Clinical Pearls & Morning Reports
Subdural hemorrhage along the tentorium is a finding commonly associated with birth trauma. Read the NEJM Case Records of the Massachusetts General Hospital Article here.
Q: What is the most common vascular malformation in infants?
A: The most common vascular malformation in infants, albeit rare, is a vein of Galen abnormality, which may be diagnosed on the basis of magnetic resonance angiographic findings such as dilated venous structures in the posterior fossa that are likely to displace cerebellar tissue.
Q: Would an infant with cerebral sinus venous thrombosis typically appear ill?
A: Although cerebral sinus venous thrombosis is rare, with an estimated incidence of 0.67 in 100,000 children per year, the development of this condition can result in severe neurologic complications and death in infants. Initial cranial imaging may show signs of intracranial hemorrhage with hemorrhagic infarction of brain tissue. It is important to note that cerebral sinus venous thrombosis does not occur without an inciting event, such as dehydration, infection, a prothrombotic disorder, or an underlying chronic disease, such as cancer or sickle-cell disease. In addition, infants with this condition usually appear ill, often presenting with seizure, focal neurologic signs, vomiting and lethargy, or a decreased level of consciousness.
A: Asymptomatic intracranial hemorrhage in the subdural, intraventricular, and parenchymal regions has been documented in full-term infants after birth. The most common type is subdural hemorrhage, which has been detected in 26 to 50% of full-term infants. Subdural hemorrhage is most often found in the posterior supratentorial region, although it may also be seen in the posterior fossa. It is usually related to the application of direct forces on the head — either compression during vaginal birth with associated stretching of the tentorium as the head is distorted, or external forces related to vacuum or forceps delivery. In addition, a small but significant number of infants delivered by uncomplicated cesarean section are found to have asymptomatic subdural hemorrhage. Most cases of subdural hemorrhage resolve within 1 month, with all cases resolving in less than 3 months. A significant number of infants have hemorrhage not only in the subdural region but also in other compartments of the brain, including parenchymal, periventricular, and subarachnoid hemorrhage.
A: In cases of suspected child abuse, a complete and detailed medical history should be taken, with attention paid to adherence to proper well-child care, nutritional status, medications and vitamins, previous episodes of trauma or unexplained bruising or bleeding, and unexplained neurologic symptoms that may represent past episodes of abuse, including a history of apnea, altered mental status, or unexplained vomiting. Symptoms of abusive head trauma occur on a spectrum, with mild injury leading to minimal symptoms that may be mistaken for viral illness or normal newborn irritability. Among patients with a diagnosis of abusive head trauma, the incidence of unrecognized past episodes of abuse has been estimated to be 25 to 30%. Making the determination of whether a child has been abused is often not clear-cut. Given the ramifications to the child and the family, the determination must be based not only on descriptions in the medical literature but also on review of all the features of the case in combination with experienced clinical judgment.