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

Other Imaging Considerations

When AHT is suspected, special attention should be paid to the retina and other orbital structures. As noted above, retinal hemorrhages are considered highly specific for AHT. They are often bilateral, extensive and multilayered in this context, and their presence indicates an acceleration-deceleration type mechanism. Intravitreous and optic nerve sheath hemorrhage and/or optic atrophy are other ophthalmologic findings of AHT that may be visible on imaging. In addition, trauma to the cisternal olfactory tracts and bulbs are frequently encountered as the result of severe coup/contrecoup injury or shearing across the cribriform plate,[73,74] which can be sustained from either a direct head strike or shaking (Figure 6). High-resolution imaging of the orbits, olfactory bulbs, and other cisternal structures can be readily performed with balanced coherent steady-state free precession (bSSFP) imaging. This sequence provides superior contrast for fine structures that are profiled by fluid or fat, making it ideal for delineating the small anatomic structures of the orbits, skull base, and exiting craniospinal nerves.

Figure 6.

Volumetric balanced coherent steady-state free precession (bSSFP) image reformatted in the coronal planes (A) demonstrates irregularity and asymmetry of the olfactory bulbs (arrows), secondary to traumatic injury. 20-directional diffusion weighted imaging in the reformatted coronal plane (B) reveals restricted diffusion within the olfactory bulbs (short arrows), confirming the acuity of the injury.

Finally, as small children typically lack the neck strength and head control to protect themselves against sudden hyper-extension/flexion forces, they are more prone to cervical spine injury, including spinal subdural hematomas and ligamentous injury.[75–79] Increasing evidence suggests cervical spine injury is more common AHT and is associated with more severe brain injury and poor outcomes; thus, cervical spine MRI is also now generally warranted.[75,77,79–81]