ABSTRACT
A 5-day-old girl was brought to the emergency department after she was noted to have seizures. Her mother noticed that her breastfeeding had decreased and first brought her to the primary care physician where the infant was noted to have repetitive movements of her left arm. There was no history of trauma. She was born at 4 kg after a term pregnancy with uneventful prenatal care. Ultrasound at 30 weeks’ gestation was normal. Delivery was complicated by a prolonged second stage of labour and her Apgar scores were 5, 7 and 9 at 10 min. She required several minutes of positive pressure ventilation after birth but was later transferred to the well-baby nursery in good condition. She was discharged on day three of life. In the emergency department, she began to have bilateral tonic-clonic seizures and she was sent for CT scan of her head. Her breathing became depressed. A lumbar puncture was performed, antibiotics and anticonvulsants were given, and she was intubated and transferred to the paediatric intensive care unit for further management. No bruises, bleeding or oral injuries were noted. Fontanelles were normal and there was no swelling palpable on her scalp. Head imaging noted intracranial blood (Image 132a) and posterior skull fracture (Images 132b and 132c). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig132a.jpg"/> 300 https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig132b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig132c.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig132d.jpg"/>
What does Image 132a show?
What does Image 132b show?
What additional testing and evaluations are helpful to evaluate potential abusive head trauma?
What further imaging is needed to determine the aetiology for this patient’s presentation?
302A large amount of intracranial blood is visualized on this head CT. The blood is located primarily in both lateral ventricles and on additional images was also seen in the third and fourth ventricles and on the left in the subdural space on the left.
A small, non-displaced lucency is noted (arrow) in the left posterior skull on this CT bone window. There is a small degree of overlying soft tissue swelling of the scalp.
Given the possibility of inflicted trauma in this presentation, full imaging of the axial skeleton using a skeletal survey was indicated. 1 The retinae should be examined for haemorrhage. Coagulation tests such as a complete blood count, prothrombin time and partial thromboplastin times were also indicated to determine if the child had an underlying coagulation disorder contributing to the bleeding. The American Academy of Pediatrics has recommended additional testing of factor VIII and factor IX levels in addition to D-dimer and fibrinogen levels to exclude additional medical causes for bleeding. 2 A clinical decision rule has concluded that a thorough evaluation should be performed when children with potential head trauma present with (1) unexplained respiratory depression, (2) bruising to the head or neck or torso, (3) subdural and/or interhemispheric intracranial bleeding, or (4) any skull fractures other than a unilateral, single, non-diastatic, linear parietal fracture. 3
Magnetic resonance imaging (MRI) of the head offers several sequences to further evaluate the blood as well as the brain and other intracranial structures with greater precision and without radiation. On the second day in the hospital, the head MRI (Image 132d) showed blood throughout the ventricular system with fluid levels layering in the bilateral occipital horns, compatible with acute intraventricular haemorrhage. Skeletal survey confirmed a small, nondisplaced parietal fracture. Susceptibility artefact in the region of the right thalamus is also compatible with haemorrhage. There are several punctate and linear areas of susceptibility artefact with associated T2 hyperintense signal in the right frontal and parietal corona radiata/centrum semiovale which may represent additional small foci of haemorrhage. In addition, there is a suggestion of diffusion restriction seen in the region of the right thalamus, right centrum semiovale and corona radiata suggestive of ischaemia. There is moderate dilatation of the ventricular system compatible with hydrocephalus. There is no abnormal parenchymal or leptomeningeal enhancement and no midline shift. The basal cisterns are patent. Additional MRI vascular sequences were obtained and showed normal internal carotid artery and branches at the level of the circle of Willis bilaterally with no evidence of vascular stenosis, occlusion, aneurysm or malformation. Evaluation of the posterior circulation demonstrated normal vertebrobasilar system with no evidence of filling defect within the dominant venous sinuses including the superior sagittal sinus, the transverse and sigmoid sinuses.
