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Radiology : Abusive Head Trauma

Suspected abusive head trauma (AHT) may require evaluation to look for skull fractures and intracranial injury. Intracranial manifestations of trauma are seen with inflicted head trauma and significant accidental injury, such as motor vehicle crashes, and may lead to significant morbidity or mortality in infants. In child abuse cases, AHT may present with minimal or no external signs of trauma.

Additional tests, such as spine imaging, chest or abdominal ultrasound or CT scans, may be considered based on history, physical and laboratory findings. 

Skull Fractures

Skull fractures are found in abused infants and young children but more commonly occur as a result of accidental injury. Unlike long bone and rib fractures, skull fractures do not show typical radiological signs of healing, such as callus formation. Assessing time since the incident causing a skull fracture or dating of the timing of the injury based on signs of healing is often not possible with skull fractures (Lasiecka 2023). For more information on skull fractures, see the Curbside Consult Skull Fractures.

Intracranial Injury

For children younger than 2 years, abusive head trauma (AHT) is the leading cause of fatal head injuries (Choudhary et al 2018). Although no single injury is diagnostic of AHT, imaging of the brain is a critical part of the evaluation to look for subdural hemorrhages and parenchymal injury.

Key Facts

  • The peak incidence of fatal AHT is between 1-2 months of age.
  • Although few infants with AHT have isolated intracranial injury without retinal hemorrhages, fractures or other manifestations of child abuse, a lack of other findings does not mean that AHT did not occur, and, when AHT is suspected, it remains important to do a complete evaluation, including imaging of the brain.
  • Follow-up imaging of the brain in child abuse is often necessary to identify parenchymal volume loss, chronic subdural hematomas or collections, and hydrocephalus. Rebleeding into long-term collections may occur.

Intracranial Manifestations of Trauma

Parenchymal injury
Swelling, infarction, hypoxia/ischemia, or axonal injury.
Subdural hemorrhages (SDH)
Occurs when rotational forces cause tearing of veins at the junction of the bridging vein and superior sagittal sinus complex with bleeding into the subdural area. Sutures do not confine the crescent appearing bleed that has a concave margin against the surface of the brain. These hemorrhages can extend along the full surface of the cerebral hemisphere. SDH are the most common intracranial lesion of infants with AHT and are most commonly seen in the parafalcine location (Bradford, Choudhary & Dias 2013).
Subarachnoid hemorrhages
A common finding in inflicted head injury. This space lies adjacent to the brain and extends into the cortical sulci.
Epidural hemorrhages
Seen commonly with accidental injury from translational forces. These hemorrhages are not usually the result of child abuse.

A complete evaluation should be done and will help identify mimics of AHT. For more information see: DIAGNOSIS: Physical Abuse, Findings suggestive of physical abuse and the Curbside Consult Abusive Head Trauma.

Magnetic Resonance Imaging (MRI) versus Computed Tomography (CT) for Evaluation of Intracranial Injuries

Skull X-rays alone may be sufficient if only skull fractures (based on the history, physical, and age of the child) are suspected. On the other hand, if multiplanar CT with 3D reconstruction is available and obtained as part of a CT scan, skull images may be unnecessary (Cosgrave et al 2022). A CT scan of the head may effectively determine bony injury to the skull or face using 3D reconstruction. Small fractures or fractures aligned in the same plane as the imaging beam can be missed and 3D reconstruction, if available, may be a valuable adjunct to evaluate for skull fractures. In all cases, the need for obtaining radiological studies should be based on the suspicion of injury and weighed against the risk of adding to a child’s lifetime exposure to radiation. The various modalities of radiologic imaging complement each other.

Overview: Magnetic Resonance Imaging (MRI) versus Computed Tomography (CT)

  • MRI is best to evaluate for sub-acute or chronic injury and is often used to observe findings over time with repeat imaging. MRI can be offered as a follow-up imaging modality for children with abnormal CT scans.
  • MRI is the best modality for fully assessing intracranial injury in the non-acute setting, including extra-axial collections, intraparenchymal hemorrhages, cerebral hypoxia and ischemia, contusions, shear injuries, and brain swelling or edema.
  • In asymptomatic infants with suspicion of abuse and noncranial abusive injuries, MRI (particularly if fast MRI is available) may be an optimal modality for brain imaging.
  • CT may be more available than MRI and efficient for determining acute blood accumulation or need for immediate surgical intervention.
  • CT demonstrates scalp swelling that may not be present clinically as well as complex or depressed skull fractures.
  • CT scan 3D reconstruction of the skull can be very helpful in identifying skull fractures.

Radiology