Neuroimaging of Pediatric Abusive Head Trauma

Mary Rolfes, MD; Julie Guerin, MD; Justin Brucker, MD; Peter Kalina, MD


Appl Radiol. 2019;48(3):30-38. 

In This Article

Abstract and Introduction


Abusive head trauma (AHT) is a major cause of morbidity and mortality in children subjected to abuse, accounting for nearly one-third of all deaths caused by child abuse.[1] Those children who do survive AHT are often left with significant and permanent disabilities, including motor and visual deficits, language abnormalities, seizures, and behavioral problems.[2–4] Despite the severe consequences of AHT, no standard criteria or objective tests exist for differentiating AHT from accidental trauma.[5] Clinical histories and presentations are often unclear and contribute to unrecognized cases or delays in diagnosis. Recent studies suggest healthcare providers had previously seen nearly one-third of children who subsequently died from AHT in the time leading up to their death.[6,7] In some cases, delay in diagnosis has been attributed to misinterpretation of radiologic studies, highlighting the need for improved education and awareness of the appropriate imaging techniques in the evaluation of AHT as well as common radiologic findings.[6–10]

Efforts continue to be made to understand the underlying pathogenesis and mechanisms of AHT. The two major categories of AHT include shaking mechanisms, in which repetitive acceleration-deceleration forces typically result in subdural hematomas (SDH), retinal hemorrhages and global parenchymal damage; and direct impact trauma, which may result in skull fractures and focal coup/contrecoup parenchymal injuries. However, the exact mechanisms of injury are often unknown and may result from a combination of forces. Parenchymal damage further can be multifactorial; for example, intracranial hemorrhage, hypoxic-ischemic injury and axonal disruption may all result in cytotoxic edema.[11–13]

Noncontrast head computerized tomography (CT) followed by conventional magnetic resonance imaging (MRI) is widely considered to be the first step in evaluating suspected AHT, with diffusion-weighted imaging (DWI) and susceptibility-weighted imaging (SWI) being critical MR sequences.[14–20] Diffusion tensor imaging (DTI), magnetic resonance spectroscopy (MRS) and arterial spin labeling (ASL) perfusion imaging of the brain also may be utilized, though these sequences are not typically included in routine protocols. In addition to evaluating brain injury, increasing emphasis has been placed on imaging of the orbits, olfactory tracts, and cervical spine. We outline current imaging techniques appropriate for the evaluation of AHT, highlighting their unique contribution to obtaining an accurate and timely diagnosis, as well as common radiologic findings.