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Shaken Baby Syndrome.

Yen-Hung Liu 1, Chia-Ching Chen 2

1Department of Emergency Medicine, China Medical University Hospital

2Department of Emergency Medicine, Losheng Sanatorium and Hospital

INTRODUCTION

Although CT is the most common initial imaging study of head injuries, an open anterior fontanelle in infants makes cranial ultrasonography a feasible imaging option.

The CT scan is currently the standard examination for diagnosing intracranial hemorrhage.

However, high-dose radiation exposure is a concern.

Ultrasound is an immediate, noninvasive, radiation-free tool for initially inspecting intracranial changes in infants without fontanelle closure.

If a significant blood clot or brain edema is detected, a more aggressive procedure is necessary.

We discuss a case of shaken baby syndrome diagnosed by POCUS.

CASE PRESENTATION

A 5-month-old infant presented to the emergency department with a 5-hour history of reduced consciousness and low-grade fever.

According to family statement, he had sudden onset drowsy consciousness and general malaise since 5 hours ago.

His family denied he had common cold symptoms, diarrhea or vomiting before this episode. His family also denied he had trauma history.

In the physical examination, left-side pupil dilatation to 4 mm was noted, and right-side muscle power declined.

Point-of-care ultrasound of the anterior fontanelle revealed a left subdural hyperechoic space-occupying lesion with midline shift which subdural hemorrhage was suspected. Brain sulcus was compressed by this subdural hemorrhage revealed blurred edges of sulcus.

Computed tomography (CT) scan of the brain revealed a 6.1-mm subdural hemorrhage at the left parietal lobe with midline shift.

Child abuse may happened due to these findings meet to the criterion of shaken baby syndrome. Emergent craniotomy and hematoma removal were arranged for this infant.

He was discharged with clear consciousness but with slightly reduced right-side muscle strength.

DISCUSSION

Head trauma is the most common cause of death in childhood. Most of these children are classified as cases of mild head injury, which is defined as a Glasgow Coma Scale (GCS) score of 13–15.

Due to the huge number of patients and low frequency of intracranial lesions in this group, obtaining a computed tomography (CT) for each and every patient is both a public health issue.

Some studies also pointed CT scan may increase risk of brain tumor and leukemia.

However, the noninvasiveness of ultrasound have made it an ideal portable bedside method for investigation of CNS lesions in young infants without above concerned.

Cranial ultrasound is popular in pediatric neurologic field, but it still less used in emergency department due to some limitations like operator skills, equipment, or small fontanelle. Acute convexity subdural hematomas were hyperechoic and subacute hematomas variable, ranging from moderately echogenic to anechoic, depending on the contents of the hematoma.

Chronic subdural hematomas were anechoic. In our case, hyperechoic subdural fluid accumulation was noted which revealed fresh blood clot. Although families denied the history of trauma, child abuse still should be concerned. But sometimes we should notice the low specificity of ultrasound in differentiating a chronic subdural hematoma from a subdural hygroma or reactive effusion in infants with meningitis, because these pericerebral collections are also anechoic.

Physical examinations and history taking are still cornerstone of diagnosis in these patients. In the future, cranial ultrasound might be the first choice for screen young infants with mild head injury because of its advantages.

REFERENCES

1.Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012;380:499–505.

2. Chen CY, Chou TY, Zimmerman RA, Lee CC, Chen FH, Faro SH (1996) Pericerebral fluid collection: differentiation of enlarged subarachnoid spaces from subdural collections with color Doppler US. Radiology 201: 389±392

3. Nonaccidental head injury in infants—the “shaken-baby syndrome.”. N Engl J Med. 1998; 338: 1822–1829

4. Fall or shaken: traumatic brain injury in children caused by falls or abuse at home—a review on biomechanics and diagnosis. Neuropediatrics. 2005;36: 240–245

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