European Radiology

, Volume 25, Issue 2, pp 299–305 | Cite as

Imaging of bridging vein thrombosis in infants with abusive head trauma: the “Tadpole Sign”.

  • Maria L. Hahnemann
  • Sonja Kinner
  • Bernd Schweiger
  • Thomas Bajanowski
  • Bernd Karger
  • Heidi Pfeiffer
  • Daniel WittschieberEmail author



Abusive head trauma (AHT) in infants is usually diagnosed using a multi-disciplinary approach by investigating the circumstances and identifying morphological indicators, for example, subdural hematomas (SDHs), subdural hygromas (SDHys), retinal haemorrhages and encephalopathy. The present morphological study investigates the incidence, radiological characteristics and non-radiological co-factors of bridging vein thrombosis (BVT) in infants with AHT.


From 2002 to 2013, computed tomography (CT) and magnetic resonance imaging (MRI) material of 628 infants aged 0-2 years were analysed retrospectively. If available, medicolegal expert opinions were additionally considered. Cases with SDHs and/or SDHys were identified and systematically evaluated as to the presence and characteristics of BVT.


SDHs and/or SDHys were present in 29 of the 81 cases exhibiting morphological abnormalities in the initial CT. Among these, 11 cases (40 %) had BVT (mean age = 5.0 months). BVT could be best depicted in the T1-weighted spin echo and T2*/susceptibility-weighted MRI. In one case, BVT could be depicted indirectly using time-of-flight MR venography. The predominant (73 %) BVT shape was found to be tadpole-like (“Tadpole Sign”).


In the absence of appropriate accidental trauma, BVT appears to be a strong indicator of AHT. Therefore, the BVT/Tadpole Sign represents compelling cause to search for other signs of AHT.

Key points

BVT is an excellent indicator of AHT in SDH/SDHy cases.

Accidental trauma must be ruled out before diagnosing AHT.

The Tadpole Sign appears to be the most characteristic shape of BVT.

BVT can be depicted using CT, MRI and MR venography.

The Tadpole Sign suggests searching for other signs of AHT.


Bridging vein thrombosis Abusive head trauma Subdural hematoma Subdural hygroma Paediatric neuroradiology 



Abusive head trauma


Shaken baby syndrome


Subdural hematoma


Subdural hygroma


Bridging vein


Bridging vein thrombosis


Computed tomography


Magnetic resonance imaging


Retinal haemorrhages


Craniocerebral injury



The scientific guarantor of this publication is Daniel Wittschieber, MD. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. Approval from the institutional animal care committee was not required because the study did not use any animals. No study subjects or cohorts have been reported previously. Methodology: retrospective, diagnostic study / observational study, performed at one institution.


  1. 1.
    American Academy of Pediatrics: Committee on Child Abuse and Neglect (2001) Shaken baby syndrome: rotational cranial injuries-technical report. Pediatrics 108:206–210CrossRefGoogle Scholar
  2. 2.
    Duhaime AC, Christian CW, Rorke LB, Zimmerman RA (1998) Nonaccidental head injury in infants–the "shaken-baby syndrome". N Engl J Med 338:1822–1829PubMedCrossRefGoogle Scholar
  3. 3.
    Jayawant S, Rawlinson A, Gibbon F et al (1998) Subdural haemorrhages in infants: population based study. BMJ 317:1558–1561PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Barlow KM, Minns RA (2000) Annual incidence of shaken impact syndrome in young children. Lancet 356:1571–1572PubMedCrossRefGoogle Scholar
  5. 5.
    Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH (2003) A population-based study of inflicted traumatic brain injury in young children. JAMA 290:621–626PubMedCrossRefGoogle Scholar
  6. 6.
    Hobbs C, Childs AM, Wynne J, Livingston J, Seal A (2005) Subdural haematoma and effusion in infancy: an epidemiological study. Arch Dis Child 90:952–955PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Talvik I, Metsvaht T, Leito K et al (2006) Inflicted traumatic brain injury (ITBI) or shaken baby syndrome (SBS) in Estonia. Acta Paediatr 95:799–804PubMedCrossRefGoogle Scholar
  8. 8.
    Fanconi M, Lips U (2010) Shaken baby syndrome in Switzerland: results of a prospective follow-up study, 2002-2007. Eur J Pediatr 169:1023–1028PubMedCrossRefGoogle Scholar
  9. 9.
    Matschke J, Herrmann B, Sperhake J, Körber F, Bajanowski T, Glatzel M (2009) Shaken baby syndrome: a common variant of non-accidental head injury in infants. Dtsch Arztebl Int 106:211–217PubMedCentralPubMedGoogle Scholar
  10. 10.
    Christian CW, Block R (2009) Committee on Child Abuse and Neglect; American Academy of Pediatrics. Abusive head trauma in infants and children. Pediatrics 123:1409–1411PubMedCrossRefGoogle Scholar
  11. 11.
    Wittschieber D, Karger B, Niederstadt T, Pfeiffer H, Hahnemann ML (2014) Subdural hygromas in abusive head trauma: pathogenesis, diagnosis and forensic implications. AJNR Am J Neuroradiol. doi: 10.3174/ajnr.A3989 PubMedGoogle Scholar
  12. 12.
    Yamashima T, Friede RL (1984) Why do bridging veins rupture into the virtual subdural space? J Neurol Neurosurg Psychiatry 47:121–127PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Morrison CN, Minns RA (2005) The biomechanics of shaking. In: Minns RA, Brown JK (eds) Shaking and other non-accidental head injuries in children. Mac Keith Press, London, pp 106–146Google Scholar
  14. 14.
    Nierenberger M, Wolfram-Gabel R, Decock-Catrin S et al (2013) Investigation of the human bridging veins structure using optical microscopy. Surg Radiol Anat 35:331–337PubMedCrossRefGoogle Scholar
  15. 15.
    Minns RA (2014) Non-accidental head injury in children. In: Madea B (ed) Handbook of forensic medicine. Wiley Blackwell, Chichester, pp 702–724CrossRefGoogle Scholar
  16. 16.
    Norman MG, Smialek JE, Newman DE, Horembala EJ (1984) The postmortem examination on the abused child. Pathological, radiographic, and legal aspects. Perspect Pediatr Pathol 8:313–343PubMedGoogle Scholar
  17. 17.
    Maxeiner H (1997) Detection of ruptured cerebral bridging veins at autopsy. Forensic Sci Int 89:103–110PubMedCrossRefGoogle Scholar
  18. 18.
    Maxeiner H (2001) Demonstration and interpretation of bridging vein ruptures in cases of infantile subdural bleedings. J Forensic Sci 46:85–93PubMedGoogle Scholar
  19. 19.
    Ehrlich E, Maxeiner H, Lange J (2003) Postmortem radiological investigation of bridging vein ruptures. Legal Med (Tokyo) 5:225–227CrossRefGoogle Scholar
  20. 20.
    Stein KM, Ruf K, Ganten MK, Mattern R (2006) Representation of cerebral bridging veins in infants by postmortem computed tomography. Forensic Sci Int 163:93–101PubMedCrossRefGoogle Scholar
  21. 21.
    Depreitere B, Van Lierde C, Sloten JV et al (2006) Mechanics of acute subdural hematomas resulting from bridging vein rupture. J Neurosurg 104:950–956PubMedCrossRefGoogle Scholar
  22. 22.
    Han H, Tao W, Zhang M (2007) The dural entrance of cerebral bridging veins into the superior sagittal sinus: an anatomical comparison between cadavers and digital subtraction angiography. Neuroradiology 49:169–175PubMedCrossRefGoogle Scholar
  23. 23.
    Monea AG, Baeck K, Verbeken E et al (2014) The biomechanical behaviour of the bridging vein-superior sagittal sinus complex with implications for the mechanopathology of acute subdural haematoma. J Mech Behav Biomed Mater 32:155–165PubMedCrossRefGoogle Scholar
  24. 24.
    Squier W, Mack J (2009) The neuropathology of infant subdural haemorrhage. Forensic Sci Int 187:6–13PubMedCrossRefGoogle Scholar
  25. 25.
    Barlow KM, Gibson RJ, McPhillips M, Minns RA (1999) Magnetic resonance imaging in acute non-accidental head injury. Acta Paediatr 88:734–740PubMedCrossRefGoogle Scholar
  26. 26.
    Adamsbaum C, Rambaud C (2012) Abusive head trauma: don't overlook bridging vein thrombosis. Pediatr Radiol 42:1298–1300PubMedCrossRefGoogle Scholar
  27. 27.
    Yilmaz U, Körner H, Meyer S, Reith W (2014) Multifocal signal loss at bridging veins on susceptibility-weighted imaging in abusive head trauma. Clin Neuroradiol Med. doi: 10.1007/s00062-014-0283-9 Google Scholar
  28. 28.
    Trübner K, Schubries M, Beintker M, Bajanowski T (2013) Genital findings in boys suspected for sexual abuse. Int J Legal Med 127:967–970PubMedCrossRefGoogle Scholar
  29. 29.
    Schulte B, Rothschild MA, Vennemann M, Banaschak S (2013) Examination of (suspected) neonaticides in Germany: a critical report on a comparative study. Int J Legal Med 127:621–625PubMedCrossRefGoogle Scholar
  30. 30.
    Herrmann B (2002) Körperliche Misshandlung von Kindern. Monatsschr Kinderheilkd 150:1324–1338CrossRefGoogle Scholar
  31. 31.
    Friedrich K, Becker K, Rothschild MA, Banaschak S (2013) Child abuse inflicted by small children. Int J Legal Med 127:627–630PubMedCrossRefGoogle Scholar
  32. 32.
    Stray-Pedersen A, Omland S, Nedregaard B, Klevberg S, Rognum TO (2011) An infant with subdural hematoma and retinal hemorrhages: does von Willebrand disease explain the findings? Forensic Sci Med Pathol 7:37–41PubMedCrossRefGoogle Scholar
  33. 33.
    Drigo P, Burlina AB, Battistella PA (1993) Subdural hematoma and glutaric aciduria type 1. Brain Dev 15:460–461PubMedCrossRefGoogle Scholar
  34. 34.
    Vinchon M, Delestret I, DeFoort-Dhellemmes S, Desurmont M, Noulé N (2010) Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature. Childs Nerv Syst 26:1195–1205PubMedCrossRefGoogle Scholar
  35. 35.
    Leventhal JM, Martin KD, Asnes AG (2010) Fractures and traumatic brain injuries: abuse versus accidents in a US database of hospitalized children. Pediatrics 126:e104–e115PubMedCrossRefGoogle Scholar
  36. 36.
    Bradley WG Jr (1993) MR appearance of hemorrhage in the brain. Radiology 189:15–26PubMedCrossRefGoogle Scholar
  37. 37.
    Barnes PD, Krasnokutsky M (2007) Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics. Top Magn Reson Imaging 18:53–74PubMedCrossRefGoogle Scholar
  38. 38.
    Vezina G (2009) Assessment of the nature and age of subdural collections in nonaccidental head injury with CT and MRI. Pediatr Radiol 39:586–590PubMedCrossRefGoogle Scholar
  39. 39.
    Schwartz ES, Barkovich AJ (2012) Brain and spine injuries in infancy and childhood. In: Barkovich AJ, Raybaud C (eds) Pediatric neuroimaging. Lippincott Williams & Wilkins, Philadelphia, pp 240–366Google Scholar

Copyright information

© European Society of Radiology 2014

Authors and Affiliations

  • Maria L. Hahnemann
    • 1
  • Sonja Kinner
    • 1
  • Bernd Schweiger
    • 1
  • Thomas Bajanowski
    • 2
  • Bernd Karger
    • 3
  • Heidi Pfeiffer
    • 3
  • Daniel Wittschieber
    • 3
    Email author
  1. 1.Institute of Diagnostic and Interventional Radiology and NeuroradiologyUniversity Hospital EssenEssenGermany
  2. 2.Institute of Legal MedicineUniversity Hospital EssenEssenGermany
  3. 3.Institute of Legal MedicineUniversity Hospital MünsterMünsterGermany

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