title: Venous injury in abusive head trauma.
abstract: BACKGROUND
  Abusive head trauma (AHT) is an important cause of serious brain injury in infants and young children who have characteristic clinical and imaging findings that are discordant with the clinical history provided. Recent attention has focused on abnormalities of the cranial venous sinuses and cortical veins, both on MRI and at autopsy. Although many have interpreted these to be secondary to the AHT, some have recently argued that these venous abnormalities represent primary cortical sinus and venous thrombosis that leads secondarily to subdural hemorrhage and secondary brain injury. Direct trauma to the veins and sinuses has been reported at autopsy in AHT, but there has been no systematic study of venous abnormalities in cases of AHT.
  
  
  OBJECTIVE
  The purpose of this study was to define the incidence and characteristics of venous and sinus abnormalities in AHT.
  
  
  METHODS
  We included all children <36 months of age who were diagnosed with abusive head trauma between 2001 and 2012 and who had MRI and magnetic resonance (MR) venography as part of their diagnostic workup. We analyzed age, gender and clinical findings. MRI and MR venography were analyzed independently by two neuroradiologists with a focus on abnormalities involving the intracranial veins and venous sinuses.
  
  
  RESULTS
  A total of 45 children were included. The median age was 3 months (range 15 days to 31 months) and 28 were boys (62%). Clinical findings included retinal hemorrhage in 71% and extracranial fractures in 55%. CT or MRI demonstrated subdural hemorrhage in 41 (91%); none had subdural effusions. In 31 cases (69%) MR venography demonstrated mass effect on the venous sinuses or cortical draining veins, with either displacement or partial or complete effacement of the venous structures from an adjacent subdural hematoma or brain swelling. We also describe the lollipop sign, which represents direct trauma to the cortical bridging veins and was present in 20/45 (44%) children.
  
  
  CONCLUSIONS
  Evidence of displacement or compression of cortical veins and sinuses from subdural hemorrhage or edema on MR venography was present in the majority of children with abusive head trauma. Evidence of direct trauma to the veins (lollipop sign) was identified in nearly half of cases. It is important to understand the superimposed effects of subdural hematoma and brain swelling on the veins and sinuses to differentiate it from cortical sinus and venous thrombosis.
authors.affiliation: Department of Radiology, Nemours A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, USA. Arabinda.choudhary@nemours.org.
authors.forename: Arabinda K
authors.initials: AK
authors.lastname: Choudhary
authors.affiliation: Department of Radiology, Hershey Medical Center, Hershey, PA, USA.
authors.forename: Ray
authors.initials: R
authors.lastname: Bradford
authors.affiliation: Department of Neurosurgery, Hershey Medical Center, Hershey, PA, USA.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Dias
authors.affiliation: Department of Radiology, Hershey Medical Center, Hershey, PA, USA.
authors.forename: K
authors.initials: K
authors.lastname: Thamburaj
authors.affiliation: Department of Radiology, Hershey Medical Center, Hershey, PA, USA.
authors.forename: Danielle K B
authors.initials: DK
authors.lastname: Boal
mesh_terms: D001921:Brain / Q000473:pathology*; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000473:pathology*; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D018810:Magnetic Resonance Angiography; D008279:Magnetic Resonance Imaging; D008297:Male; D010690:Phlebography; D015203:Reproducibility of Results; D012189:Retrospective Studies
keywords: Abusive head trauma; Cortical veins; Infants; Magnetic resonance imaging; Magnetic resonance venography; Thrombosis; Venous sinuses