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

Acta Neurochirurgica (2022) 164:1161–1172

Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises.

Methods The 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.

Results Twenty-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).

Conclusions BEH 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.

Management of subdural hygromas associated with arachnoid cysts

Subdural hygromas associated with cysts

J Neurosurg Pediatrics 12:434–443, 2013

Arachnoid cysts may occasionally be associated with subdural hygromas. The management of these concurrent findings is controversial.

Methods. The authors reviewed their experience with arachnoid cysts and identified 8 patients with intracranial arachnoid cysts and an associated subdural hygroma. The medical records and images for these patients were also examined.

Results. In total, 8 patients presented with concurrent subdural hygroma and arachnoid cyst. Of these 8 patients, 6 presented with headaches and 4 had nausea and vomiting. Six patients had a history of trauma. One patient was treated surgically at the time of initial presentation, and 7 patients were managed without surgery. All patients experienced complete resolution of their presenting signs and symptoms.

Conclusions. Subdural hygroma may lead to symptomatic presentation for otherwise asymptomatic arachnoid cysts. The natural course of cyst-associated subdural hygromas, even when symptomatic, is generally benign, and symptom resolution can be expected in most cases. The authors suggest that symptomatic hygroma is not an absolute indication for surgical treatment and that expectant management can result in good outcomes in many cases.

Subdural Hematoma in Patients With Cancer

Neurosurgery 71:74–79, 2012 DOI: 10.1227/NEU.0b013e3182517938

Subdural hematoma (SDH) in patients with cancer is poorly described, and its frequency and causes may have changed with recent oncologic advances.

OBJECTIVE: We conducted an analysis of the clinical and radiographic features, etiologies, treatments, and outcomes of patients with SDHs and cancer.

METHODS: We retrospectively identified patients at Memorial Sloan-Kettering Cancer Center with a diagnosis of SDH and cancer from January 2000 to December 2007. We analyzed clinical and radiographic data; multivariate Cox regression was performed to associate tumor type and etiology with survival outcome.

RESULTS: There were 90 patients; 66 had acute or subacute SDHs, 9 chronic SDHs, 11 subdural hygromas, and 4 SDHs of unclear chronicity. Gliomas (16%), leukemias (14%), and prostate cancers (14%) were the most frequent malignancies. The most common single etiologies were coagulopathy (27%) and trauma (11%). SDHs with multiple etiologies occurred in 25 patients (28%) with the combination of coagulopathy and trauma occurring in 15. Sixty patients (67%) were either completely or partially independent after SDH, and 1-year survival was 43% (95% confidence interval: 32.1-52.9). Overall survival correlated with etiology (P , .0001) and whether the malignancy was in remission (P = .005). Trauma was associated with the best overall survival compared with coagulopathy.

CONCLUSION: Leukemia and prostate cancer are the most common systemic cancers associated with SDH, and gliomas may predispose to SDH more often than previously recognized. Coagulopathy is common and associated with the worst outcome, but many patients experience good functional outcome and survival.

Interhemispheric hygroma after decompressive craniectomy: does it predict posttraumatic hydrocephalus?

Journal of Neurosurgery, June 2010. DOI: 10.3171/2010.4.JNS10132

The aim of this study was to determine the incidence of posttraumatic hydrocephalus in severely head-injured patients who required decompressive craniectomy (DC). Additional objectives were to determine the relationship between hydrocephalus and several clinical and radiological features, with special attention to subdural hygromas as a sign of distortion of the CSF circulation.

Methods The authors conducted a retrospective study of 73 patients with severe head injury who required DC. The patients were admitted to the authors’ department between January 2000 and January 2006. Posttraumatic hydrocephalus was defined as: 1) modified frontal horn index greater than 33%, and 2) the presence of Gudeman CT criteria. Hygromas were diagnosed based on subdural fluid collection and classified according to location of the craniectomy.

Results Hydrocephalus was diagnosed in 20 patients (27.4%). After uni- and multivariate analysis, the presence of interhemispheric hygromas (IHHs) was the only independent prognostic factor for development of posttraumatic hydrocephalus (p < 0.0001). More than 80% of patients with IHHs developed hydrocephalus within the first 50 days of undergoing DC. In all cases the presence of hygromas preceded the diagnosis of hydrocephalus. The IHH predicts the development of hydrocephalus after DC with 94% sensitivity and 96% specificity. The presence of an IHH showed an area under the receiver-operator characteristic of 0.951 (95% CI 0.87–1.00; p < 0.0001).

Conclusions Hydrocephalus was observed in 27.4% of the patients with severe traumatic brain injury who required DC. The presence of IHHs was a predictive radiological sign of hydrocephalus development within the first 6 months of DC in patients with severe head injury.