Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

Joseph Scheller,Knut Wester

doi:10.1007/s00701-021-04786-3

Joseph Scheller, Knut Wester

Open Access

https://doi.org/10.1007/s00701-021-04786-3

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Journal: Acta neurochirurgica	Publication Date: Mar 12, 2021
Citations: 8	License type: open-access

Affiliation: University of Bergen

Abstract

BackgroundCriteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises.MethodsThe authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)—mean age 5.1 month, without age difference between genders.ResultsTwenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH).ConclusionsBEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors’ experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

Highlights

Child abuse has been recognised as an important paediatric problem for the last half century
The present study describes and analyses a group of infants that were diagnosed as having been violently shaken, but where clinical and radiological features were more compatible with benign external hydrocephalus (BEH) complicated by a chronic subdural haematoma (CSDH) or hygroma than with SBS/abusive head trauma (AHT)
All the children had fluid collections that were described as chronic subdural haematomas, and none of the infants had evidence of direct impact to the head or signs of any other external trauma, such as rib fracture, limb fracture or neck injury

Summary

Introduction

Child abuse has been recognised as an important paediatric problem for the last half century. In 1971, the British neurosurgeon Norman Guthkelch published an article on subdural haematomas (SDH) in infants with the title Infantile Subdural Haematoma and Its Relationship to Whiplash Injuries [25]. His patient material consisted of 23 children suspected of suffering from “battered child syndrome”. Thirteen of these had subdural haematoma, but in two of these infants—both six-month-old boys—there. Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; these conditions might be diagnosed on failing premises

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