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  • Mixed Density Subdural Hematoma May Not be Pathognomonic for Non-accidental Trauma in Infants

    Final Number:

    Gunjan Goel MD; John Crawford; Mark Calayag MD; Hal S. Meltzer BS, MD; David D. Gonda MD; Michael L. Levy MD, PhD

    Study Design:

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2016 Annual Meeting

    Introduction: Traumatic head injury is the leading cause of death in pediatric non-accidental trauma, particularly in children younger than 2 years. Mixed density hematoma along with retinal hemorrhage and encephalopathy are considered to be indicative of non-accidental head injury in children. It is known that subdural hemorrhage in the infant has a different pattern from that seen in the older child and adult. Research has not been conclusive on the origin of the subdural hemorrhage in infants. Though the secondary membranes formed are noted to have increased vascularity on CD-31 and CD-34 stains, this does not correlate with bleeding clinically. In this paper, we consider an alternative hypothesis for SDH in infants. Anatomical and clinical observations indicate that vessels intrinsic to the dura and/or bridging veins may be a source of bleeding. The senior author has observed the presence of arterialized veins draining into superior sagittal sinus in infants undergoing craniotomy for evacuation of mixed density subdural hemorrhage, presumably for non-accidental trauma in 4 cases. These arterialized veins may be the source of both primary and recurrent SDH in infants. In order for such consideration, we examine the unique anatomy of the infant cranial venous system. We know through our understanding of the embryology of the cranial venous circulation that the evolution of the venous system during development continues into the post-natal period such that an infant may display sinuses or veins not usually seen in adults. Also, the vasculature of an infant is constantly in flux and ever-changing.

    Methods: We operated on four infants with mixed density hematomas and a presumed diagnosis of NAT over the course of one year.

    Results: We found arterialized veins draining into the superior sagittal sinus in all four patients.

    Conclusions: We propose that arterialized draining veins in neonates and infants may rupture serially and present as mixed density subdural hemorrhage. As to whether this mixed density hematoma is the result of repeated non-accidental head injury remains unclear, but an important consideration given the importance of diagnostic criteria in supporting a diagnosis of NAT.

    Patient Care: Subdural hematoma is an important variable (together with fractures and retinal hemorrhage) potentially indicative of pediatric non-accidental head injury; it is particularly unique in its appearance and distribution in the infant population. The origin and etiology of infant subdural hematoma is not well understood in the current literature. As the possibility of NAT is raised, it becomes critically important in the interpretation of the scan appearances to understand the unique anatomy and physiology of the infant cranial venous system and dura. Important legal and social ramifications exist in our ability to distinguish between subdural hematomas from accidental or non-accidental causes. By proposing an alternative hypothesis for mixed density subdural hematomas, we may be able to better define whether these findings are signs of an age-related response to trauma or an indication of response to NAT.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Understand basic embryology of the cranial venous circulation 2) Identify differences between infant and adult dura 3) Identify anatomical differences in infant and adult cranial venous system 5) Understand the difference in appearance of subdural hematoma in infants versus older children and adults 6) Evaluate the observed arterialized vein as a possible and alternative etiology of mixed density hematoma in infants.

    References: 1. Tung, G.A., et al., Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography. Pediatrics, 2006. 118(2): p. 626-33. 2. Park, H.R., et al., Multiple Densities of the Chronic Subdural Hematoma in CT Scans. J Korean Neurosurg Soc, 2013. 54(1): p. 38-41. 3. Squier, W. and J. Mack, The neuropathology of infant subdural haemorrhage. Forensic Sci Int, 2009. 187(1-3): p. 6-13. 4. Nuno, M., et al., Outcomes and factors associated with infant abusive head trauma in the US. J Neurosurg Pediatr, 2015: p. 1-8. 5. Mullan, S., et al., Cerebral venous malformation-arteriovenous malformation transition forms. J Neurosurg, 1996. 85(1): p. 9-13. 6. Mullan, S., et al., Embryological basis of some aspects of cerebral vascular fistulas and malformations. J Neurosurg, 1996. 85(1): p. 1-8. 7. Padget, D.H., The cranial venous system in man in reference to development, adult configuration, and relation to the arteries. Am J Anat, 1956. 98(3): p. 307-55. 8. Raimondi, A.J. and H. White, Cerebral angiography in the newborn and infant: general principles. Ann Radiol (Paris), 1967. 10(3): p. 147-64. 9. Okudera, T., et al., Development of posterior fossa dural sinuses, emissary veins, and jugular bulb: morphological and radiologic study. AJNR Am J Neuroradiol, 1994. 15(10): p. 1871-83. 10. Morris, P. and R2 Library (Online service), Practical neuroangiography. 2007, Lippincott Williams & Wilkins,: Philadelphia. 11. Stopford, J.S., The Functional Significance of the Arrangement of the Cerebral and Cerebellar Veins. J Anat, 1930. 64(Pt 3): p. 257-61. 12. Pearl, M., L. Gregg, and D. Gandhi, Cerebral venous development in relation to developmental venous anomalies and Vein of Galen aneurysmal malformations. Semin Ultrasound CT MR, 2011. 32(3): p. 252-63. 13. Harwood-Nash, D.C. and C.R. Fitz, Neuroradiology in infants and children. 1976, Saint Louis: Mosby. 14. Squier, W., The "Shaken Baby" syndrome: pathology and mechanisms. Acta Neuropathol, 2011. 122(5): p. 519-42. 15. Gupta, A. and A. Periakaruppan, Intracranial dural arteriovenous fistulas: A Review. Indian J Radiol Imaging, 2009. 19(1): p. 43-8. 16. Mack, J., W. Squier, and J.T. Eastman, Anatomy and development of the meninges: implications for subdural collections and CSF circulation. Pediatr Radiol, 2009. 39(3): p. 200-10. 17. Kotagal, M., et al., Iatrogenic arteriovenous fistula in the arm in an infant: diagnostic and therapeutic considerations. J Clin Ultrasound, 2012. 40(6): p. 381-4. 18. Iizuka, Y., et al., Multiple cerebral arteriovenous shunts in children: report of 13 cases. Childs Nerv Syst, 1992. 8(8): p. 437-44. 19. Plunkett, J., Sudden death in an infant caused by rupture of a basilar artery aneurysm. Am J Forensic Med Pathol, 1999. 20(2): p. 211-4. 20. Cohen, M.C. and I. Scheimberg, Evidence of occurrence of intradural and subdural hemorrhage in the perinatal and neonatal period in the context of hypoxic Ischemic encephalopathy: an observational study from two referral institutions in the United Kingdom. Pediatr Dev Pathol, 2009. 12(3): p. 169-76. 21. Cohen, M.C., A. Sprigg, and E.H. Whitby, Subdural hemorrhage, intradural hemorrhage and hypoxia in the pediatric and perinatal post mortem: are they related? An observational study combining the use of post mortem pathology and magnetic resonance imaging. Forensic Sci Int, 2010. 200(1-3): p. 100-7. 22. Geddes, J.F., et al., Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'? Neuropathol Appl Neurobiol, 2003. 29(1): p. 14-22. 23. Smith, C., et al., Dural haemorrhage in nontraumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'? Geddes JE et al. A response. Neuropathol Appl Neurobiol, 2003. 29(4): p. 411-2; author reply 412-3. 24. Squier, W., "Shaken baby syndrome" and forensic pathology. Forensic Sci Med Pathol, 2014. 10(2): p. 248-50. 25. Pearse Morris. Practical Neuroangiography. Embryology of the cranial circulation. 123-124 26. Padget, DH The development of the cranial venous ystem in man, from a viewpoint of comparative anatomy. Contrib Embryol 1957; 37:80-140

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