Head injuries in children are common, accounting for 
about 600,000 or more ED visits annually.  CT is the 
method of choice for the evaluation of intracranial injury.  
It is useful in identifying epidural, subdural, 
subarachnoid and intracerebral hemorrhage.  MRI is not 
generally used acutely, but it may play a role in 
identifying more subtle injuries.  The purpose of this 
case is to describe the classic CT appearance of the 
various types of intracranial hemorrhages in children.  
Since each type of intracranial hemorrhage has a 
different prognosis and a different management 
approach, it is important to be able to distinguish their 
appearances on CT so that they can be best described 
to a consulting neurosurgeon.
     There is a fixed volume within the skull.  Head 
trauma causing bleeding or swelling on one side of the 
tentorium leads to increased pressure in that 
compartment.  To equalize the pressure there is a shift 
in volume leading to brain herniation.  It is important to 
be able to detect early edema so that therapy may be 
started for increased intracranial pressure to hopefully 
avert herniation.  Early brain edema on CT can be 
identified with a decrease in the size of the third 
ventricle and the basal cisterns.  With cerebral edema 
there is loss of the sulci, the lateral ventricles are small, 
and the brain (supratentorial) is hypodense.
     The different brain herniation syndromes are 
described in Case 6 of this volume.

Types of Intracranial Hemorrhages
     1.  Epidural hematoma
     2.  Subdural hematoma
     3.  Subarachnoid hematoma
     4.  Intracerebral hemorrhage
     5.  Intraventricular hemorrhage

     Epidural hematomas usually result from rupture of 
arteries and large superficial venous sinuses.  The 
incidence is 1% to 3% in patients hospitalized after 
head injury.  There is an underlying fracture in 60% to 
90% of the patients.  The prognosis is usually better 
than with subdural hematomas as the calvarium 
absorbs some of the force.  The brain is relatively 
spared.  There is no intradural injury in about 50% of 
the cases.  The mortality rate is 25% to 50%.  The 
middle meningeal artery is the most commonly injured 
vessel, in the temporal region 70% to 75% of the time.  
The epidural hematoma may subsequently lead to 
transtentorial herniation.  The classic description of 
symptoms includes a brief loss of consciousness, 
followed by a lucid period, and then neurologic 
deterioration (signs and symptoms of increased 
intracranial pressure).  These classic symptoms are 
present only 33% of the time.  With children, the classic 
symptoms are rare.  The extradural hemorrhage is 
often venous and loss of consciousness may be 
gradual.  In 50% of the cases of epidural hematomas in 
children, there is no underlying skull fracture.  In 
children 6 years and older the most common event 
causing an epidural hematoma is a blow to the side of 
the head, such as a fall off a bicycle.  CT is the method 
of choice to evaluate an epidural hematoma.  An acute 
epidural hematoma is described as biconvex (lentiform, 
elliptical, or football-shaped) in appearance.  The dura 
is closely applied to the inner table and, as the 
hematoma from the bleeding expands, the dura bulges 
inward, giving it the biconvex or lens-shaped 
appearance.  The dura is anchored at the suture lines 
so epidural hematomas generally do not cross sutures.  
They may extend across a venous sinus crossing the 
midline distinguishing it from a subdural hematoma.  
The treatment for most epidural hematomas is 
neurosurgical evacuation.

     A subdural hemorrhage may be caused from direct 
trauma, severe acceleration-deceleration trauma, or 
shaking injury.  The bleeding is from tearing of the 
cortical bridging veins.  The subdural hemorrhage may 
be bilateral and is frequently associated with diffuse 
brain injury.   The functional and structural brain 
damage is often much more severe than the degree of 
bleeding.  The incidence is 5% following head injury.  
After trauma it is 6-times more likely to have a subdural 
than epidural hematoma.  A skull fracture is found in 
only about 30% of cases.  The location is mostly 
supratentorial and along the brain convexity.  Less 
common locations are interhemispheric, subtemporal, 
and tentorial.
     Subdural hemorrhages have a poor prognosis with 
mortality rates between 60% to 90%.  If the patient has 
surgery within 4 hours of the initial injury the mortality 
rate drops to 30%.  The significant mortality rate is 
attributed to the high incidence of associated 
irreversible brain damage.  Typically a subdural 
hematoma is not an isolated finding, rather it is a 
component of more severe head injuries.  Associated 
conditions include focal or diffuse cerebral edema, 
diffuse axonal shearing, severe contusions, and 
epidural hematomas.  The signs of a subdural 
hematoma usually have a slower time course compared 
to an epidural hematoma.  The bleeding is not 
constrained by a tight dura and the clot has room to 
expand.  The patients may have similar symptoms to 
the classic epidural history.  Typically, there is history of 
head trauma accompanied by loss of consciousness, 
with some recovery but not completely back to normal.  
There are usually external signs of trauma and 
immediate loss of consciousness.  The patient may 
have a headache, pupillary dilation, personality change, 
stiff neck, seizure, vomiting, irritability, and low-grade 
fever.  Signs and symptoms of a subdural hematoma in 
an infant may include irritability, lethargy, a bulging 
fontanelle, and vomiting.
     In the pediatric population an acute interhemispheric 
subdural hematoma is most common.  This is usually 
due to shaking associated with child abuse (Shaken 
infant syndrome.  See Case 1 of Volume 1, Toxic Infant 
With a Full Fontanelle).  Subdural hematomas in the 
posterior fossa are rare, mostly occurring in neonates 
with birth trauma.  A subdural hematoma should be 
ruled-out in an infant with seizures following a difficult 
delivery.  With child abuse/shaken baby syndrome, 
children with subdural hematomas may present with 
coma, seizures, or other signs of increased intracranial 
pressure.  Chronic subdural hematomas are rare in 
children except in abused infants from 2 to 6 months.  
They may present with a history of recurrent vomiting, 
seizures, and may have retinal hemorrhages and a 
tense fontanelle.
     CT can identify the subdural hematomas and 
underlying brain injury that is commonly associated.  
The hematoma is described as crescent shape as it 
conforms to the calvarium and underlying cerebral 
cortex.  The blood with subdural hematomas extends 
freely along the convexity of the brain, rather than 
causing a localized inward bulge like epidural 
hematomas (subdurals are crescent shaped, while 
epidurals are biconvex; ie., lentiform, football shaped).  
Rarely a subdural hematoma may have a atypical 
configuration making it indistinguishable from an 
epidural hematoma.  This may occur with an abnormally 
shaped calvarium and/or loculation by fibrotic bands 
secondary to previous trauma or inflammation.  At 
times, the subdural hematoma may be relatively small 
on CT, and there may appear to be a disproportionately 
large mass effect.  The collection of blood is usually 
very extensively spread along the surface of the brain.  
As the hematoma ages, it becomes isodense with 
respect to the gray matter (7th - 21st day) and then 
hypodense.  Contrast enhancement may be needed to 
delineate subacute or chronic injury on CT.  Fresh 
blood tends to layer in the dependent portion of a 
subdural collection.  Tentorial hematomas are hard to 
distinguish from subarachnoid blood layering on the 
tentorium.  Coronal CT or MRI may be necessary for 
the diagnosis.  Coronal CT also facilitates diagnosis of 
subdural hematomas located in the middle cranial 
fossa, subtentorial region, and vertex.  The treatment 
for subdural hematomas is intensive medical therapy to 
control increased intracranial pressure, even with 
surgery.  The patient should have neurosurgical 
evaluation.  Surgery may not be necessary unless the 
hematoma is large or a significant factor in the 
increased intracranial pressure.  Subdural taps may be 
done in infants.

     Subarachnoid hemorrhage is the most common 
location for bleeding after an acute head injury.  The 
bleeding is usually venous rather than arterial in origin.  
Hemorrhage into the subarachnoid space results in 
bloody CSF on lumbar puncture.  Ruptured berry 
aneurysm is a classic cause of subarachnoid 
hemorrhage.  A common cause of subarachnoid 
hemorrhage in pediatric patients is shaken infant 
syndrome (see Case 1 of Volume 1, Toxic Infant With a 
Full Fontanelle).  While shaken infant syndrome 
generally results in the classic posterior 
interhemispheric subdural hematoma, there is 
hemorrhage into the subarachnoid space as well.  Such 
infants often present appearing toxic, and a lumbar 
puncture done to rule out meningitis will reveal 
homogeneously bloody CSF.
     Newborn intracranial hemorrhages associated with 
birth trauma are most commonly subarachnoid.  The 
patients may present with a stiff neck and lethargy.  
Often, the patient may be asymptomatic.  The most 
common symptom associated with either a 
subarachnoid or subdural hemorrhage in the newborn is 
development of seizures after 48 hours of life.
     Noncontrast CT will detect up to 90% of all 
subarachnoid bleeds within the first 24 hours regardless 
of etiology.  The initial CT should be done without 
contrast as contrast may obscure the presence of 
subarachnoid blood.  Subarachnoid hemorrhage is 
commonly seen in the basilar cisterns of patients 
following head trauma.  The basilar cisterns may 
appear denser or isodense to brain due to hemorrhage.  
Blood may accumulate in the cortical sulci making them 
more dense than the underlying cerebral cortex.  The 
suprasellar cistern should be examined carefully as 
small amounts of blood may collect around the skull 
base.  The falx and tentorium appear hyperdense on 
CT with subarachnoid hemorrhage.  The falx borders 
may be irregular or scalloped from blood entering into 
neighboring sulci.  The pseudodelta sign occurs when 
blood outlines the border of the dependent portion of 
the superior sagittal sinus.  On CT, subarachnoid 
hemorrhage may have a similar appearance with 
pronounced cerebral edema.  With cerebral edema, the 
brain is hypodense and the normal falx may appear to 
have increased density.  The cerebral tissue is usually 
of normal density with subarachnoid bleeding, and the 
dense falx should be examined closely for a scalloped 
appearance due to blood.  The treatment of 
subarachnoid hemorrhage is often medical rather than 
surgical.

     Intracerebral hematomas occur 1% to 2% of the 
time following head injury requiring hospitalization.  The 
most common locations are the anterior portion of the 
temporal lobe and the posterior portion of the frontal 
lobe.  The mortality rate is 55%.  The brain substance 
may become necrotic and the temporal lobe may 
become edematous and herniate through the tentorium.  
Intracerebral hematomas are uncommon in children.  
Blood in the parenchyma is usually the result of severe 
focal injury or penetrating trauma.  The prognosis is 
poor, with a high risk of developing increased 
intracranial pressure and cerebral herniation or severe 
neurologic compromise.  A delayed traumatic 
intracerebral hematoma may develop 48 hours to 72 
hours after an injury.  The initial CT scan may show an 
area of cerebral contusion.  If the patient suddenly 
deteriorates neurologically, a repeat CT scan should be 
done.  The intracerebral hematoma may be surgically 
drained.  These patients are followed closely in the ICU 
usually with fluids at 2/3 maintenance.

     Intraventricular hemorrhage has an incidence of 3% 
to 35% of patients with head injury.  The most common 
etiology is the rupture of subependymal veins.  This is 
due usually to rotational forces.  Injury to the corpus 
callosum commonly occurs.  Intraventricular 
hemorrhage is usually caused by extension of an 
intraparenchymal bleed if the corpus callosum is not 
injured.  The blood is most commonly in the lateral 
ventricles.  Rare causes of cerebrovascular disease in 
children may predispose one to acute intraventricular 
hemorrhage.

Case Examples
     Review the following CT scan images.  Each is an 
example of a type of intracranial hemorrhage.  Click on 
each letter and review the interpretations below.



Case A

     This CT shows a right frontal epidural hematoma.  
There is the classic biconvex (lentiform or football) 
shaped appearance with the dura bulging inward.  



Case B

     This is a 2-year old male who fell from a couch to 
the tile floor.  There is no history of loss of 
consciousness.  The CT shows a right parietal epidural 
hematoma.  The hematoma is biconvex or lens-shape 
in appearance.  There is a midline shift to the left.



Case C
[C1 below]


[C2 below]

     This is a 9-month old female with history of closed 
head trauma the day prior.  She presented with 
increasing lethargy, emesis, and a right sided scalp 
hematoma.
     [C1] The CT scan reveals a right temporo-parietal 
epidural hematoma with considerable shift of the 
midline structures from right to left.  There is a 
non-depressed right parietal skull fracture overlying the 
epidural hematoma.  There is compression of the right 
lateral ventricle.
     [C2]  These are lower cuts (from lowest to highest 
cuts:
     Left upper:  Five-pointed star of the suprasellar 
cistern is fairly well preserved.  Fourth ventricle 
posterior to this.
     Right upper:  Six-pointed star of the suprasellar 
cistern is shown.  The right uncus is pushing into the 
suprasellar cistern (early uncal herniation).  Fourth 
ventricle posterior to this.
     Left lower:  Quadrigeminal cistern is compressed.  
Right lateral ventricle compressed.  Midline shift to the 
left.
     Right lower:  The right epidural hematoma is visible.  
The ipsilateral ventricle is compressed.  Midline shift to 
the left.



Case D

     This is a 7-year old male with history of hemophilia.  
This CT shows a subdural hematoma over the left 
parietal and occipital lobes causing a moderate mass 
effect and slight deviation of the midline.  This 
hematoma follows along the convexity of the brain 
(crescent shaped).  The suprasellar cistern is fairly well 
preserved.  The quadrigeminal cistern is within normal 
limits.
     The following views are shown (highest to lowest):
     Left upper:  Left subdural hematoma with overlying 
soft tissue swelling.  Ipsilateral ventricular compression.  
Midline shift to right.
    Right upper:  Quadrigeminal cistern size within 
normal limits.
     Left lower:  Six-sided star of the suprasellar cistern 
fairly well preserved.  Compression of the 
quadrigeminal cistern.
     Right lower:  Six-sided star of the suprasellar 
cistern.  Fourth ventricle located posterior to the 
suprasellar cistern.




Case E

     This is a 4-month old with suspected shaken baby 
syndrome.  The CT shows frontal subacute (or chronic) 
subdural effusions with an acute right temporo-parietal 
subdural hematoma.  There is probably a small amount 
of blood in the interhemispheric fissure posteriorly.  The 
posterior interhemispheric subdural hematoma is felt to 
be indicative of shaken baby syndrome unless other 
explanations of severe trauma can account for the 
findings. 



Case F

     This is an 8-month old male who fell down 6 stairs 
while in a walker.  He had a brief loss of consciousness 
and an episode of emesis.  There is a focal extra-axial 
(probably epidural, possibly subdural) hematoma over 
the right frontal and parietal cortex with minimal mass 
effect.  There is no fracture.



Case G

     This is a 21-month old female admitted to the PICU.  
There is history of previous injuries including a left 
clavicle fracture and greenstick fracture of the distal 
portion of the shaft of the left radius and ulna.  The CT 
shows an acute subdural hematoma in the right 
fronto-temporal region.  There is compression of the 
right lateral ventricle with shift of the midline structures 
from right to left.  This hematoma is crescent shaped as 
classically described with subdural hematomas.



Case H
[H1 below]


[H2 below]

     This is a 14-month old male with history of a closed 
head injury.  He clinically is bradycardic and has dilated 
pupils.
     [H1] These CT cuts (without contrast) show 
hypodensity of the cerebral hemispheres with loss of 
white-gray matter differentiation suggesting cerebral 
edema.  The ventricles are slit-like and the 
subarachnoid spaces are obliterated, suggesting 
cerebral edema and ICP elevation.  There is blood in 
the interhemispheric regions, posteriorly and anteriorly.
     [H2] There is subarachnoid hemorrhage in the basal 
cisterns (suprasellar cistern and quadrigeminal cistern), 
posterior fossa, and interhemispheric fissure.  The 
suprasellar cistern and the quadrigeminal cisterns are 
obliterated, indicating severe intracranial hypertension.



Case I

     This is a 6-year old male with a closed head injury.  
He collided with a moving while van riding his bicycle 
without a helmet.  There is a small amount of blood in 
the occipital horns of the lateral ventricles.  There is a 
moderate amount of subarachnoid hemorrhage in the 
posterior fossa which is more extensive on the left.  
There is a small amount of subarachnoid or subdural 
hemorrhage in the posterior interhemispheric fissure.
     The left image shows the six-sided star of the 
suprasellar cistern which is well preserved.  The center 
image shows a well preserved quadrigeminal cistern.


Case J

     This is a 7-year old female involved in a motor 
vehicle accident.  There is extensive subarachnoid 
hemorrhage with a mild degree of lateral and third 
ventricular dilation.  Blood/CSF levels are visible in the 
occipital horns of the lateral ventricles.  The left image 
shows a moderate amount of blood in the fourth 
ventricle (This may look like the quadrigeminal cistern, 
but it is too low.  The quadrigeminal cistern is visible in 
cuts above the suprasellar cistern, not below the 
suprasellar cistern).  The center image shows blood in 
the five-pointed star of the suprasellar cistern.  The right 
view shows blood in the posterior interhemispheric 
space.



Case K

     This is a 3-week old dropped three feet by an older 
sister.  The patient "stopped breathing" on impact and 
was cyanotic.  There is a questionable history of 
seizure activity.  The CT shows a small amount of blood 
on the surface of the brain in both parietal regions and 
in the posterior interhemispheric fissure.  The blood is 
probably both subarachnoid and subdural in location.  
The findings are suspicious for shaken baby syndrome.



Case L

     Severe bilateral intraventricular hemorrhage.  The 
left image shows an obliterated suprasellar cistern.  The 
center image shows an obliterated (or blood filled) 
quadrigeminal cistern.  The right view shows ventricular 
dilatation.



Case M

     There is a left subdural hematoma.  There is soft 
tissue swelling noted over the left scalp.  There is a 
midline shift to the right.  There is compression of the 
ipsilateral lateral ventricle and dilatation of the 
contralateral lateral ventricle.  The left image shows an 
obliterated suprasellar cistern.  The center image shows 
a severely compressed quadrigeminal cistern that is 
pushed posteriorly.  The right image shows probable 
subfalcine herniation (herniation under the falx, refer to 
Case 6 of this volume).


Case N

     Severe bilateral intraventricular hemorrhage.  The 
left image shows obliterated suprasellar and 
quadrigeminal cisterns (or blood filled).


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