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      <h1 class="highwire-cite-title" id="page-title">Head Circumference: A Key Sign in Dating Abusive Head Trauma</h1>  
    	<div class="highwire-cite-authors"><span  class="highwire-citation-authors"><span class="highwire-citation-author first" data-delta="0">C. Adamsbaum</span> and <span class="highwire-citation-author" data-delta="1">C. Rey-Salmon</span></span></div>
  
    	<div class="highwire-cite-metadata"><span  class="highwire-cite-metadata-journal highwire-cite-metadata">American Journal of Neuroradiology </span><span  class="highwire-cite-metadata-date highwire-cite-metadata">May 2015,  </span><span  class="highwire-cite-metadata-volume highwire-cite-metadata">36 </span><span  class="highwire-cite-metadata-issue highwire-cite-metadata">(5) </span><span  class="highwire-cite-metadata-pages highwire-cite-metadata">E36; </span><span  class="highwire-cite-metadata-doi highwire-cite-metadata">DOI: https://doi.org/10.3174/ajnr.A4306 </span></div>
  
  
  
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<div id="hw-article-author-popups-top-node-13895--61627364378" style="display: none;"><div class="author-tooltip-0"><div class="author-tooltip-name">C. Adamsbaum </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>a</span>Faculté de Médecine
Université Paris Sud
Le Kremlin Bicêtre, France</div><div class='author-affiliation'><span class='nlm-sup'>b</span>Assistance Publique-Hôpitaux de Paris
Centre hospitalier universitaire Bicêtre
Service d'Imagerie Pédiatrique
Le Kremlin Bicêtre, France</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=C.%2BAdamsbaum%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Adamsbaum%20C&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AC.%2BAdamsbaum%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div><div class="author-tooltip-1"><div class="author-tooltip-name">C. Rey-Salmon </div><div class="author-tooltip-affiliation"><span class="author-tooltip-text"><div class='author-affiliation'><span class='nlm-sup'>c</span>Assistance Publique-Hôpitaux de Paris
Centre hospitalier universitaire Hôtel Dieu
Unité Médico-Judiciaire
Paris, France</div></span></div><ul class="author-tooltip-find-more"><li class="author-tooltip-gs-link first"><a href="/lookup/google-scholar?link_type=googlescholar&amp;gs_type=author&amp;author%5B0%5D=C.%2BRey-Salmon%2B" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on Google Scholar</a></li><li class="author-tooltip-pubmed-link"><a href="/lookup/external-ref?access_num=Rey-Salmon%20C&amp;link_type=AUTHORSEARCH" target="_blank" class="" data-icon-position="" data-hide-link-title="0">Find this author on PubMed</a></li><li class="author-site-search-link last"><a href="/search/author1%3AC.%2BRey-Salmon%2B" rel="nofollow" class="" data-icon-position="" data-hide-link-title="0">Search for this author on this site</a></li></ul></div></div></div>  </div>

  
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    <div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml" data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><p id="p-1">The article by Wittschieber et al<sup><a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a></sup> offers very interesting insights into subdural hygromas (SDHys) in the particular context of abusive head trauma (AHT).</p><p id="p-2">We definitely agree that any pericerebral subdural collections—that is, hygromas or chronic subdural hematomas (true evolution within a few weeks of a subdural hematoma)—should prompt pediatricians to strongly consider AHT if all other classic etiologies have been ruled out.</p><p id="p-3">We would, however, like to comment on the issue of dating the causal episode in cases of SDHy. The authors offered 2 possible concepts to explain SDHy formation: delayed formation as an intermediate stage of a subdural hematoma and rapid formation from a tear in the arachnoid membrane. The term “acute SDHy” is suggested for the latter case, which usually consists of both CSF and blood (giving it its so-called “mixed-attenuation” appearance). As a result, the mixed-attenuation pattern cannot be used to date the causal event. We agree with this completely.</p><p id="p-4">However, we disagree with the idea that in the context of violent acceleration-deceleration, an acute SDHy can occur without any hemorrhagic component and, therefore, present as a homogeneous hypoattenuated pattern such as that shown in Fig 3 of the article. In fact, consideration of the head circumference is of major importance. Figure 3 illustrates the case of an infant presenting with a sudden increase in head circumference—from the 50th to 90th percentile—in 1 month. We could hypothesize that the sudden increase in head circumference suggests the presence of a previous subdural hematoma, 1 month earlier, due to previous shaking. The small, hyperintense, subacute subdural hematoma in the posterior fossa, along with retinal hemorrhages, may indicate more recent bleeding due to a more recent shaking episode. Such an “age-different” pattern is important to recognize, given that shakings are often repeated.<sup><a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a></sup> In our opinion, the head circumference is a key sign—when available—that a subdural collection may be related to a previous subdural hematoma and therefore to a previous episode of shaking. Therefore, we disagree with the authors' conclusion that “the SDHy in this well-documented case can be regarded as a result of acute injury,” and we believe that this is a case of repeated shaking.</p><p id="p-5">Considering all previous clinical signs and symptoms, including head circumference, is crucially important when using imaging features to assess the “age-different” patterns of subdural collections.<sup><a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a></sup> This is not only a legal issue in the courts but also a key diagnostic sign for AHT.</p><div class="section ref-list" id="ref-list-1"><h2 class="">REFERENCES</h2><ol class="cit-list ref-use-labels"><li><span class="ref-label">1.</span><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1. in text" id="ref-1">↵</a>

<div class="cit ref-cit ref-journal" id="cit-36.5.E36.1" data-doi="10.3174/ajnr.A3989"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Wittschieber</span>  <span class="cit-name-given-names">D</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Karger</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Niederstadt</span>  <span class="cit-name-given-names">T</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Subdural hygromas in abusive head trauma: pathogenesis, diagnosis, and forensic implications</span>. <abbr class="cit-jnl-abbrev">AJNR Am J Neuroradiol</abbr> <span class="cit-pub-date">2015</span>;<span class="cit-vol">36</span>:<span class="cit-fpage">432</span>–<span class="cit-lpage">39</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiYWpuciI7czo1OiJyZXNpZCI7czo4OiIzNi8zLzQzMiI7czo0OiJhdG9tIjtzOjE5OiIvYWpuci8zNi81L0UzNi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">2.</span><a class="rev-xref-ref" href="#xref-ref-2-1" title="View reference 2. in text" id="ref-2">↵</a>

<div class="cit ref-cit ref-journal" id="cit-36.5.E36.2" data-doi="10.1542/peds.2009-3647"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Adamsbaum</span>  <span class="cit-name-given-names">C</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Grabar</span>  <span class="cit-name-given-names">S</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Méjean</span>  <span class="cit-name-given-names">N</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Abusive head trauma (AHT): judicial admissions highlight violent and repetitive shaking</span>. <abbr class="cit-jnl-abbrev">Pediatrics</abbr> <span class="cit-pub-date">2010</span>;<span class="cit-vol">126</span>:<span class="cit-fpage">546</span>–<span class="cit-lpage">55</span></cite></div><div class="cit-extra"><a href="/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MTA6InBlZGlhdHJpY3MiO3M6NToicmVzaWQiO3M6OToiMTI2LzMvNTQ2IjtzOjQ6ImF0b20iO3M6MTk6Ii9ham5yLzM2LzUvRTM2LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==" class="cit-ref-sprinkles cit-ref-sprinkles-ijlink"><span><span class="cit-reflinks-abstract">Abstract</span><span class="cit-sep cit-reflinks-variant-name-sep">/</span><span class="cit-reflinks-full-text"><span class="free-full-text">FREE </span>Full Text</span></span></a></div></div></li><li><span class="ref-label">3.</span><a class="rev-xref-ref" href="#xref-ref-3-1" title="View reference 3. in text" id="ref-3">↵</a>

<div class="cit ref-cit ref-journal" id="cit-36.5.E36.3" data-doi="10.1007/s00247-014-3171-1"><div class="cit-metadata"><ol class="cit-auth-list"><li>
</li><li><span class="cit-auth"><span class="cit-name-surname">Adamsbaum</span>  <span class="cit-name-given-names">C</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Morel</span>  <span class="cit-name-given-names">B</span></span>, </li><li><span class="cit-auth"><span class="cit-name-surname">Ducot</span>  <span class="cit-name-given-names">B</span></span>, <span class="cit-etal">et al</span></li></ol><cite>. <span class="cit-article-title">Dating the abusive head trauma episode and perpetrator statements: key points for imaging</span>. <abbr class="cit-jnl-abbrev">Pediatr Radiol</abbr> <span class="cit-pub-date">2014</span>;<span class="cit-vol">44</span>(<span class="cit-supplement">suppl 4</span>):<span class="cit-fpage">578</span>–<span class="cit-lpage">88</span></cite></div><div class="cit-extra"><a href="/lookup/external-ref?access_num=10.1007/s00247-014-3171-1&amp;link_type=DOI" class="cit-ref-sprinkles cit-ref-sprinkles-doi cit-ref-sprinkles-crossref"><span>CrossRef</span></a></div></div></li></ol></div><ul class="copyright-statement"><li class="fn" id="copyright-statement-1">© 2015 by American Journal of Neuroradiology</li></ul><span class="highwire-journal-article-marker-end"></span></div><span class="related-urls"></span></div></div>  </div>

  
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