks
- Appearance – Methemoglobin shows up
- Intracellular: Hyperintense on T1 weighted images from peripheral to central; hypointense on T2 weighted images
- Extracellular: Hyperintense on both T1 and T2 weighted images
- Timing – > 3 weeks
- Appearance – Generally hypointense on the T1 and T2 weighted images. However there may be multiple compartments with variable signals (especially if rebleeding occurs) with septation; hemosiderin deposition causes low signals
Questions for Further Discussion
1. What is the radiographic appearance of acute and healing fractures and what timing is associated with each stage?
2. What legal and ethical responsibilities does a health care professional have for protecting a minor?
3. Locally, how do the medical and legal systems work together to coordinate care and protection of a minor?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
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ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
20. Respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development are demonstrated.
21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Resmiye Oral, M.D.
Clinical Associate Professor of Pediatrics, University of Iowa Children’s Hospital
Simon C. Kao, M.D., F.A.C.R.
Professor of Radiology, University of Iowa Children’s Hospital
December 3, 2007