Case 90

A 5-month-old baby girl was brought to the emergency department by ambulance. The mother said she had been at home alone with the infant when she became pale, floppy and stopped breathing. Mother then noticed some twitching movements of her left arm and leg. She called the ambulance. The infant was mildly hypothermic, floppy and responding poorly to handling. She had a bulging fontanel. During assessment in the emergency department she had a generalized seizure needing intravenous medications to control it. She was then intubated due to apnoea. Once she was stabilized, a non-contrast CT head scan was requested (Image 90). https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig90.jpg"/>

What diagnoses would you consider?

What imaging would you request?

What does the image show?

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First consider meningitis and treat ‘in case’ then investigate, including blood count and blood cultures. Also, consider hypoglycaemia, head trauma, metabolic or biochemical disturbance. ¹

Once the baby is stabilized then consider imaging tests:

Chest x-ray to exclude pneumonia

Computed tomography (CT) scan of the head to look for conditions such as haemorrhage and abscesses and exclude major haemorrhage that might need neurosurgical intervention

Magnetic resonance imaging (MRI) to detect small areas of surface bleeding and focal brain change, as it is much more sensitive than CT (MRI is usually performed electively at about 3–7 days post-presentation.

Skeletal survey

Ophthalmoscopy

The image shows acute blood (white) along the falx in the midline. This brightness is not due to the normal falx. Trauma scans are always performed without intravenous contrast being given. The dating of acute blood radiologically means bleeding at any time within 7 days or so. There is also midline shift from right to left due to a mixed density subdural collection over the right frontal lobe. Finding blood of two densities may mean bleeding of two different dates. It can also be explained by the mixing of clotted and unclotted (hyperacute) blood or mixing of acute blood with an acute traumatic effusion. There is subtle loss of grey white matter differentiation in the right frontal lobe which matches the clinical presentation with encephalopathy (better assessed with MRI). An MRI after a few days may assist in this differential diagnosis. Further investigations should exclude underlying coagulation disorder and metabolic disease. In addition, ophthalmoscopy revealed bilateral multilayer retinal haemorrhages. A full skeletal survey showed no bony injury. A follow-up chest x-ray at 2 weeks showed multiple unilateral healing posterior rib fractures even though no acute rib fractures were identifiable on the first chest x-ray of the skeletal survey even in retrospect. Later the mother admitted a squeeze and shake injury for a few seconds, when the baby would not stop crying in the early hours of the morning. The exact amount of force needed to cause subdural haemorrhage is unknown, as is the duration of the shaking. It is likely to involve a force well outside that of normal handling in a baby with immature neck control.