Age: 9 months
Sex: Male
Indication: Concern for nonaccidental trauma
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Case #15
Findings
- Diffuse patchy T2/FLAIR hyperintensity involving the bilateral cerebral hemispheres, basal ganglia, and cerebellum
- Diffuse gyral swelling with generalized cerebral sulcal effacement, downward transtentorial herniation with effacement of the basal cisterns, and cerebellar tonsillar herniation with crowding at the foramen magnum
- Thin bilateral T1 hyperintense subdural collections along the cerebral convexities and interhemispheric falx with associated susceptibility artifact
- Trace susceptibility artifact within right greater than left cerebral sulci, which is focally thicker over the right parietal region
- Mixed T1/T2 signal material layering in the vitreous chamber of the right globe with associated susceptibility artifact
- Small right greater than left mastoid effusions
Diagnosis
- Hypoxic-ischemic encephalopathy (child) with retinal hemorrhage
Sample Report
Constellation of findings is highly concerning for nonaccidental trauma.
Profound cerebral and cerebellar edema with involvement of the bilateral basal ganglia. Associated mass effect with generalized cerebral sulcal effacement, downward transtentorial herniation with effacement of the basal cisterns, and cerebellar tonsillar herniation with crowding at the foramen magnum.
Thin bilateral subdural hematomas along the cerebral convexities and interhemispheric falx and scattered small volume sulcal subarachnoid hemorrhage. Focally thicker susceptibility artifact along the right parietal convexity could represent a thrombosed/disrupted cortical vein.
Vitreous hemorrhage layering in the right globe.
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