Background/Aim: Benign enlargement of subarachnideal space (BESS) is a known risk factor for subdual hematoma after minor or no head injury (spontaneous bleeding), but a subdural hematoma is also a major imaging finding in abusive head trauma. To distinguish between the pathogeneses and to also consider further underlying congenital or acquired disorders is a diagnostic challenge.
Method/Case Report: We present a case of a 6-month-old boy with rapidly growing head evident during routine examination (U4) who was referred for further evaluation of mild ventriculomegaly in cranial ultrasound and because of transitory and mild symptoms of emesis and fuzziness during the last weeks. Physical examination showed no abnormalities except for the head circumference at the 97th percentile (47 cm) which jumped from 45 cm (90th percentile) in 4 weeks.
Parents remembered a minor head trauma ∼4 weeks ago. The patient fell from the couch on the floor. During a follow-up visit, a bruise on the right cheek was noticed.
Results: Cranial ultrasound showed a subdural hematoma on the left side and BESS throughout. Cranial magnetic resonance imaging (MRI) supported ultrasound findings. Resorption of the left-sided subdural hemorrhage was shown on the following ultrasound studies.
A control MRI 2 months later could demonstrate a new subdural hematoma on the right side. MRI ruled out any hemorrhagic shearing lesions due to posttraumatic diffuse axonal injury. Skeletal survey was negative.
Ophthalmologic examination showed no retinal hemorrhages on fundoscopy. Screening for organic acids in urine showed no signs for a glutaric aciduria I. Coagulation work-up was negative initially but revealed a reduced factor VIII (chromogen) of 35% 2 months later. Genetic testing showed a hemizygote missense mutation (c.396A>C for p.Glu132Asp) on exon 4 of the F8 gene.
Conclusion: Subdural bleeding is often synonymous with nonaccidental head injury but without the presence of concurrent suspicious injuries, we explained the subdural hemorrhage with tearing of bridge veins due to BESS and the minor head trauma reported by the parents.
Thus, child protective service was not informed. However, when the second hemorrhage occurred, we informed child protective service with a high suspicion for child abuse. Simultaneously, the coagulation work-up was repeated because of implausible results the first time and let to the final diagnosis of a mild hemophilia A explaining both subdural hemorrhages and the cheek bruise. As of now, a secondary prophylaxis is not in place. This case demonstrates the difficulty to decide which trauma is caused by child abuse and when to involve authorities to protect the child but not unrightfully harm the family. Though staying suspicious with every nonaccidental injury, we advise to always do a thorough work-up for underlying congenital or acquired disorders.
