Between 2013 and 2022, 38 patients under the age of 2 years were referred to the Department of Neurosurgery at Bethlehem Garden Hospital with symptoms attributable to an acute subdural hematoma (SDH). The full clinical data on the patients, their CT (in some cases also MRI) findings, and interview records were analyzed. Fifteen of the patients received the diagnosis of IASDH, which was originally defined as an acute subdural hematoma in infants caused by minor head trauma without loss of consciousness or any associated cerebral contusion [2]. Patients thought to have AHT based on an evaluation by a multidisciplinary team, including a child abuse pediatrician, were excluded. Mild-type IASDH was diagnosed in eight of the 15 infants based on their normal consciousness status, absence of motor disturbances, and the presence of vomiting and/or irritability on admission [2]. After excluding four patients who were not evaluated by MRI, the remaining four patients with long-term follow-up (> 5 years) were analyzed. Table 1 shows the details of their history.
Case 1
An 8-month-old male patient with no significant medical history fell backward while trying to stand and struck his occipital area against a carpeted floor. The infant immediately began crying. While holding him in her arms, his mother noted signs of altered consciousness, seizure-like activities, including an upward gaze, and tremor of the left arm followed by generalized tonic convulsion. The infant was taken to a nearby emergency room.
When the physician began to examine the patient, he cried again and displayed purposeful movement in all his extremities. A standard, general physical examination revealed no abnormalities. Although the patient returned to baseline on the same day, emergency CT revealed SDH on the left side (Fig. 1), prompting an ophthalmological examination, which found bilateral multiple, multilayered retinal hemorrhages (RH). The infant was admitted for further observation and underwent MRI on hospital day 12, which revealed a thin, film-like, high-intensity SDH on the left cerebral convexity. (Fig. 1)
No mass effect or parenchymal abnormality was observed. At his ten-year follow-up examination, the patient had normal development with no deficits.
Case 2
A 10-month-old male infant who began walking fell and struck his occipital region on a floor covered by a 15 mm-thick carpet while trying to steady himself by grabbing a table leg. The scene was witnessed by his mother and grandparents who were sitting in front of the patient at the time. The infant immediately began crying. While his mother held him in her arms to comfort him, he lost consciousness and exhibited seizure-like activity, including an upward gaze and tremor of the left upper extremities followed by a generalized tonic seizure. He was taken to an emergency room where he seemed alert and noted to return to baseline. Although no neurological abnormalities or external signs of trauma were observed, CT revealed a thin SDH with mixed density on the right side. Fundoscopy on the same day found bilateral multiple, multilayered RH. The infant was admitted for further observation for ten days without presenting any neurological abnormalities. MRI on day 3 revealed an SDH on the left side and a posterior interhemispheric fissure. No mass effect or parenchymal abnormality was noted. (Fig. 3)
During the observation at the hospital, the infant was asymptomatic. The subsequent outpatient follow-up for 9 years showed normal development.
Case 3
A 7-month-old male infant with no significant medical history fell backwards from a seated position and struck his occipital region on a cushion mattress. The event was witnessed by his parents, who happened to be in front of the patient. The infant began crying immediately upon striking his head. His father held him in his arms and noted altered consciousness, upward deviation of both eyes, cyanosis and flaccidity of the body. The infant was taken by ambulance to the emergency department. Enroute to the hospital, he regained consciousness and returned to baseline. In the emergency room, a pediatrician identified a thin SDH with a maximum thickness of 2 mm on CT (Fig. 4) and decided to admit the patient for continued observation. No neurological abnormalities or external signs of trauma were noted. Two days after admission, fundoscopy revealed multiple multilayered RH on both sides. A full skeletal survey, including a 3-D cervical spinal CT, revealed no abnormalities. MRI performed 19 days after symptom onset revealed a thin, film-like, high-intensity SDH on the right side. No mass effect or parenchymal abnormality was observed. His clinical course was unremarkable, and the patient showed normal development at regular follow-up visits over six years.
Case 4
A 6-month-old male infant with no significant medical history fell backward while trying to stand up in the living room and hit the occipital region on a carpeted floor. The infant began crying on impact and soon thereafter had vomiting incessantly. After signs of irritability appeared, the infant was taken to a nearby hospital where a physical examination failed to find any abnormalities. However, the physician referred the infant to a pediatric hospital where CT was performed at the mother’s request, and an acute, low-density SDH on the left side was disclosed. (Fig. ５) Although no neurological abnormalities or external signs of trauma were noted, the infant was admitted for continued observation.
On the day of admission, vomiting and irritability subsided, and the subsequent clinical course was uneventful. Two days after admission, fundoscopy revealed multiple, multilayered RH on both sides. MRI performed 11 days after symptom onset revealed a thin, high-intensity SDH on the right side. No mass effect or parenchymal abnormality was noted. (Fig. ５)
The patient achieved normal developmental milestones over 5 years of regular follow-up visits.