Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse

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Object. The dating of inflicted head injuries in infants is a recurrent and difficult problem in the forensic evaluation of child abuse. The dating of hemorrhagic lesions when using magnetic resonance (MR) imaging is delicate because many confusing factors interact. In particular, infants frequently develop subdural hematomas (SDHs), which are generally composed of a supernatant, similar to cerebrospinal fluid (CSF), and a sediment, similar to blood clots. In the absence of a validated theoretical model predicting the evolution of blood signal in head-injured infants, clinical data are much needed; however, reliably dated information regarding head injuries in infants is scarce.

Methods. The authors prospectively studied infants who presented with dated and corroborated head injury to investigate the temporal modifications of computerized tomography (CT) and MR imaging in relation to the delay since trauma. In cases of SDH, the authors distinguished between sediment and supernatant based on their CT scanning appearance. They then studied the MR imaging signal of these two components in T1- and T2-weighted, fluid-attenuated inversion recovery (FLAIR), and gradient-echo sequences.

Whereas the signal of the supernatant showed little difference from that of the CSF and did not yield information about the date of trauma, the signal in the sediment, especially on the T1-weighted and FLAIR sequences, showed time-related modifications that could be used to date the trauma.

Conclusions. The authors propose a method by which to develop a time scale for the dating of head injuries in infants based on the modifications of signal and location of blood on CT and MR images.

Article Information

Address reprint requests to: Matthieu Vinchon, M.D., Ph.D., Service de Neurochirurgie Pédiatrique, Center Hospitalier Regional, Universitaire de Lille, 59 037 Lille Cedex, France. email: m-vinchon@chru-lille.fr.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 4. A CT—MR imaging correlation in an 8-month-old girl who was involved in a traffic accident and suffered a direct blow to the left parietal region. A: A CT scan performed 2 hours after the trauma, demonstrating left-sided brain contusion with wide fracture indicative of a dural tear. B: Control CT scan performed 6 hours later, demonstrating the rapid constitution of a parenchymal hematoma as well as a small hypodense subdural collection (arrow). C: Axial gradient-echo MR imaging study performed on Day 3, demonstrating an increase in the volume of the SDH (hyperintense), and clotted blood (hypointense) in the brain parenchyma.

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    Magnetic resonance images of hemorrhagic lesions. A: Case 13. Axial T1-weighted image obtained 7 days postinjury in a 4-month-old girl who was involved in a traffic accident. The subdural collection is hypointense, whereas hyperintense blood is seen in the subarachnoid space in the frontal paramedian region (arrow). B: Case 8. Axial T1-weighted image obtained 4 days after birth in a girl who was born by traumatic breech delivery with retained head. The clotted blood is located in the subdural space at the convexity and in the falcorial region, indicating a dural tear during the delivery process. C: Case 1. This 3-month-old boy was involved in a shaken baby syndrome incident. Axial T1-weighted image obtained on Day 3 of clinical presentation demonstrating hyperintense sediment in the occipital region (arrow) and hypointense supernatant. D: Case 16. This 2.5-month-old boy was involved in a shaken baby syndrome incident. Gradient-echo sequence 9 days after trauma, demonstrating hemosiderin pigment lining the inner membrane of the SDH (arrow).

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    Graph illustrating CT scanning—documented density of the pericerebral blood collection stratified by delay since injury. The number of occurrences are plotted in the y axis. Overall, blood hyperdensity was present in all cases studied less than 7 days after the trauma and was absent after Day (D) 11. One notable exception is due to spontaneous rebleeding on Day 28 after trauma, which occurred after surgical drainage of the collection, and was likely of iatrogenic

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    Case 5. Computerized tomography scans obtained in a 4-month-old girl involved in a shaken baby syndrome incident, demonstrating constitution of the SDH. A: Initial image obtained 4 hours posttrauma, demonstrating fresh clots in the subdural space at the convexity. B: Control image obtained 24 hours posttrauma, demonstrating the falx thickened with blood clots (arrow). The clots in the subdural space are smaller. C: Scan obtained 7 days after trauma. The clots in the subdural space have thinned, but a hypodense SDH has developed, associated with intracranial hypertension, requiring surgical drainage.

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    Bar graphs depicting MR imaging signals of the supernatant (left column) and sediment (right column) in the four imaging sequences obtained in the 20 cases. For greater clarity, the legend of the y axis, which represents the number of occurrences, has been omitted. As a rule, the supernatant had the characteristics of CSF, whereas the signal of the sediment varied with time, especially in the T1-weighted and FLAIR sequences. These findings show that heterogeneous collections develop after a single trauma, and that only the signal in the sediment can be used for its dating.

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    Schematic summary of the temporal evolution of CT and MR images. The semiquantitative (density, signal) as well as qualitative variables (macroscopic aspect, location of blood) are converted into binary variables (presence or absence) and plotted against the delay since trauma in the 20 cases. The lines end in a black circle when the corresponding date marks the boundary of a period of overlap between one state and the other of a binary variable (for example, presence and absence of hyperdensity on CT scan); the lines end in an arrowhead when the feature is assumed to persist beyond the last occurrence observed in our series. This synoptic figure, based on observed corroborated cases, is proposed as a method for establishing a time scale for the dating of head injuries in infants.

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