[Subdural hematomas in children: role of cerebral and spinal MRI in the diagnosis of child abuse]. / Collections sous durales de l'enfant: place de l'IRM cerebrale et medullaire dans le diagnostic de maltraitance.

PURPOSE: To determine if the presence of multiple subdural hematomas (SH) of varying signal intensities at MRI was suggestive of repeated injuries allowing a diagnosis of non accidental head injury (NAHI). MATERIAL AND METHODS: We included 13 patients (9 boys/4 girls; mean age 15.3 weeks) with suspected NAHI and bilateral SH. Six patients had MRI during acute admission (first week) and seven patients between 10 and 30 days after head trauma (mean 12.6 days). A total of 8/13 patients had spinal MRI. We assessed the distribution and signal intensity of SH, brain, epidural and spinal cord abnormalities. Our findings were compared to medico-legal investigations in 7/13 patients to evaluate the correlation between the age of SH on MRI and the date of injuries. RESULT: Lesions detected included cerebral edema, ischemia, contusions and cranio-cervical axonal injury and 2/8 patient had spinal epidural hematomas. Multiple SH with varying signal intensities were seen. The commonest location was the frontoparietal areas (100%) and suboccipital region (77%). In 5/6 cases, MRI during the acute admission revealed multiple and small SH having the same signal intensity. When MRI was performed later multiple SH of varying signal intensity were found in 54% of cases. We found a good correlation between the age of the SH and the date of suspected injuries in all cases. Nevertheless, in 5 patients, other SH of various ages were present suggesting rebleeding. CONCLUSION: Our findings confirm the value of MRI in the detection of brain and spinal cord lesions and SH of varying signal intensities in non accidental head injury. MRI is not able to predict whether different signal intensities correspond to spontaneous repeated bleedings or repeated injuries. The presence of these lesions without clinical evidence of accidental trauma justifies a medico-legal evaluation to confirm the diagnosis of child abuse and to protect these patients.

Subduroperitoneal drainage for subdural hematomas in infants: results in 244 cases.

OBJECT: Subduroperitoneal drainage (SDPD) is commonly used in the treatment of infantile subdural hematomas (SDHs). Few studies have focused on this technique and most series have included SDHs of various origins in children of different ages. The surgical procedure is not standardized and results achieved using this technique have not been well documented. The authors reviewed their cases of traumatic SDH treated with SDPD in infants (< 2 years of age). Their standard technique includes bilateral SDPD whenever the SDH is bilateral, placement of a free shunt, and systematic removal of the drainage unit after a few months. METHODS: The authors performed SDPD in 244 infants with traumatic SDH. The patients' SDHs were controlled by SDPD in 241 cases, and 78.9% of the patients recovered to live a normal life. Complications of SDPD occurred in 38 patients (15.6%): obstruction in 22 cases (9%), infection in eight cases (3.28%), and internal hydrocephalus in eight cases (3.28%). Early complications could be ascribed to surgical technique, delayed complications were associated with the severity of the initial clinical presentation, and late complications were time dependent and unrelated to initial clinical severity. Poor clinical outcome was correlated to the severity of the initial presentation, but not to complications of surgery. CONCLUSIONS: Because of its efficacy and low complication rate, SDPD is the procedure of choice when subdural taps fail to control SDH. The authors prefer bilateral drainage because of the low rate of complications. Drains should be systematically removed after a few months to prevent long-term complications.