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The brain swelling following acute subdural hemorrhage, so-called ‘bigblack brain’ has been reported in infants, while the pathophysiology remainsunclear so far. We report a fourteen-month-old boy who showed brain swellingfour days after acute subdural hemorrhage and performed arterial spin labeling(ASL) perfusion MRI analysis. The patient was delivered to our hospital becauseof right hemiconvulsion and decreased mental status after falling down from thetable and head banging. He showed right hemiparesis. Brain CT showed acutesubdural hematoma on the left hemisphere and mild midline shift without a signof loss of gray-white matter differentiation. On the same day, hematomaevacuation was operated. Although the hemiparesis was gradually improving in afew days, repetitive vomiting and left-sided eye deviation appeared three daysafter head trauma and mental status and right hemiparesis were aggravated again.Brain CT showed loss of gray-white matter differentiation on the lefthemisphere. Brain MRI on day 5 demonstrated restricted diffusivity in leftcerebral white matter. ASLperfusion MRI showed left cerebral hyperperfusion. One month after traumaticbrain injury, he had mild right hemiplagia, right facial palsy and lefthemianopsia. Brain MRI showed left cerebral atrophy and disappearance of hyperperfusionon left hemisphere. In recent years, the trigeminovasular system, which isneurogenic regulation system of cerebral vessels, is possible to explain the ‘bigblack brain’ pathophysiology. In conclusion, MRI analysis in our case supportsthe idea that trigeminovasculr system causes brain swelling following acutesubdural hemorrhage.

big black brain; infant; hyperperfusion; arterial spin labeling; acute subdural hemorrhage; trigeminovascular system