Subdural hemorrhage in pediatric patients with enlargement of the subarachnoid spaces

Clinical article

Restricted access

Object

Enlargement of the subarachnoid spaces has been theorized as a risk factor for the development of subdural hemorrhage (SDH). As the finding of unexplained SDH in children often raises suspicion for nonaccidental trauma, the possibility of increased risk of SDH in children with enlargement of the subarachnoid spaces has important clinical, social, and legal implications. Therefore, the authors evaluated the frequency of SDH in a cohort of children with enlargement of the subarachnoid spaces.

Methods

The authors identified children younger than 2 years of age who were diagnosed with enlargement of the subarachnoid spaces on MRI or CT scanning in a large primary care network between July 2001 and January 2008. The authors excluded children who had enlargement of the subarachnoid spaces diagnosed on imaging performed for trauma or developmental delay, as well as children with a history of prematurity, diagnosis of intracranial pathology, or metabolic or genetic disorders. Chart review recovered the following data: patient demographics, head circumference, history of head trauma, and head imaging results. For the subset of children with SDH, information regarding evaluation for other injuries, including skeletal survey, ophthalmological examination, and child protection team evaluation, was abstracted.

Results

There were 177 children with enlargement of the subarachnoid spaces who met the inclusion criteria. Subdural hemorrhage was identified in 4 (2.3%) of the 177 children. All of the children with SDH underwent evaluations for suspected nonaccidental trauma, which included consultation by the child protection team, skeletal survey, and ophthalmological examination. Additional injuries (healing rib fractures) were identified in 1 of 4 patients. None of the 4 children had retinal hemorrhages. Only the child with rib fractures was reported to child protective services due to concerns for abuse.

Conclusions

Only a small minority of the patients with enlargement of the subarachnoid spaces had SDH. Evidence of additional injuries concerning for physical abuse were identified in a quarter of the children with enlargement of the subarachnoid spaces and SDH, suggesting that an evaluation for suspected nonaccidental trauma including occult injury screening should be performed in cases of SDH with enlargement of the subarachnoid spaces. In the absence of additional injuries, however, the presence of an unexplained SDH in the setting of enlargement of the subarachnoid spaces may be insufficient to support a diagnosis of nonaccidental trauma.

Abbreviations used in this paper:BESS = benign enlargement of the subarachnoid spaces; CHOP = Children's Hospital of Philadelphia; SDH = subdural hemorrhage.

Article Information

Address correspondence to: Heather McKeag, M.D., 800 Washington Street, Boston, Massachusetts 02111. email: hmckeag@tuftsmedicalcenter.org.

Please include this information when citing this paper: published online February 8, 2013; DOI: 10.3171/2012.12.PEDS12289.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Assembly of study cohort. HC = head circumference; US = ultrasonography; y.o. = years old.

References

1

Alvarez LAMaytal JShinnar S: Idiopathic external hydrocephalus: natural history and relationship to benign familial macrocephaly. Pediatrics 77:9019071986

2

Amodio JSpektor VPramanik BRivera RPinkney LFefferman N: Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces. Pediatr Radiol 35:111311172005

3

Barkovich A: Pediatric Neuroimaging ed 4PhiladelphiaLippincott Williams & Wilkins2005. 686689

4

Datta SStoodley NJayawant SRenowden SKemp A: Neuroradiological aspects of subdural haemorrhages. Arch Dis Child 90:9479512005

5

Daymont CHwang WTFeudtner CRubin D: Head-circumference distribution in a large primary care network differs from CDC and WHO curves. Pediatrics 126:e836e8422010

6

Hellbusch LC: Benign extracerebral fluid collections in infancy: clinical presentation and long-term follow-up. J Neurosurg 107:2 Suppl1191252007

7

Jayawant SParr J: Outcome following subdural haemorrhages in infancy. Arch Dis Child 92:3433472007

8

Jenny CHymel KPRitzen AReinert SEHay TC: Analysis of missed cases of abusive head trauma. JAMA 281:6216261999

9

Keenan HTRunyan DKMarshall SWNocera MAMerten DFSinal SH: A population-based study of inflicted traumatic brain injury in young children. JAMA 290:6216262003

10

Kleinman PK: Diagnostic Imaging of Child Abuse ed 2St. LouisMosby1998. 312

11

Kleinman PKZito JLDavidson RIRaptopoulos V: The subarachnoid spaces in children: normal variations in size. Radiology 147:4554571983

12

Matschke JVoss JObi NGörndt JSperhake JPPüschel K: Nonaccidental head injury is the most common cause of subdural bleeding in infants <1 year of age. Pediatrics 124:158715942009

13

McNeely PDAtkinson JDSaigal GO'Gorman AMFarmer JP: Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse. AJNR Am J Neuroradiol 27:172517282006

14

Papasian NCFrim DM: A theoretical model of benign external hydrocephalus that predicts a predisposition towards extra-axial hemorrhage after minor head trauma. Pediatr Neurosurg 33:1881932000

15

Parent AD: Pediatric chronic subdural hematoma: a retrospective comparative analysis. Pediatr Neurosurg 18:2662711992

16

Prassopoulos PCavouras DGolfinopoulos SNezi M: The size of the intra- and extraventricular cerebrospinal fluid compartments in children with idiopathic benign widening of the frontal subarachnoid space. Neuroradiology 37:4184211995

17

Raul JSRoth SLudes BWillinger R: Influence of the benign enlargement of the subarachnoid space on the bridging veins strain during a shaking event: a finite element study. Int J Legal Med 122:3373402008

18

Ravid SMaytal J: External hydrocephalus: a probable cause for subdural hematoma in infancy. Pediatr Neurol 28:1391412003

19

Vinchon MDelestret IDeFoort-Dhellemmes SDesurmont MNoulé N: Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature. Childs Nerv Syst 26:119512052010

20

Zahl SMEgge AHelseth EWester K: Benign external hydrocephalus: a review, with emphasis on management. Neurosurg Rev 34:4174322011

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 18 18 15
Full Text Views 46 46 25
PDF Downloads 121 121 44
EPUB Downloads 0 0 0

PubMed

Google Scholar