It seems conceivable that arachnoid cysts also rupture in infants and are not yet acknowledged as such. The authors proposed a mechanism whereby SDHy directly originates from shaking the baby: during acceleration and deceleration of the brain, acute shear strains between arachnoid and dura may disrupt both the BVs and the weak arachnoid attachments to the parasagittal dura (Pacchioni granulations). These retinal hemorrhages were not present yet in a check-up examination 1 month after birth. Forensically, it is important to know that long-term observations of infants with BESS as well as a finite element study indicated no increased risk for developing SDH.92⇓⇓–95 The hypothesis was that stretching of the BV due to enlargement of the subarachnoid space may result in a predisposition to developing SDH. Particularly in infants, SDHys are not well described and only little understood. The suggested process describes the conversion of acute SDH into cSDH via SDHy as an intermediate stage (blue pathway in Fig 2).47,66 Because most acute SDHs resolve rapidly, reflecting the high levels of tissue thromboplastin in brain tissue and CSF,67 this approach has been refined by other authors. A review of 26 cases, Delayed evolution of post-traumatic subdural hygroma, The clinical course of surgically treated post-traumatic subdural hygromas, The pathogenesis and fate of traumatic subdural hygroma, Mechanisms and management of subdural hemorrhage, Shaking and Other Non-Accidental Head Injuries in Children, The epidemiology of non-accidental head injury, Inflicted traumatic brain injury in infants and young children, Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI, Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies, Further characterization of traumatic subdural collections of infancy. Left chronic subdural hygroma (protein laden fluid is less hypointense than spinal fluid). On CT imaging, an acute SDH often presents as a hyperdense subdural collection (Fig. Swift DM, McBride L. Chronic subdural hematoma in children. Two-month-old boy with huge hypodense, CSF-like, subdural collections lacking encapsulating membranes (A, cranial CT). Vessels rarely cross through the lesion in contrast-enhanced studies (see cortical vein sign) 1. Enter multiple addresses on separate lines or separate them with commas. While acute SDH, representing 1 of the leading indicators for Shaken Baby syndrome, can be reliably diagnosed by means of CT and MR imaging, other pathologic fluid collections are often termed interchangeably as SDHys, cSDHs, subdural effusions, chronic hygromas, or simply subdural collections. Alternatively, Mack et al36 suggested that CSF could physiologically move from the subarachnoid space into interstitial spaces of the dura mater and subsequently via the dural venous plexus into the dural sinuses. Differentiating Accidental Trauma From Child Abuse, Genital findings in boys suspected for sexual abuse, Examination of (suspected) neonaticides in Germany: a critical report on a comparative study, Nonaccidental head injury in infants–the “shaken-baby syndrome.”, American Academy of Pediatrics: Committee on Child Abuse and Neglect, Shaken baby syndrome: rotational cranial injuries—technical report, Nichtakzidentelle kopfverletzungen und schütteltrauma–klinische und pathophysiologische aspekte, Subdural haemorrhages in infants: population based study, Annual incidence of shaken impact syndrome in young children, A population-based study of inflicted traumatic brain injury in young children, Subdural haematoma and effusion in infancy: an epidemiological study, Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia, Shaken baby syndrome in Switzerland: results of a prospective follow-up study, 2002–2007, Abusive head trauma in infants and children, Fatal head injury in children younger than 2 years in New York City and an overview of the shaken baby syndrome, Shaken baby syndrome: a common variant of non-accidental head injury in infants, Ocular pathology in shaken baby syndrome and other forms of infantile non-accidental head injury, A multicentre and prospective study of suspected cases of child physical abuse, The “shaken baby” syndrome: pathology and mechanisms, Neuroimaging of nonaccidental head trauma: pitfalls and controversies, Spinal subdural hemorrhage in abusive head trauma: a retrospective study, Intracranial hematomas at a glance: advanced visualization for fast and easy detection, What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra‐axial fluid collections in infants. Hence, the SDHy in this well-documented case can be regarded as a result of acute injury. In subdural hematoma, the position of the veins may be similar to that in subdural hygroma or may be ruptured as shown. Following the concept of delayed SDHy formation, the presence of SDHy may be medicolegally interpreted as later consequence of AHT that occurred some days or a few weeks before. In addition, free CSF communication between subarachnoid and subdural space was proved in all cases by radiotracer injection. “Free” fluid collections without any capsule. Among neurotraumatologists it is generally known that SDHys usually derive from head injuries and represent rare posttraumatic complications that may coexist with epidural or subdural hematomas.33,42,43,57⇓⇓–60 Unfortunately, the causes of SDHys cannot always be read directly from the CT or MR images. A current neuroradiologic textbook by Osborn55 defines SDHys as “hypodense, CSF-like, crescentic extraaxial collections that consists purely of CSF, have no blood products, lack encapsulating membranes, and show no enhancement following contrast administration” (Fig 1). MRI studies have shown that almost half of all new‐borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Many believe that chronic subdural hygromas in infants are caused by leakage of cerebrospinal fluid from the subarachnoid space into the potential subdural space. In any cases of alteration of this CSF absorption pathway—for instance from bleeding into the dural layers—a disruption of the transport mechanism may result in delayed accumulation of CSF within the subdural space producing imaging findings of SDHy. A systematic review, Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? The heterogeneous appearances of SDHys prompted Unterharnscheidt37 to differentiate between 2 general morphologic types: Cystic and often multichambered formations encapsulated by a membrane. Numerous scientists from different disciplines sought to address this problem in the last decades. 1). Therefore, the current knowledge on subdural hygromas is summarized and forensic conclusions are drawn. As further clinical diagnostics have ruled out coagulopathies, neoplastic diseases, and metabolic disorders, the presence of SDH and retinal hemorrhage prove substantial (sub)acute head trauma and therefore strongly suggest child abuse (AHT). Kobayashi M, Toshinami N, Maeda T, Ito K, Hisada K. "[Post-meningitis subdural hygroma in a child showing abnormal RI accumulation in 169Yb-DTPA RI cisternography]." To differentiate subdural hygromas from other pathologies, additional MR imaging of the infant's head is indispensable after initial CT scan. An advanced approach was developed considering additional aspects of SDHy formation. CSF accumulation communicating freely with the subarachnoid space-SAS) [8], or an effusion. Left chronic subdural hygroma. 23 The convexities of the cerebral hemispheres (Fig 1A), the falx cerebri, the tentorium cerebelli, and the middle and posterior cranial fossae are considered typical locations. Additionally, a subdural hygroma was seen at the lower thoracic and up-per lumbar levels with anterior displacement of her lower thoracic cord, conus medullaris, and cauda equina (Fig. Two common causes of infant macrocephaly are BESS (benign expansion of subarachnoid spaces) and subdural hygroma. In the presence of BESS, the vessels, which run through the subarachnoid space, are localized away from the brain. In neuroradiology, frontotemporal atrophy as well as SDHys and/or SDHs are diagnosed.77,78 Glutaric aciduria type I should therefore be diagnostically excluded in infants with SDHy, because misdiagnosing as AHT may occur in exceptional cases.79,80. As mentioned above (Fig 2), cSDHs were commonly shown, at least in adult trauma cases (mostly traffic crashes), to derive from SDHys with incidence rates between 8% and 58%.33,47,58,59 Thus, the fate of SDHy is either resolution or cSDH formation.33,59,75 Under a normal pressure situation, the SDHy resolves. It is our opinion that a wide opening of the external membrane of SACs may predispose the CSF fluid to accumulate within the subdural space, where its absorption is insufficient. A better understanding of the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental trauma may help distinguish this group of patients from those who suffer subdural hematomas as a result of NAT. SHMs usually resolve spontaneously but a number of these may become a hygroma, a type of external hydrocephalus and precursor of chronic subdural hematoma (CSHM) [7]. The BIH is a diagnosis of exclusion. The initial neuroradiologic evaluation is of particular importance and indispensable for correct medicolegal conclusions. However, as long as scientific data do not support this possibility, this remains mere speculation. While in CT (A), BESS could be misdiagnosed as SDHy, MR imaging (B, T1-weighted image; C, T2-weighted image) clearly demonstrates the presence of BESS. These pathogenetic considerations show why it is important for the forensic expert to differentiate between cSDH and SDHy. Both concepts presented have 1 thing in common: if other infrequent reasons and differential diagnoses have been excluded, the presence of SDHy strongly suggests trauma, or more precisely: a posttraumatic state. Hereafter, the 2 current basic concepts of SDHy formation with their different medicolegal implications, as well as important alternative explanations, are presented. In all probability, multiple mechanisms exist and also coexist. Infant with subdural hygroma and expanded subarachnoid space. An acute subdural hygroma results from the acute accumulation of CSF within the dural border cell layer. It does not open until the dura-arachnoid interface is mechanically separated, for instance due to brain shrinking, trauma, or neurosurgical interventions.33⇓–35 This opening is actually regarded as a cleaving of the so-called dural border cell layer—the innermost zone of the dura mater—and therefore also referred to as intradural lesion.33,36 Nevertheless, in this article, the traditional term subdural is used to describe accordant pathologies within that space such as SDHy. Accordingly, early hypodensity in infantile SDH has also been observed by others51,98⇓–100 arguing against an overhasty diagnosis of a chronic process but suggesting a significant role of CSF. But what about SDHy versus cSDH? in majority of cases, there is a family history of macrocephaly It appears to be widely presumed that SDHys represent liquefied and/or deposited remnants of a previous acute SDH52,62⇓⇓–65,82 suggesting that, in a case of suspected child abuse, the baby could have been abused weeks ago. Epidemiologically there are striking similarities between chronic SDH and BEH in infants. An acute subdural hygroma results from the acute accumulation of CSF within the dural border cell layer. Therefore, it is important to understand how SDHys develop or what they originate from. Magnetic resonance imaging of the spine demonstrated intramedullary T2 hyperintensity at the level of T-2 and T-3, indicative of spinal cord contusion. MRI, magnetic resonance imaging SDH, subdural haemorrhage Subdural haemorrhage (SDH) arising from intentional injury is relatively common in infants, with an annual incidence figure of 21/100 000. More precisely, it is a type of bleed that occurs within the skull of head but outside the actual brain tissue. SDHys can be regarded and examined from 2 different points of view: first, the traditional perspective of the neuropathologist, forensic pathologist, or neurosurgeon who directly investigate or treat colorful 3D pathologies in the human head; and second, the perspective of the neuroradiologist who indirectly evaluates and interprets 2D black-and-white cross-sectional images from CT, MR imaging, or sonography. If there is a mass of proteinaceous liquid within the subdural space that appears to be associated with bacterial meningitis, it is generally spoken of as a subdural effusion.54⇓–56. "Letter to the Editor: Subdural hygromas and arachnoid cysts" published on May 2014 by American Association of Neurological Surgeons. Methods. Subdural hematomas in infants are often equated with nonaccidental trauma (NAT). Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. In the context of AHT, subdural hematoma (SDH) is described as the most common intracranial pathology in infants and toddlers. Subdural hygroma. A direct transformation from remnants of an acute SDH into a cSDH is therefore not plausible in all cases. While in a subdural hygroma, the veins are displaced away from the inner table because the arachnoid … Kaku Igaku 1976;13:553-557. MR imaging confirmed the diagnosis of frontoparietal SDHys on both sides (B, axial T2-weighted image; C, coronal T2-weighted image). A subdural hematoma is a type of bleed inside your head. Figure 14. Schematic drawing of the right parietal region as seen in the coronal view imaging. Tucker J, Choudhary AK, Piatt J. Macrocephaly in infancy: benign enlargement of the subarachnoid spaces and subdural collections. Subdural Hygromas in Abusive Head Trauma: Pathogenesis, Diagnosis, and Forensic Implications, Understanding Subdural Collections in Pediatric Abusive Head Trauma, Limitations of T2*-Gradient Recalled-Echo and Susceptibility-Weighted Imaging in Characterizing Chronic Subdural Hemorrhage in Infant Survivors of Abusive Head Trauma, Head Circumference: A Key Sign in Dating Abusive Head Trauma, Child abuse and neglect: diagnosis and management, General aspects of fractures in child abuse, Forensic Aspects of Paediatric Fractures. 2.3). Consequently, the terms cSDH and SDHy are often used as synonyms in practice. Therefore, the present review addresses the following questions: What are the current theories regarding the pathogenesis of SDHy? This can result from an acute tear in both the arachnoid and the dural border cell layer, resulting in communication of these two spaces. These collections are then interchangeably termed as subdural hygromas (SDHys), chronic subdural hematomas (cSDHs), or a terminologic mixture of both: chronic hygromas. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Benign enlargement of the subarachnoid space. The usage of SDHy for age estimation of head trauma is difficult and should not be considered as the most important factor in determining the time of injury.53 Hence, as already proposed by Vezina,51 in initial CT investigations, it is best to describe subdural collections only in terms of density (hypo-, hyper-, isodense, or mixed) and strongly avoid labels such as “acute” or “chronic.”, If additional presurgical MR imaging scans of the head exist, further assessment is possible. Child abuse represents a very heterogeneous, unfortunately still present, and therefore well-established research field within the forensic sciences.1⇓⇓⇓⇓–6 According to the Committee on Child Abuse and Neglect of the American Academy of Pediatrics, abusive head trauma (AHT), also referred to as nonaccidental head injury, is still the leading cause of child abuse fatalities.7⇓–9 The incidence of AHT in children under 1 year of age ranges between 14 and 28 per 100,000 live births in Western countries.10⇓⇓⇓⇓–15 Direct blunt force to the head and the so-called Shaken Baby syndrome are currently assumed to be the main etiologic factors of AHT.9,16⇓–18 The full-blown clinical picture of Shaken Baby syndrome is characterized by the triad of subdural hematomas (SDHs), retinal hemorrhages, and encephalopathy. 18. The purpose of this retrospective study was to verify our conclusion drawn from the model, namely, that the cortical vein sign is specific for atrophy and excludes a diagnosis of subdural hygroma. Note the vessels (thin arrows) spanning through the subarachnoid space. Acute subdural hemorrhage is a common complication, thought to be due to stretching of small vessels across the expanded subdural space as well as due to membranous bleeding. They are commonly seen in elderly people after minor trauma but can also be seen in children following infection or trauma. general hygroma is a capsule that is filled with fluid and is surrounded by a layer of fibrous tissue While cSDHs in infants are rare and rather implicate a delayed and nonacute process, SDHys may develop rapidly or be delayed. A wide range of neurosurgical techniques has been developed to treat patients with intracranial disorders such as hemorrhage, infection, and tumor. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Moreover, in some cases suspected for AHT, radiologists are confronted with almost homogeneous fluid collections within the subdural space, which appear isodense/isointense or nearly isodense/isointense to CSF. These cSDHs are particularly vulnerable to be accidentally referred to as SDHys. The presence of SDHy in infants therefore represents compelling reason to search for other signs of AHT such as retinal hemorrhages, fractures, bruises, or inadequate explanations for trauma. The connection between the two conditions would explain why this child has both. Thereby, a mixture of CSF and blood products can flow into the traumatically opened subdural space resulting in an acute subdural hematohygroma.53. A subdural hygroma (SDG) is a collection of cerebrospinal fluid (CSF), without blood, located under the dural membrane of the brain. If other infrequent reasons can be excluded, the presence of subdural hygromas strongly suggests a posttraumatic state and should prompt the physician to search for other signs of abuse. 4 McKeag et al. Pediatrics. A subdural hygroma radiographically appears as a crescentic near-CSF density/signal accumulation in the subdural space that does not extend into the sulci and rarely exerts significant mass-effect 5. More recently, in the study by Greiner et al., among 108 infants with BESS, 6 cases (5.6%) had subdural collections, and review of hospital records indicated that 2 of the 6 had been reported to state agencies for suspicion of abuse. Illustrative cases from forensic practice are presented. Radiotracer and cisternography studies performed in infants with SDHy were able to show that radioisotopes (eg, indium-111) injected into the subarachnoid space move into the subdural compartment.44,53 In addition, the CSF-specific β-trace protein and other proteins have been found up to 100% of SDHys,74,75 indicating that there really is CSF in the subdural space. Once the radiologic diagnosis of SDHy is made, the forensic expert will likely be confronted with 2 questions: Does the SDHy represent a result of AHT? While cSDHs appear to be very rare and delayed consequences of subdural collections, SDHys can apparently develop delayed or rapidly. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Accordingly, it is not adequate to state different ages of injuries when SDH and SDHy are present concomitantly. As SDHys mostly lack neomembranes, this aspect could be another morphologic criterion for differentiation. Accordingly, SDHys were frequently observed not to be restricted to the brain side of the “original pathology” (eg, acute SDH).45, SDHy can then develop neomembranes from the proliferating dural border cells that are principally able to proliferate in any pathologic process with cleavage of the dural borderzone tissues.50 Forming of neomembranes is accompanied by neovascularization. There are the most subdural hygroma are believed to be derived from the chronic subdural hematomas. Moreover, experimental studies failed to reproduce cSDH from acute subdural blood.83,84 It has also been reported that, based on histopathology85 and CT,66 chronic and acute SDH should actually be regarded as different entities. MR imaging scan of a 5-month-old female infant who showed a sudden increase of head circumference (from 50th to 97th percentile within 1 month). Other causes of subdural hygroma include, spontaneous subdural hygroma that may occur due to rupture of arachnoid cyst, and post-operative that develops after decompressive craniectomy, cranioplasty or shunt installation [4] [8] . In radiology, the definition of SDHy is more difficult, and the terminology is very heterogeneous. Subdural Hygroma Definition:- A Subdural Hygroma is a collection of cerebrospinal fluid, without blood (while not blood), located under the dural membrane of the brain. Thus, it remains at least questionable whether these results can be applied to infants at all. = wet, moist) was first introduced by Rudolph Virchow in 1856.37 Many other terms, such as subdural hydroma, Meningitis serosa traumatica, traumatic subdural effusion, or simply subdural fluid accumulation have also been used.33,38⇓⇓⇓–42 SDHys are classically described as protein-rich, clear, pink-tinged, or xanthochromic fluid collections within the subdural space.22,37,42⇓⇓⇓⇓–47 Likewise, if the principal component of a subdural collection appears to be CSF-like, the term SDHy is used.44,48⇓–50 A mixture of blood and CSF is referred to as hematohygroma.51⇓⇓–54. Case report and review of the literature, Arachnoid cyst rupture with subdural hygroma: report of three cases and literature review, Pathogenesis of chronic subdural hematoma. Pathology is always based on anatomy. BACKGROUND: Infratentorial subdural hygromas causing secondary occlusive hydrocephalus are extremely rare in children. Ophthalmologic examination revealed sub- and epiretinal hemorrhages distributed over the whole fundus area of both eyes. 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Surgeons and pathologists know cSDH as subdural liquid with a dark brown “crank case oil” appearance.47 Many cSDHs also contain a mixture of both CSF and blood, such as breakdown products of hemoglobin or other proteins.55,82 Furthermore, multiple hemorrhages of different ages are supposed to be common (so-called mixed-age SDH).55 This may sometimes also lead to an attenuation approximating that of CSF.