Journal of Child & Adolescent Trauma

, Volume 11, Issue 2, pp 241–247 | Cite as

The Big Black Brain: Subdural Hemorrhage with Hemispheric Swelling and Low Attenuation

  • Francois M. Luyet
  • Kenneth W. Feldman
  • Barbara L. KnoxEmail author


The term “Big Black Brain” was first coined in 1993 to describe cases of abusive head trauma associated with subdural hematoma(s), brain swelling, and uni- or bilateral hypo-density involving the entire supratentorial compartment on CT scan imaging. This constellation of findings was invariably followed by extensive cerebral parenchymal destruction and a dismal neurological outcome or death. We describe two such cases and review the pathophysiology and differential diagnosis of this entity.


Big black brain Abusive head trauma Cerebral edema Cerebral hypodensity Subdural hematoma Brain damage 



The authors would like to thank Kara G. Gill, MD for contributing radiologic imaging to this manuscript.

Compliance with ethical standards

Disclosure of Interest

Drs. Knox and Feldman both testify in civil and criminal trials. Monies earned are given to their respective institutions and to Dr. Feldman. Drs. Knox and Luyet are currently authoring a book on child torture as a form of child abuse.

Ethical Standards and Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation [institutional and national] and with the Helsinki Declaration of 1975, as revised in 2000. This manuscript discusses two cases of children with big black brain presentations. Both the University of Wisconsin Health Sciences IRB and the University of Washington IRB did not require IRB approval for these case reports. Additionally, no informed consent of patients was required.


  1. Adelson, P. D., Ragheb, J., Kanev, P., Brockmeyer, D., Beers, S. R., Brown, S. D., & Levin, H. (2005). Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery, 56(4), 740–754. discussion 740-754.CrossRefPubMedGoogle Scholar
  2. Barlow, K., Thompson, E., Johnson, D., & Minns, R. A. (2004). The neurological outcome of non-accidental head injury. Pediatric Rehabilitation, 7(3), 195–203. doi: 10.1080/13638490410001715331.CrossRefPubMedGoogle Scholar
  3. Bird, C. R., McMahan, J. R., Gilles, F. H., Senac, M. O., & Apthorp, J. S. (1987). Strangulation in child abuse: CT diagnosis. Radiology, 163(2), 373–375. doi: 10.1148/radiology.163.2.3562816.CrossRefPubMedGoogle Scholar
  4. Cantu, R. C. (2016). Dysautoregulation/Second impact syndrome with recurrent athletic head injury. World Neurosurgery. doi: 10.1016/j.wneu.2016.04.056.PubMedGoogle Scholar
  5. Cantu, R. C., & Gean, A. D. (2010). Second-impact syndrome and a small subdural hematoma: an uncommon catastrophic result of repetitive head injury with a characteristic imaging appearance. Journal of Neurotrauma, 27(9), 1557–1564. doi: 10.1089/neu.2010.1334.CrossRefPubMedPubMedCentralGoogle Scholar
  6. Carré, M. (2006). Neuroradiology. In K. Rauth-Farley, L. Frasier, R. Alexander, & R. Parrish (Eds.), Abusive head trauma in infants and children: A medical, legal, and forensic reference (pp. 73–98). St. Louis: GW Publishing.Google Scholar
  7. Case, M. E. (2008). Inflicted traumatic brain injury in infants and young children. Brain Pathology, 18(4), 571–582. doi: 10.1111/j.1750-3639.2008.00204.x.CrossRefPubMedGoogle Scholar
  8. Dias, M. S., Backstrom, J., Falk, M., & Li, V. (1998). Serial radiography in the infant shaken impact syndrome. Pediatric Neurosurgery, 29(2), 77–85.CrossRefPubMedGoogle Scholar
  9. Donkin, J. J., Nimmo, A. J., Cernak, I., Blumbergs, P. C., & Vink, R. (2009). Substance P is associated with the development of brain edema and functional deficits after traumatic brain injury. Journal of Cerebral Blood Flow and Metabolism, 29(8), 1388–1398. doi: 10.1038/jcbfm.2009.63.CrossRefPubMedGoogle Scholar
  10. Duhaime, A. C., Bilaniuk, L., & Zimmerman, R. (1993). The “big black brain”: radiographic changes after severe inflicted head injury in infancy. Journal of Neurotrauma, 10, S59.Google Scholar
  11. Duhaime, A. C., & Durham, S. (2007). Traumatic brain injury in infants: the phenomenon of subdural hemorrhage with hemispheric hypodensity (“Big Black Brain”). Progress in Brain Research, 161, 293–302. doi: 10.1016/S0079-6123(06)61020-0.CrossRefPubMedGoogle Scholar
  12. Figaji, A. A., Fieggen, A. G., Argent, A. C., Le Roux, P. D., & Peter, J. C. (2008). Intracranial pressure and cerebral oxygenation changes after decompressive craniectomy in children with severe traumatic brain injury. Acta Neurochirurgica Supplement, 102, 77–80.CrossRefPubMedGoogle Scholar
  13. Gilles, E. E., & Nelson, M. D., Jr. (1998). Cerebral complications of nonaccidental head injury in childhood. Pediatric Neurology, 19(2), 119–128.CrossRefPubMedGoogle Scholar
  14. Goldstein, J. L., Leonhardt, D., Kmytyuk, N., Kim, F., Wang, D., & Wainwright, M. S. (2011). Abnormal neuroimaging is associated with early in-hospital seizures in pediatric abusive head trauma. Neurocritical Care, 15(1), 63–69.CrossRefPubMedGoogle Scholar
  15. Grant, P. (2015). Abusive head trauma: parenchymal injury. In P. Kleinman (Ed.), Diagnostic imaging of child abuse. Cambridge UK: Cambridge University Press.Google Scholar
  16. Graupman, P., & Winston, K. R. (2006). Nonaccidental head trauma as a cause of childhood death. Journal of Neurosurgery, 104(4 Suppl), 245–250.PubMedGoogle Scholar
  17. Huh, J. W., & Raghupathi, R. (2009). New concepts in treatment of pediatric traumatic brain injury. Anesthesiology Clinics, 27(2), 213–240.CrossRefPubMedPubMedCentralGoogle Scholar
  18. Ichord, R. N., Naim, M., Pollock, A. N., Nance, M. L., Margulies, S. S., & Christian, C. W. (2007). Hypoxic-ischemic injury complicates inflicted and accidental traumatic brain injury in young children: the role of diffusion-weighted imaging. Journal of Neurotrauma, 24(1), 106–118.CrossRefPubMedGoogle Scholar
  19. Kemp, A. M., Jaspan, T., Griffiths, J., Stoodley, N., Mann, M. K., Tempest, V., & Maguire, S. A. (2011). Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Archives of Disease in Childhood, 96(12), 1103–1112.CrossRefPubMedGoogle Scholar
  20. Kemp, A. M., Stoodley, N., Cobley, C., Coles, L., & Kemp, K. W. (2003). Apnoea and brain swelling in non-accidental head injury. Archives of Disease in Childhood, 88(6), 472–476. discussion 472-476.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Kuroda, Y., & Bullock, R. (1992). Local cerebral blood flow mapping before and after removal of acute subdural hematoma in the rat. Neurosurgery, 30(5), 687–691.PubMedGoogle Scholar
  22. Liesemer, K., Bratton, S. L., Zebrack, C. M., Brockmeyer, D., & Statler, K. D. (2011). Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. Journal of Neurotrauma, 28(5), 755–762.CrossRefPubMedGoogle Scholar
  23. Maguire, S., Pickerd, N., Farewell, D., Mann, M., Tempest, V., & Kemp, A. M. (2009). Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Archives of Disease in Childhood, 94(11), 860–867. doi: 10.1136/adc.2008.150110.CrossRefPubMedGoogle Scholar
  24. Marmarou, A. (2007). A review of progress in understanding the pathophysiology and treatment of brain edema. Neurosurgical Focus, 22(5), E1.CrossRefGoogle Scholar
  25. McKinney, A. M., Thompson, L. R., Truwit, C. L., Velders, S., Karagulle, A., & Kiragu, A. (2008). Unilateral hypoxic-ischemic injury in young children from abusive head trauma, lacking craniocervical vascular dissection or cord injury. Pediatric Radiology, 38(2), 164–174. doi: 10.1007/s00247-007-0673-0.CrossRefPubMedGoogle Scholar
  26. McLendon, L. A., Kralik, S. F., Grayson, P. A., & Golomb, M. R. (2016). The controversial second impact syndrome: a review of the literature. Pediatric Neurology, 62, 9–17. doi: 10.1016/j.pediatrneurol.2016.03.009.CrossRefPubMedGoogle Scholar
  27. Oehmichen, M., Schleiss, D., Pedal, I., Saternus, K. S., Gerling, I., & Meissner, C. (2008). Shaken baby syndrome: re-examination of diffuse axonal injury as cause of death. Acta Neuropathologica, 116(3), 317–329. doi: 10.1007/s00401-008-0356-4.CrossRefPubMedGoogle Scholar
  28. Parizel, P. M., Ceulemans, B., Laridon, A., Ozsarlak, O., Van Goethem, J. W., & Jorens, P. G. (2003). Cortical hypoxic-ischemic brain damage in shaken-baby (shaken impact) syndrome: value of diffusion-weighted MRI. Pediatric Radiology, 33(12), 868–871. doi: 10.1007/s00247-003-1025-3.CrossRefPubMedGoogle Scholar
  29. Peiniger, S., Nienaber, U., Lefering, R., Braun, M., & Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie. (2012). Glasgow coma scale as a predictor for hemocoagulative disorders after blunt pediatric traumatic brain injury. Pediatr Crit Care Med, 13(4), 455–460. doi: 10.1097/PCC.0b013e31823893c5.
  30. Scholefield, B., Duncan, H., Davies, P., Gao Smith, F., Khan, K., Perkins, G. D., & Morris, K. (2013). Hypothermia for neuroprotection in children after cardiopulmonary arrest. Cochrane Database of Systematic Reviews, 2, CD009442. doi: 10.1002/14651858.CD009442.pub2.Google Scholar
  31. Squier, W., Mack, J., Green, A., & Aziz, T. (2012). The pathophysiology of brain swelling associated with subdural hemorrhage: the role of the trigeminovascular system. Childs Nervous System, 28(12), 2005–2015. doi: 10.1007/s00381-012-1870-1.CrossRefGoogle Scholar
  32. Stam, A. H., Luijckx, G. J., Poll-The, B. T., Ginjaar, I. B., Frants, R. R., Haan, J., & van den Maagdenberg, A. M. (2009). Early seizures and cerebral oedema after trivial head trauma associated with the CACNA1A S218L mutation. Journal of Neurology, Neurosurgery, and Psychiatry, 80(10), 1125–1129. doi: 10.1136/jnnp.2009.177279.CrossRefPubMedGoogle Scholar
  33. Tantsis, E. M., Gill, D., Griffiths, L., Gupta, S., Lawson, J., Maksemous, N., & Menezes, M. P. (2016). Eye movement disorders are an early manifestation of CACNA1A mutations in children. Developmental Medicine and Child Neurology, 58(6), 639–644. doi: 10.1111/dmcn.13033.CrossRefPubMedGoogle Scholar
  34. Topal, N. B., Hakyemez, B., Erdogan, C., Bulut, M., Koksal, O., Akkose, S., & Korfali, E. (2008). MR imaging in the detection of diffuse axonal injury with mild traumatic brain injury. Neurological Research, 30(9), 974–978. doi: 10.1179/016164108X323799.CrossRefPubMedGoogle Scholar
  35. Weinstein, E., Turner, M., Kuzma, B. B., & Feuer, H. (2013). Second impact syndrome in football: new imaging and insights into a rare and devastating condition. Journal of Neurosurgery Pediatrics, 11(3), 331–334. doi: 10.3171/2012.11.PEDS12343.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing 2017

Authors and Affiliations

  • Francois M. Luyet
    • 1
  • Kenneth W. Feldman
    • 2
  • Barbara L. Knox
    • 1
    Email author
  1. 1.Department of PediatricsUniversity of Wisconsin American Family Children’s HospitalMadisonUSA
  2. 2.Department of PediatricsUniversity of Washington School of MedicineSeattleUSA

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