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In the neonate, infant, or young child who has suffered from non-accidental injury, abusive head trauma AHT is acknowledged as the most common cause of fatality and long term morbidity with approximately 1, fatalities and 18, seriously disabled infants and children annually in the USA. Beyond the tragedy of an injured or murdered child is the broader social and community impact of this national and international health blight. In addition to the emotional, family, and social costs caused by inflicted trauma, the societal financial burden is astounding. Subdural hemorrhage SDH is the most common pathology associated with abusive head trauma. Hemorrhage in this location conforms to the classic morphology of subdural bleeding concavoconvex. The authors also point out that in the first two years of life, the inner dural border zone plays an important role in the resorption of CSF as the arachnoid granulations are maturing. More recently, Julie Mack and colleagues have advanced our understanding of a more dynamic vascularized dura.

One possibility is shrinkage of extracellular space due to resorption of plasma with clot retraction 18 - 20which causes high viscosity. Other possible explanations include changes in the conformation of the hemoglobin molecule 2621 and a contraction of intact red blood cells together with decreased intracellular space 6 Previous studies have suggested that the cause of hypointensity within a hyperacute hematoma, seen on T2-weighted images, may be the early presence of paramagnetic deoxyhemoglobin 458.

The hypointense rim of hyperacute ICH seen at T2WI was more obvious on gradient-echo images with stronger susceptibility effect. However, the hypointense rim seen at DWI did not accurately correspond to that seen on T2-weighted and gradient-echo images Fig.

Despite the stronger susceptibility effect, it is not certain why this is so. The focal hypointensity seen at DWI within a hyperacute hematoma might involve another causative factor: one possibility is a portion of unclotted liquid separated from a retracted clot. A year-old man with hyperacute intracerebral hematoma seen on MR images obtained 2 hours after the onset of symptoms.

Diffusion-weighted image shows the hematoma as hyperintense, and a peripheral focal area of marked hypointensity is observed thin arrows. In addition, a hyperintense rim arrow is demonstrated around the hematoma. T1-weighted image shows an isointense hematoma with a hypointense rim arrow in the left frontal lobe. The hypointense area thin arrow apparent at DWI corresponds to the hyperintense area seen inside the hypointense rim on the T2-weighted image, which appears to be a liquid separated from a clot.

In our study, the cores of lesions found in acute and early subacute hematomas were markedly hypointense at DWI as well as on T2-weighted images.

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This hypointensity has been attributed to the magnetic field inhomogeneity caused by paramagnetic intracellular deoxyhemoglobin in acute hematoma 12162324 and paramagnetic intracellular methemoglobin in early subacute hematoma 1 Does et al.

Likewise, in our study, the cores of acute and early subacute ICHs showed reduced ADC values compared with normal contralateral white matter, an in addition, a variable, markedly hyperintense rim surrounding hyperacute, acute and early subacute hematomas was identified in all patients at DWI.

Although Wiesmann et al. We believe that the rim is not caused by a susceptibility artifact due to a paramagnetic substance such as intracellular deoxyhemoglobin or methemoglobin, but may be related to the T2 shine-through effect caused by vasogenic edema surrounding the hematoma. Evidence for this is that the rim corresponded to the area of hyperintense perilesional edema seen on T2-weighted images to surround the hematomas, and that its ADC value was higher than that of normal contralateral white matter.

Subdural Hemorrhage in Abusive Head Trauma: Imaging Challenges and Controversies

Our data showed that in late subacute hematoma the lesion core was hyperintense at DWI and its ADC value was lower than that of normal white matter. Atlas et al. According to Ebisu et al. We believe that variations in ADC do not depend simply on whether or not red blood cell membranes are intact. At the late subacute stage of hematoma, red blood cell lysis occurs and the compartmentalization of methemoglobin is lost, resulting in the elimination of the inhomogeneous susceptibility effect 12 In addition, the intracellular contents are distributed in the extracellular space, possibly causing high viscosity.

Other biological changes at this stage include high cellularity resulting from the infiltration of inflammatory cells and macrophages 23. All these changes may affect molecular diffusion and the ADC of a hematoma. At the late subacute stage, this latter may, therefore, be related to the nature of the biological change occurring in hematomas, and during the evolution of these, ADCs appear to vary. At the chronic stage of ICH, paramagnetic hemosiderin and ferritin 1227 are found at the periphery and seen at DWI and on T2-weighted images as a dark rim surrounding the hematoma.

At DWI, because the ADC value increases as the lesion approaches a cystic cavity, the lesion core of a chronic hematoma appears isointense at the early chronic stage and hypointense at the late chronic stage.

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In our study, all chronic hematomas were at the late chronic stage, and their ADC values were therefore higher than those of normal white matter. The limitations of this study include the lack of histopathological confirmation and the small number of cases.

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Although a complete understanding of the underlying biophysical basis may require further studies with a large population, our data suggest that the appearance of intracerebral hematomas on diffusion-weighted images is influenced not only by ADC values but also by magnetic susceptibility and T2 shine-through effects. In addition, our study corroborates the key features of evolving intracerebral hematomas, as depicted by conventional MR imaging. In conclusion, DWI demonstrated the characteristic MR features of intracerebral hematoma at various stages.

We suggest that the biophysical mechanisms behind the signal changes observed at DWI are multifactorial. A better understanding of the DWI findings of intracerebral hematoma can be helpful for the differentiation of intracerebral hematoma from acute infarction and for the further characterization of intracranial hemorrhagic lesions.

National Center for Biotechnology InformationU. Journal List Korean J Radiol v. Korean J Radiol. Published online Dec Find articles by Bo Kiung Kang. Find articles by Dong Gyu Na. Find articles by Jae Wook Ryoo. Find articles by Hong Sik Byun. Find articles by Hong Gee Roh. Find articles by Yong Seon Pyeun. Author information Article notes Copyright and License information Disclaimer.

Corresponding author. Telephone:Fax:rk.

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Received Apr 6; Accepted Jul This article has been cited by other articles in PMC. Results DWI showed that hematomas were hyperintense at the hyperacute and late subacute stages, and hypointense at the acute, early subacute and chronic stages. Keywords: Brain, hemorrhage; Magnetic resonance MRdiffusion study. MR imaging For MR imaging, a 1.

Analysis Two radiologists visually evaluated the signal intensities at the center and periphery of each ICH, reaching a consensus. Open in a separate window. Acute and early subacute stages In all 14 patients whose hematomas were acute or early subacute, these appeared markedly hypointense on diffusion-weighted, T2-weighted, FLAIR, and gradient echo images Figs.

Chronic stage At DWI, four of the eight chronic hematomas appeared homogeneous and markedly hypointense, and the remaining four showed an isointense center surrounded by a hypointense rim. References 1. Intracranial hematomas: imaging by high-field MR.

Bradley WG. MR appearance of hemorrhage in the brain. Hemorrhagic and nonhemorrhagic stroke: diagnosis with diffusion-weighted and T2-weighted echo-planar MR imaging. MRI characteristics of spontaneous intracerebral hemorrhage. Diffusion measurements in intracranial hematomas: implications for MR imaging of acute stroke.

Am J Neuroradiol. Diffusion-weighted MRI and proton MR spectroscopic imaging in the study of secondary neuronal injury after intracerebral hemorrhage.

detecting intraparenchymal hemorrhage, particularly in the subacute and chronic phases. In addition, it is an excellent, noninvasive way to screen for, and follow, intracranial neoplasms. In patients who present with a hemorrhage on MR, how­ ever, it may be necessary to determine the Cited by: 2. Dec 31,   To document the signal characteristics of intracerebral hemorrhage (ICH) at evolving stages on diffusion-weighted images (DWI) by comparison with conventional MR our retrospective study, 38 patients with ICH underwent a set of imaging sequences. Dec 23,   Late remains of the hemorrhage on MR can be seen as a rim of Hemosiderin deposits - that is just black. Gradient Echo (T2*) (GRE) sequences show hemorrhage as black since it is a sort of susceptibility artefact. It also exaggerates the volume of bleeding ("blooming artefact"). You may also check: Neonatal Intraventricular Hemorrhage.

Eur Radiol. Early detection of regional cerebral ischemia in cats: comparison of diffusion- and T2-weighted MRI and spectroscopy.

Dating intracranial hemorrhage using CT and MRI. Estimating the age of intracranial hemorrhage provides critical forensic information for the investigation of suspected abusive head trauma. I have found that CT and MRI findings are complementary when it comes to tackling the dating of an injury and characterization of intracranial hemorrhage. Patients may present to the hospital at various times after an ischemic stroke. Many present weeks after a neurologic deficit has occurred, as is often the case with elderly patients and those in a nursing home. The ability to determine the age of an ischemic stroke provides useful clinical information for the patient, his or her family, and Cited by: Apr 01,   Though few studies suggest that dating of subdural haematoma cannot be done accurately using radiological methods [], the present study, yet gives a reliable and a reproducible method for the estimation of the age of early subdural haemorrhage. Not many studies have been conducted recently on the radiological dating of by: 3.

Magn Reson Med. MR diffusion imaging of cerebral infarction in humans. Hyperacute stroke: evaluation with combined multisection diffusion-weighted and hemodynamically weighted echo-planar MR imaging. Acute and chronic stroke: navigated spin-echo diffusion-weighted MR imaging.

Diffusion-weighted MR imaging: diagnostic accuracy in patients imaged within 6 hours of stroke symptom onset. Hyperacute stroke: ultrafast MR imaging of triage patients prior to therapy. Detection of hyperacute primary intraparenchymal hemorrhage by magnetic resonance imaging.

MR detection of hyperacute parenchymal hemorrhage of the brain. MRI features of intracerebral hemorrhage within 2 hours of symptom onset. Acute hematomas: effects of deoxyhemoglobin, hematocrit, and fibrinclot formation and retraction on T2 shortening. Effect of clot formation and retraction on spin-echo MR images of blood: an in vitro study.

T2 effect of hemoglobin concentration: assessment with in vitro MR spectroscopy. Nuclear magnetic resonance patterns of intracellular water as a function of HeLa cell cycle. Sickle-cell hemoglobin: fall in osmotic pressure upon deoxygenation. Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI.

Pediatric Radiol, ; Huisman TA. Eur Radiol, ; MR characteristics of subdural hematomas and hygromas at 1.

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AJNR ; Nelson M. Unraveling the puzzle. The computed tomographic attenuation and the age of subdural hematomas. J Korean Med Sci ; Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse. J Neurosurg Pediatrics 1 ; Radiology ; J Forensic Sci.

Magnetic resonance in imaging of chronic subdural hematoma. Neurosurg Clin N Am. Comparison of accidental and nonaccidental traumatic head injury in children on noncontrast computed tomography.

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Comparison of intracranial computed tomographic findings in pediatric abusive and accidental head trauma. Pediatr Rad ; Munro D, Merritt H. Surgical pathology of subdural hematoma.

Based on a study of cases. Arch Neurol Psychiatr. Hanna JA. The aetiology of subdural hematoma: an anatomical and pathological study. J Nerv Ment Dis. Intacranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies.

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Child Maltreat ; Intracranial hemorrhage in term with newborns: management and outcomes. Pediatr Neurol ; Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. Sonographic findings in infants with macrocrania. AJR ; CT and MR in infants with pericerebral collections and macrocephaly: Benign enlargement of the subarachnoid spaces versus subdural collections.

Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical view of the literature. Online Publication: Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse. Ravid S, Maytal J. External hydrocephalus: a probable cause for subdural hematoma in infancy.

Influence of the benign enlargement of the subarachnoid space on the bridging veins strain during a shaking event: a finite element study. Int J Legal Med. Spektor Amodio, Pramanik B et al. Spontaneous development of bilateral subdural hematomas in an infant with benign infantile hydrocephalus: color Doppler assessment of vessels traversing extra-axial spaces. Pediatr Radiol ; Superior sagittal sinus thrombosis followed by subdural hematoma.

Surg Neurol ; Cerebral venous sinus thrombosis associated with systemic multiple hemangiomas manifesting as chronic subdural hematoma - case report. Neurol Med Chir Tokyo ; Cohen MC, Scheimberg I.

Dating intracranial hemorrhage mri

Evidence of occurrence of intradural and subdural hemorrhage in the perinatal and neonatal period in the context of hypoxic ischemic encephalopathy. An observational study from two referral institutions in the United Kingdom.

Pediatr Dev Pathol ; Neuropathol Appl Neurobiol. Is there a casual relationship between the hypoxia-ischemia associated with cardiorespiratory arrest and subdural hematomas? An observational study. The British Journal of Radiology. Sirotnak A. Medical disorders that mimic abuse head trauma. Abusive Head Trauma in Infants and Children.

Retinal hemorrhages in type I osteogenesis imperfect after minor trauma. Ophthalmology ; Subdural hematoma as clinical presentation of osteogenesis imperfecta. Type I glutaric aciduria part 1: natural history of 77 patients. Semin Med Genet ; Massive subdural hematomas in Menkes disease mimicking shaken baby syndrome.

Childs Nerv Syst ; The value of the metabolic autopsy in the pediatric hospital setting. J Pediatr ; DeWolfe CC. Apparent life-threatening event: a review.

Intracranial hemorrhage an approach

Pediatr Clin North Am ; Jaudes PK, et al. Child Abuse Neglect. E-pub Jul; 32 7 : Back To Top. December 15, About the Author.

Aging blood on MRI is dependent on the varying MRI signal characteristics of hemorrhagic collections with time and can be very useful in correlating the imaging findings with the clinical cbeebies-games.comr, as it can be complicated to recall the MRI features of aging blood through the five stages of hematoma evolution several mnemonics have been devised. Appearance on MRI is variable depending on: Field strength of the magnet Whether the image is T1 or T2 weighted Time course of the ICH Hyperacute 3 Days Late > 7 Days Chronic > 14 DaysFile Size: KB. Dec 07,   The appearance and evaluation of intracranial hemorrhage on MRI (see the images below) primarily depend on the age of the hematoma and on the imaging sequence or parameters (eg, T1 weighting, T2 weighting). Other influences are the site of the hemorrhage, the local partial pressure of oxygen in the tissues, the local pH, the patient's hematoc.

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