Ocular and optic nerve hemorrhages in abused infants with intracranial injuries

Rapid Amplification of Cerebrospinal Fluid Pressure as a Possible Mechanism for Optic Nerve Sheath Bleeding in Infants With Nonaccidental Head Injury

Purpose

Subdural hemorrhage along the optic nerve (ON) is a histopathological indicator of abusive head trauma (AHT) in infants. We sought to determine if this bleeding could be caused by an abrupt increase in intracranial pressure transmitted to cerebrospinal fluid (CSF) at the optic foramen (OF).

Methods

A theoretical model is developed to simulate the effect of a pressure perturbation of maximal amplitude P applied at the optic foramen for a short duration T on the CSF-filled ON subarachnoid space (ONSAS). The ONSAS is modelled as a fluid-filled channel with an elastic wall representing the flexible ONSAS-arachnoid/dura interface. A constitutive law describing the relationship between CSF pressure and ONSAS deformation is inferred from published measurements. CSF pressure profiles along the ONSAS are examined systematically over a broad range of P and T.

Results

The pressure perturbation initiated at the OF produces a pressure wave that stretches the ONSAS. This wave propagates rapidly along the ONSAS toward the scleral end of the ON, where it is reflected back toward the brain. For sufficiently small T a shock wave with amplification up to six times larger than P over a timescale of tens of milliseconds is observed at the scleral end of the ON. Comparatively smaller amplifications are observed for slower perturbations.

Conclusions

A sudden increase in CSF pressure in the cranial cavity can cause a rapid expansion of the ONSAS, which may lead to rupture of the bridging blood vessels. Our study predicts a plausible mechanism for subdural hemorrhage that occurs in abusive head trauma in infants.

New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review

(1) Background: Head trauma represents the first cause of death in abused children, but diagnostic knowledge is still limited. The characteristic findings of abusive head trauma (AHT) are retinal hemorrhages (RH) and additional ocular findings, including optic nerve hemorrhages (ONH). However, etiological diagnosis must be cautious. (2) Methods: The Preferred Reporting Items for Systematic Review (PRISMA) standards were employed, and the research focus was the current gold standard in the diagnosis and timing of abusive RH. (3) Results: Sixteen articles were included for qualitative synthesis. The importance of an early instrumental ophthalmological assessment emerged in subjects with a high suspicion of AHT, with attention to the localization, laterality, and morphology of the findings. Sometimes it is possible to observe the fundus even in deceased subjects, but the current techniques of choice consist of Magnetic Resonance Imaging and Computed Tomography, also useful for the timing of the lesion, the autopsy, and the histological investigation, especially if performed with the use of immunohistochemical reactants against erythrocytes, leukocytes, and ischemic nerve cells. (4) Conclusions: The present review has made it possible to build an operational framework for the diagnosis and timing of cases of abusive retinal damage, but further research in the field is needed.

Novel in vivo depiction of optic nerves hemorrhages in child abuse: a 3D-SWI pilot study

Purpose

Until now, the diagnosis of optic nerves hemorrhages in abusive head trauma (AHT) has been obtained only in the postmortem setting. The aim of the IRB-approved study was to assess the presence of optic nerves hemorrhages in AHT patients using 3D-SWI.

Methods

Thirteen children with a final confirmed multidisciplinary diagnosis of AHT underwent coronal and axial 3D-SWI imaging of the orbits. The presence of optic nerve sheath (ONS) hemorrhages was defined by thickening and marked 3D-SWI hypointensity of the ONS, resulting in mass effect upon the CSF space. Optic nerve (ON) hemorrhages were defined by areas of susceptibility artifacts in the ON parenchyma. Superficial siderosis was defined by susceptibility artifact coating the ON. Furthermore, data about post-traumatic deformity of the ONS at the head of the optic nerve were collected.

Results

The average age of the population was 7.9 ± 5.9 months old. The average GCS was 11.8 ± 4.5. The male to female ratio was 7:6. ONS hemorrhages were identified in 69.2% of cases. Superficial siderosis and ON hemorrhages were identified in 38.5 and 76.9% of cases, respectively. 3D-SWI also depicted traumatic deformity of the ONS at the level of the optic nerve head in 10 cases (76.9%). No statistical correlations were identified between RetCam findings and 3D-SWI findings or GCS and ON hemorrhages.

Conclusion

This research shows that dedicated MRI with volumetric SWI of the orbits can depict hemorrhages in the ON, ONS, and ONS injury, in AHT victims.

Evidence-Based Clinical Practice Guideline: Comprehensive Pediatric Eye and Vision Examination

Republished with written permission granted from the American Optometric Association, October 2, 2020.

An insight into the vision impairment following traumatic brain injury

Traumatic brain injury (TBI) is one of the major cause of morbidity and mortality and it affects more than 1.7 million Americans each year. Depending on its location and severity, TBI leads to structural and functional damage in several parts of the brain such as cranial nerves, optic nerve tract or other circuitry involved in vision, and occipital lobe. As a result, the function associated with vision processing and perception are significantly affected and cause blurred vision, double vision, decreased peripheral vision and blindness. In this mini-review, we will focus the recent progress made to understand the pathology and underlying cellular/molecular mechanisms involved in the impairment of the integrity of visual systems following TBI.

The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: A 13-year study in a tertiary hospital

Fatal abusive head trauma is a major cause of death in children and toddlers who suffer from cruel physical abuse. Postmortem differentiation of fatal abusive head trauma from accidental head trauma can be a complicated process. This consecutive case series study aimed to determine the role of subdural optic nerve sheath hemorrhage (ONSH) in 70 autopsy cases of children ≤3 years old in making this differentiation. The study took place over a 13 year period (between August 1st 2003 and July 31st 2016) at a tertiary hospital in Thailand. Eleven cases were diagnosed with fatal abusive head trauma and 10 were identified as being accidental closed head trauma cases. Bilateral retinal hemorrhage was noted in antemortem medical records in every hospitalized abusive head trauma case (n=10). Upon autopsy, ONSH was observed in all 11 fatal cases of abusive head trauma (bilateral=10 and unilateral=1) but not in any cases of accidental head trauma (0/5). Subdural hemorrhage was found in 10 out of 11 abusive head trauma victims but not in any of the 10 with accidental head trauma. Other postmortem findings in abusive head trauma included subarachnoid hemorrhage (5/11), marked brain swelling (3/11), skull fracture (4/11) and brain contusion (1/11). This study suggests that ONSH, together with subdural hemorrhage, plays an essential role in an accurate postmortem diagnosis of fatal abusive head trauma. Therefore, an ocular investigation should be performed in all autopsy cases where child abuse is suspected and where there is no reliable history/witnesses, confession or antemortem ophthalmologic examination.

Deaths Due to Child Abuse: A 6-Year Review of Cases in The Cook County Medical Examiner's Office

Case files from the Cook County Medical Examiner's Office from 2007 to 2012 were reviewed to analyze homicides due to physical child abuse in children <3 years old. Fatal cases mostly involved younger subjects. Intracranial injuries were the leading cause of death, while death due to extracranial injuries was uncommon. Eyes were involved in most of the cases. Spinal cord was involved in about 1/3 of the cases, mostly in the thoracic area. In some cases, previous injuries were present. There were significant differences in the pattern of injuries between age groups. Subjects showing signs of impact to the head and subjects with no evidence of an impact showed no significant difference in internal injuries. The association of multiple injuries is highly suggestive of child abuse. In suspected child abuse, a postmortem examination including neuropathological, ophthalmological, and radiological information should be always evaluated, together with investigative reports and the medical history.

[Retinal bleeding and venous stasis in a 10-month-old infant after a fall?]

This report describes the case of a 10-month-old infant, who was delivered to our hospital by the emergency physician intubated and in an unclear unconscious state. The father reported that the child had fallen from the couch to the ground. The consulted ophthalmologist reported venous stasis in both eyes including intraretinal and preretinal bleeding in all four quadrants, a diffuse vitreous hemorrhage in the right eye and temporal retinal wrinkling in both eyes. Based on these particular clinical findings a shaken baby syndrome was suspected. This report demonstrates the importance of recognizing and correctly interpreting the typical ophthalmological signs of physical child abuse in order to detect and prevent further mistreatment of children; moreover, the increasing importance of photographic documentation and histological work-up of the findings for forensic reasons are emphasized.

The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse

In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.

Distinguishing accidental from inflicted head trauma at autopsy

This article will discuss accidental and inflicted head injuries in infants and young children and how forensic pathologists distinguish between these types of injuries. The article begins with a consideration of the special and unique features of the anatomy and development of the child's head and neck and then relates these features to the mechanisms of traumatic brain injury and how these unique features influence the mechanisms of injury. The article very specifically notes that accidental head injuries in young children that occur in and around the home are focal head injuries in distinction to inflicted head injuries, which are diffuse brain injuries. The article discusses the mechanisms by which traumatic brain injury causes loss of consciousness and relates those mechanisms to the differences in the clinical features that occur in both accidental and inflicted head injury. The article discusses and illustrates the pathological findings in accidental head injuries consisting of the crushing head injuries and the head injuries sustained in short falls including epidural hemorrhage and focal subdural hemorrhage. The article discusses and illustrates the pathological findings that occur in inflicted head trauma, including subdural and subarachnoid hemorrhages and retinal and optic nerve sheath hemorrhages.

The eye in child abuse: key points on retinal hemorrhages and abusive head trauma

This review presents an up-to-date overview of ocular injuries resulting from child abuse, with a spotlight on abusive head trauma. Retinal hemorrhage is a principle finding of inflicted head trauma. The specific pattern of hemorrhages holds valuable diagnostic information, which can help to guide multidisciplinary assessments of the likelihood of abuse. Indirect ophthalmoscopy through dilated pupils by an ophthalmologist is necessary for adequate examination and documentation of retinal findings. Initial pediatrician evaluation of the eye and indications for ophthalmological consultation are reviewed. Focus is then placed upon understanding retinal hemorrhage patterns, their diagnostic significance and likely pathophysiological mechanisms. The differential diagnosis of retinal hemorrhage in young children is discussed, highlighting key distinctions among retinal hemorrhage patterns, severity and frequencies, as well as other ocular findings. The most common cause of retinal hemorrhage in an infant is trauma, and most other causes can be identified by considering the hemorrhage pattern, ocular or systemic signs and the results of laboratory and imaging tests, when indicated.

Fatal spontaneous subdural bleeding due to neonatal giant cell hepatitis: a rare differential diagnosis of shaken baby syndrome

A 7-week-old girl showed vomiting after feeding, facial pallor, loss of muscle tone and respiratory depression. An emergency doctor performed successful resuscitation and after arrival in hospital, cranial ultrasound showed left-sided subdural hemorrhage, cerebral edema with a shift of the midline, and a decrease in cerebral perfusion. Ophthalmologic examination showed retinal hemorrhage. In view of this, the doctors suspected shaken baby syndrome and approached the parents with their suspicions, but they denied any shaking or trauma. Despite surgery for the subdural hemorrhage the girl died a few hours later with a severe coagulopathy. Autopsy verified subdural hemorrhage, cerebral edema and retinal hemorrhage, but also revealed intact bridging veins and a lack of optic nerve sheath hemorrhage, therefore shaken baby syndrome could not be proven by autopsy. Histological examination showed severe neonatal giant cell hepatitis as the cause of the severe coagulopathy and the associated spontaneous subdural bleeding. Neonatal giant cell hepatitis may be responsible for unexpected deaths in infancy and, although rarely associated with subdural bleeding, must be considered as a potential differential diagnosis of shaken baby syndrome.

Evaluation and management of retinal hemorrhages in infants with and without abusive head trauma

Extensive intraocular hemorrhage in young infants in the setting of acute brain injury and in the absence of a history of severe accidental trauma or underlying medical cause must be considered to be nonaccidental injury until otherwise proven. In the absence of any obvious explanation, the presence of any retinal hemorrhage should raise the possibility of abusive head trauma in the differential diagnosis and perhaps lead to such testing as skeletal radiography and neuroimaging, consultation with a child abuse specialist, as well as workup for other relevant systemic conditions. Physicians who treat infants and children are mandated to report suspected child abuse to child welfare agencies for investigation, and ophthalmologists who encounter children with ophthalmic manifestations of abuse need to ensure that the proper steps are taken to protect their patients from the potential for further harm. Ascertainment of abusive head trauma is critical to prevent a potentially fatal recurrence.

Ocular hemorrhages in neonatal porcine eyes from single, rapid rotational events

PURPOSE

To characterize ocular hemorrhages from single, rapid head rotations in the neonatal pig.

METHODS

Three- to 5-day-old anesthetized piglets (n=51) underwent a single, rapid (117-266 rad/s) head rotation in the sagittal (n=13), coronal (n=7), or axial (n=31) planes. Six hours after injury, the animals were euthanatized and perfusion fixed, and the brain and eyes were harvested for gross and histopathologic examination by masked neuro- and ocular pathologists.

RESULTS

Ocular hemorrhage was found in 73% of animals (51% bilateral). Intraocular hemorrhage was primarily located near the vitreous base (70% of injured animals had ciliary body hemorrhage, and 11% had peripheral retinal hemorrhage). Hemorrhages were also found in the anterior chamber (11%), vitreous (5%), and optic nerve (disc, 8%; nerve sheath, 57%). Rapid axial head rotations resulted in a higher incidence of intraocular hemorrhage than coronal or sagittal head rotations, but the difference did not reach statistical significance (P=0.06). Control eyes had no injuries.

CONCLUSIONS

Optic nerve sheath and ciliary body hemorrhages were common in piglets that experienced a single, rapid head rotation. Retinal hemorrhage was present in a smaller number of animals. Most intraocular hemorrhages were located in regions of strong vitreous attachment, suggesting that this animal model will be useful in investigating the effect of vitreoretinal adhesion on ocular hemorrhage caused by inertial head rotations. Extrapolation of this model to the human infant should not be made until the effect of anatomic differences between the human and pig on the occurrence and patterns of ocular injuries is further investigated.

A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma

TOPIC

To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT).

CLINICAL RELEVANCE

Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed.

METHODS

A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy.

RESULTS

The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions.

CONCLUSIONS

Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.

Ischemic retinopathy and neovascular proliferation secondary to shaken baby syndrome

BACKGROUND

Ocular lesions known to occur after shaken baby syndrome (SBS) are epiretinal, intraretinal, and subretinal hemorrhages, which are present in up to 100% of patients. Retinoschisis and retinal folds have also been described. We describe three patients with SBS who presented with tractional retinal detachments secondary to neovascular proliferation and discuss the role of ischemia at the retinal level.

PATIENTS

Three patients (two 4-month-old babies and one 4-year-old child) with a history of SBS in the first year of life presented with tractional retinal detachment due to severe preretinal fibrovascular proliferation. Peripheral retinal ischemia and vascular disorganization were noted during clinical examination.

CONCLUSION

Although physiopathology of SBS remains disputed, ischemia has been accepted as the main feature of cerebral lesions. Ischemia could also be present at the retinal level as suggested by our patients' presentation. It could be induced by direct vitreous shearing of the capillary network or more probably by vascular leak due to brain edema and hypoxic damage of capillaries. Long-term ocular follow-up is necessary in SBS to treat these patients preventively.

Ocular autopsy and histopathologic features of child abuse

PURPOSE

To study the ocular histopathologic features in eyes of children with fatal suspected child abuse.

DESIGN

Retrospective case series.

PARTICIPANTS

One hundred eighteen autopsy cases of known or suspected child abuse.

METHODS

The ocular autopsy and histopathologic features of a cohort of consecutive cases of known or presumed child abuse submitted by Maryland's Office of the Chief Medical Examiner or Johns Hopkins Hospital to the Wilmer Eye Pathology Laboratory were tabulated.

MAIN OUTCOME MEASURE

Ocular hemorrhage or structural abnormality.

RESULTS

Retinal hemorrhage was present in 44% of cases. Circumferential folds with macular schisis cavities were present in 23% of cases and were bilateral in half of those cases. Peripapillary scleral hemorrhage was present in 38% of cases, and subdural hemorrhage was present in the distal optic nerve in 46% of cases. Hemosiderin was present in 27% of cases.

CONCLUSIONS

Intraretinal hemorrhages, circumferential macular folds with schisis cavities, peripapillary scleral hemorrhages, and subdural hemorrhages are common pathologic findings in cases of fatal known or suspected child abuse. Their presence on autopsy should raise the suspicion of shaking or blunt nonaccidental trauma.

Postmortem orbital findings in shaken baby syndrome

PURPOSE

To compare postmortem orbital findings in pediatric accidental head injury to Shaken Baby Syndrome (SBS).

DESIGN

Retrospective study.

METHODS

SETTING

Institutional.

STUDY POPULATION

Thirty-six patients underwent postmortem modified exenteration with sectioning of the orbital contents; 18 victims of SBS and 18 cases of fatal accidental head trauma.

OBSERVATION PROCEDURE

In all cases of children who died from accidental head trauma, the orbital tissues were separated to expose the optic nerve sheath. Patients with gross evidence of hemorrhage within the sheath were included. All cases of SBS were included. After accidental head injury, exenteration was performed only if optic nerve sheath hemorrhage was suspected on gross examination. All children younger than 18 years old with head injury as primary cause of death were included. SBS is defined as having at least two of the following: (1) typical abnormal findings on neuroimaging, (2) typical skeletal injury, (3) retinal hemorrhages, (4) history of abusive shaking with or without blunt head trauma, or (5) an inadequate history to explain the observed injuries.

MAIN OUTCOME MEASURE

Presence or absence of orbital hemorrhage.

RESULTS

Orbital tissue injury is more common in SBS than accidental head trauma without orbital fracture. In addition, optic nerve sheath and optic nerve intradural hemorrhage are also significantly more common in SBS (P < .0001).

CONCLUSIONS

Our study reports new evidence of injury to orbital tissues in SBS and supports the concept that these finding are due to unique acceleration-deceleration forces of this type of abusive head injury.

Retinal hemorrhage and pediatric brain injury: etiology and review of the literature

Retinal hemorrhages have long been linked with child abuse and, in particular, the "shaken baby/shaking-impact" syndrome. However, the presence of retinal hemorrhages is neither necessary nor sufficient for the diagnosis of child abuse. Additionally, retinal hemorrhages are also associated with an ever-expanding list of conditions, each of which carries important implications for patients and their families. To correctly interpret a patient's retinal hemorrhages, the physician requires a broad knowledge base, including of child abuse, the "shaken baby/shaking-impact" syndrome, the differential diagnosis of retinal hemorrhages and the types of retinal hemorrhage and their diagnostic implications. We review the literature regarding types of retinal hemorrhage and their associated etiologies.

Protective ocular mechanisms in woodpeckers

AIMS

Woodpeckers possess mechanisms protecting the eye from shaking/impact. Mechanisms available to woodpeckers but not humans may help explain some eye injuries in Shaken Baby syndrome (SBS).

METHODS

Gross dissection and histologic examination of eyes and orbits of seven woodpeckers.

RESULTS

All birds showed restricted axial globe movement due to the tight fit within the orbit and fascial connections between the orbital rim and sclera. The sclera was reinforced with cartilage and bone, the optic nerve lacked redundancy, and the vitreous lacked attachments to the posterior pole retina.

CONCLUSIONS

Woodpecker eyes differ from human infants by an inability of the globe to move axially in the orbit, the sclera to deform, and the vitreous to shear the retina. These findings support current hypotheses that abusive acceleration-deceleration-induced ocular injury in human infants may be related to translation of vitreous within the globe and the globe within the orbit. The woodpecker presents a natural model resistant to mechanical forces that have some similarity to SBS.

A computational study of the passive mechanisms of eye restraint during head impact trauma

A finite element model of the eye and the orbit was used to examine the hypothesis that the orbital fat provides an important mechanism of eye stability during head trauma. The model includes the globe, the orbital fat, the extra-ocular muscles, and the optic nerve. MRI images of an adult human orbit were used to generate an idealized geometry of the orbital space. The globe was approximated as a sphere 12 mm in radius. The optic nerve and the sclera were represented as thin shells, whereas the vitreous and the orbital fat were represented as nearly incompressible solids of low stiffness. The orbital bone was modelled as a rigid shell. Frontal head impact resulting from a fall onto a hard floor was simulated by prescribing to the orbital bone a triangular acceleration pulse of 200 g (1962 m/s(2)) peak for a duration of 4.5 ms. The results show that the fat provides the crucial passive mechanism of eye restraint. The mechanism is a consequence of the fact that the fat is incompressible and that its motion is restricted by the rigidity of the orbital walls. Thus, the acceleration loads of short duration cannot generate significant distortion of the fat. In contrast, the passive muscles provide little support to the globe. When the connection between the orbital fat and the eye is absent the eye is held mainly by the optic nerve. We discuss the possible role that this loss of contact may have in some cases of the evulsion of the eye and the optic nerve.

Age of Retinal Hemorrhages by Iron Detection

Intraretinal hemorrhages have been found in some abusively injured infants and children. Intraretinal hemosiderin has been proposed as an indication of previous injury. The limits of the accuracy of the proposal have not been established. Experimental central retinal vein occlusion (CRVO) was produced in 20 eyes of adult rhesus monkeys as part of ongoing research by one of the authors (SSH). The animal experiments were conducted in accordance with a research protocol approved by the Animal Care Committee, University of Iowa. CRVO produced diffuse intraretinal hemorrhages. Clinical ocular examinations assessed the onset and time course of retinal hemorrhages. Enucleation specimens were used to assess hemosiderin in the retinas. Hemosiderin was detected within 2 days of induction of retinal hemorrhages. It was detected in only 4 of 11 eyes (36%) studied more than 1 week following induction of hemorrhages. In 2 eyes, hemosiderin was found 9 and 16.8 months after development of hemorrhages. Hemosiderin can represent organization of current hemorrhage rather than evidence of prior hemorrhage. This study does not allow specifying the duration of hemorrhages with greater precision than "more than 2 days prior to death," and that, only if there is no survival interval. Failure to detect hemosiderin does not exclude prior retinal hemorrhages.

Pediatric fractures of the humerus

Humeral shaft fractures constitute only 3% of fractures in children younger than age 16 years. They are most common in children younger than 3 and older than 12 years old. They can be classified according to the fracture pattern, location, and tissues damaged. Fractures resulting from minor trauma may be caused by an occult unicameral bone cyst. Each age group requires different diagnosis, treatment, and prognosis. Fractures at birth are seen mostly with macrosomic and breech presentation. In children younger than 3 years, humeral fractures often are linked to child abuse. In those older than 10 years, fractures are related to direct or indirect trauma. Sports activities have been reported also to cause injuries in skeletally immature patients. Most humeral fractures are controlled nonoperatively; however, potential operative indications include open fractures, multiple trauma, bilateral injuries, compartment syndromes, pathological fracture, significant nerve injuries, and inadequate closed reduction.

A rapid noninvasive method of detecting elevated intracranial pressure using bedside ocular ultrasound: application to 3 cases of head trauma in the pediatric emergency department

Managing pediatric head trauma with elevated intracranial pressure in the acute setting can be challenging. Bedside ocular ultrasound for measuring optic nerve sheath diameters has been recently proposed as a portable noninvasive method to rapidly detect increased intracranial pressure in emergency department patients with head trauma. Prior study data agree that the upper limit of normal optic nerve sheath diameters is 5.0 mm in adults, 4.5 mm in children aged 1 to 15, and 4.0 mm in infants up to 1 year of age. We report the application of this technique to 3 cases of head trauma in the pediatric emergency department.

Why do histology on retinal haemorrhages in suspected non-accidental injury?

The detailed documentation of ocular pathology has become an important component in the autopsy investigation of suspected cases of non-accidental injury in infants and young children. Careful histological examination of retinal haemorrhages is of critical importance, but there remains debate about the significance of some findings. This issue has been thrown into sharper relief by recent neuropathological studies questioning the mechanisms of some CNS findings. To discuss the importance of histological findings in the retina and their potential significance and specificity, we have invited contributions from authors in the USA and UK.

Inflicted childhood neurotrauma (shaken baby syndrome): ophthalmic findings

Inflicted childhood neurotrauma (shaken baby syndrome) is the term used for violent, nonaccidental, repetitive, unrestrained acceleration-deceleration head and neck movements, with or without blunt head trauma, combined with a unique, age-related biomechanical sensitivity in children typically younger than 3 years. This syndrome is typically characterized by a combination of fractures, intracranial hemorrhages, and intraocular hemorrhages. Retinal hemorrhage is the most common ophthalmic finding, and usually occurs at all levels of the retina. In recent years, increasing pressure has been placed on ophthalmologists to render diagnostic interpretations of the retinal findings in children suspected to be victims, which may have great forensic implications in criminal proceedings. New research has increased our understanding of the pathophysiology of retinal hemorrhages, the importance of specifically characterizing the types, patterns, and extent of these retinal hemorrhages, and the differential diagnosis.

Technical Communication

Most victims of fatal child abuse are under the age of 2 years and have a fairly typical pattern of injuries that involve the brain and spinal cord. Documenting these injuries in a systematic fashion is of paramount importance in establishing the cause and manner of death. Although the importance of recognizing these injuries is widely understood, there are few guidelines for the optimal examination of the central nervous system to document these changes. A standard procedure for postmortem dissection of the brain and spinal cord that preserves the anatomy of the cervicomedullary junction is outlined. Changes in the cervicomedullary junction and spinal cord are an underappreciated marker for shaking injury in children. This technique, along with examination of the eyes and optic nerves, will optimally identify the injuries associated with shaking injuries. A standard series of histologic sections are also outlined to document the corresponding microscopic changes.

Retinal hemorrhage asymmetry in inflicted head injury: a clue to pathogenesis?

OBJECTIVE

To determine whether regional cerebral parenchymal injury patterns correlate with the distribution of retinal hemorrhages after inflicted head injury.

STUDY DESIGN

Retrospective case series of funduscopic photographs and serial computerized tomographic imaging of 14 children with confirmed inflicted head injury.

MAIN OUTCOME MEASURES

Retinal Hemorrhage Score per eye and per subject, visual field examination, regional patterns of parenchymal injury on computerized tomographic scans and necropsy, and retinal/optic nerve sheath hemorrhage distribution at necropsy.

RESULTS

Ten of 14 children had retinal hemorrhages (71%); 90% were asymmetric (mean retinal score, 4.89 vs 2.56; P=.006). Retinal hemorrhages were maximal on the side of greatest cerebral injury in seven of 10 children initially. Subsequent imaging asymmetry predicted retinal hemorrhage distribution in all eight survivors. Children's Coma Scores, apnea or cardiorespiratory arrest, initial hemoglobin, and plasma glucose concentration did not predict laterality. Asymmetry was greatest if dilated ophthalmoscopy was performed during the first 24 hours (P=.03). Visual outcome was poor; three had homonymous hemianopia and four had cortical visual loss, all correlating with parenchymal atrophy patterns.

CONCLUSION

The distribution of retinal hemorrhages after inflicted head injury correlates with acute and evolving regional cerebral parenchymal injury patterns.

Ophthalmologic findings in suspected child abuse victims with subdural hematomas

PURPOSE

Shaken baby syndrome consists of intracranial and intraocular hemorrhages in young children in the absence of signs of direct head trauma. Because it has major medicolegal implications, it must be distinguished from accidental trauma. This study aimed to determine the ophthalmologic manifestations and their natural course in child abuse victims and whether ophthalmologic examination can help to distinguish shaken babies from children with accidental impact head trauma.

DESIGN

Prospective comparative observational case series.

METHODS

A prospective study was conducted from January 1996 to September 2001 on 241 consecutive infants hospitalized for a subdural hematoma to determine the frequency and the type of ocular abnormalities encountered. At admission, 186 children were highly presumed to have been shaken (group 1), 38 children had signs of direct head trauma without any relevant history of trauma (group 2), some of them having been possibly shaken, whereas 7 children had proven severe accidental head trauma (group 3).

RESULTS

Intraocular hemorrhages were the main finding. Their shape, laterality, and size were not significantly different in groups 1 and 2. However they were significantly more frequent in nonaccidental head trauma than in infants with head impact (77.5% versus 20%). None of the group 3 children had intraocular hemorrhage. Eighty-two percent of intraocular hemorrhages resolved within 4 weeks.

CONCLUSIONS

Intraocular hemorrhages are frequent in shaken babies but not specific of this syndrome. When associated with a subdural hematoma, they are strongly suggestive of shaken neglect. They are rare in pediatric accidental head trauma.

Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome

PURPOSE

To report correlation between retinal and intracranial abnormalities and to evaluate pathogenesis of retinal hemorrhages in the shaken baby syndrome (SBS).

DESIGN

Observational case series.

METHODS

Seventy-five children with apparent nonaccidental head trauma consistent with SBS had complete physical examination, complete ophthalmologic examination, neuroimaging by CT or MRI, or both, and skeletal radiographic survey. In this retrospective review, ophthalmoscopic and intracranial abnormalities were correlated.

RESULTS

The age of patients ranged from 2 to 48 months (mean - SD, 10.6 +/- 10.4 months). Neuroimaging was abnormal in all 75 cases. Findings included subdural hematoma (70 children, 93%), cerebral edema (33 children, 44%), subarachnoid hemorrhage (12 children, 16%), vascular infarction (nine children, 12%), intraparenchymal blood (six children, 8%), parenchymal contusion (six children, 8%), and epidural hemorrhage (one child, 1%). Sixty-four (64/75, 85%) children had retinal abnormalities, mostly (53/64, 82%) confluent multiple hemorrhages that were subretinal, intraretinal, and preretinal in 47/64 (74%) and bilateral in 52/64 (81%). No association was found between anatomic site (left, right, or bilateral) of intracranial and retinal findings (McNemar test kappa = -0.026-0.106) or between any of the intracranial findings mentioned above and the following retinal findings: normal or abnormal retinal examination, multiple (>10) or few retinal hemorrhages (< or =10), symmetric or asymmetric retinal findings, or retinoschisis (kappa = -0.127-0.104). Signs of possible increased intracranial pressure were not correlated with any retinal abnormality (kappa = -0.03-0.073). There was no correlation between evidence of impact trauma to the head and retinal hemorrhages (kappa = 0.058). Total Cranial Trauma Score and Total Retinal Hemorrhage Score, both indicating the severity of injury, were correlated (P =.032).

CONCLUSIONS

Our study supports previous observations that the severity of retinal and intracranial injury is correlated in SBS. We cannot support the suggestions that in most children with SBS retinal bleeding is caused by sustained elevated intracranial, elevated intrathoracic pressure, direct tracking of blood from the intracranial space, or direct impact trauma. The correlation in severity of both eye and head findings may suggest, however, that retinal abnormalities are the result of mechanical shaking forces.

Review of shaken baby syndrome

1. Shaken baby syndrome can lead to substantial neuropsychological deficits that can alter children's normal developmental course. 2. Clinical acumen can be critical in identifying shaken baby syndrome and preventing further difficulties. 3. Education and treatment for caregivers can be important in reducing the likelihood of shaken baby syndrome.

Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990-1995

Child death due to repeated episodes of physical assault or neglect has been termed the child abuse-maltreatment syndrome (CAMS). We characterized the injuries in a series of fatally abused or maltreated child to delineate objective diagnostic criteria for the CAMS for use by clinicians and pathologists. All deaths (age <17 years) investigated by the Office of the Chief Coroner for Ontario, Canada during the time period 1990-1995 were reviewed. Cases of CAMS were defined as death due to lethal recent injury or malnutrition in the presence of significant old (healing or healed) injuries indicative of repeated episode of inflicted trauma. The nature and frequency of the various injuries was determined. The frequency of the shaken baby syndrome, and the types and frequency of ano-genital injuries were also studied. Twenty-one cases of fatal CAMS were found in the study period. Most cases had significant recent head injury with intra-cranial hemorrhage (71%). Other significant recent injuries commonly observed included blunt injuries of the skin and soft tissues (67%), blunt abdominal trauma with visceral injuries (14%), and fractures (18%). Eight cases (38%) fulfilled accepted criteria for the shaken baby syndrome. Many children with fatal head injuries had evidence of older head trauma (38% of all cases). A significant minority of cases had evidence of malnutrition due to neglect (10%) or ongoing ano-genital injuries (10%). Most cases of child homicides due to repeated episodes of abuse or maltreatment involve head trauma including shaken baby syndrome. Fractures of long bone and ribs, the classical markers of child abuse, were relatively infrequent compared with head injury. A proportion of cases had ano-genital injuries due to repeated sexual abuse or punitive maltreatment. All clinicians and pathologists must recognize the wide spectrum of injuries in child abuse to ultimate protect the victim or other children in an at-risk situation.

Overview and clinical presentation of inflicted head injury in infants

Child abuse is a widespread phenomenon which is increasingly recognized in our culture. In this chapter, the epidemiology, clinical presentation, and commonly associated injuries are reviewed. The typical presentation and clinical assessment of inflicted head injury is also described.

The spectrum of postmortem ocular findings in victims of shaken baby syndrome

BACKGROUND

Ophthalmologists and ocular pathologists are called on to help identify children who have undergone violent shaking. The objective of this study was to describe the spectrum of postmortem ocular findings in victims of shaken baby syndrome and to correlate the ocular findings with the nonocular features found at autopsy.

METHODS

The ocular pathology registry at the University of Ottawa Eye Institute was reviewed to identify all victims of fatal shaken baby syndrome whose eyes had been submitted for examination between Apr. 1, 1971, and Dec. 31, 1995. Autopsy reports were accessed from the hospital charts of the identified patients.

RESULTS

Six patients, aged 1 to 34 months, were identified. Intraocular findings ranged from a focal globular hemorrhage at the posterior pole to extensive intraocular hemorrhage involving the entire retina with perimacular folds. All the children had evidence of optic nerve sheath hemorrhage. Nonocular findings included intracranial hemorrhage (in all cases), skull fracture (in two), rib fractures (in three) and high spinal cord hemorrhage (in four). The extent of the intraocular hemorrhage was not consistent with the nonocular findings.

INTERPRETATION

Abused children may display a range of postmortem ocular findings, with intraocular hemorrhage varying from minimal to severe. These findings may not correlate with the severity of the child's other injuries. The presence of any retinal or optic nerve sheath hemorrhage in an infant, in the absence of an appropriate explanation for these findings, should raise suspicion of child abuse.

Manifestations of the shaken baby syndrome

Retinal hemorrhages are the most common fundus finding in the shaken baby syndrome. They vary in type and location; no particular type is pathognomonic for the condition. Retinal hemorrhages are not needed to make a diagnosis of shaken baby syndrome. However, in a child under age 3 years, the presence of extensive bilateral retinal hemorrhages raises a very strong possibility of abuse, which must be investigated. The other possible causes for hemorrhages in this age child can be investigated and eliminated. The diagnosis of abuse should be made by someone particularly trained in this area, who can put together the entire picture of inadequate or changing history, fractures of various ages, particularly rib fractures, subdural hematoma of the brain, and retinal hemorrhages. Photographs of retinal hemorrhages are very helpful to child advocacy experts who take these cases to court.

MR imaging of shaken baby syndrome manifested as chronic subdural hematoma

Shaken baby syndrome (SBS) is a form of child abuse that can cause significant head injuries, of which subdural hematoma (SDH) is the most common manifestation. We report the MRI findings of chronic SDH in three cases of SBS, involving two-, three- and eight-month-old babies. The SDH signal was mostly low on T1-weighted images and high on T2-weighted images, suggesting chronic SDH. In chronic SDH, a focal high signal on T1-weighted images was also noted, suggesting rebleeding. Contrast-enhanced MRI revealed diffuse dural enhancement.

Early management of the child with multiple injuries

Resuscitation of the child with multiple injuries is similar to that for adults, except that instrumentation and therapy must be tailored in accordance with variable patient size, emotional maturity, and injury response. Because this response is rapid and often compensatory, there is greater reliance on noninvasive means to diagnose and manage the injured child. Children who suffer multisystem trauma typically present with head injury, followed in decreasing frequency by limb fracture and trauma to the torso. The timing of fracture fixation in a patient with multiple injuries remains controversial. In general, clinical judgment will determine the optimal timing for fracture reduction or operative fracture fixation. Management of an associated vascular injury must take into consideration the mechanism of injury, tissue viability, vessel size, and technical limitations. With appropriate initial resuscitation, careful monitoring, and sound clinical judgement, most injured children can be expected to have a good clinical outcome.

Bilateral periopticointrascleral hemorrhages associated with traumatic child abuse

PURPOSE

To report a case of bilateral periopticoscleral hemorrhages associated with traumatic child abuse.

METHODS

Postmortem gross examination and histopathologic studies of both eyes and the optic nerves of a 6-month-old infant who died from subdural hematoma.

RESULTS

Gross examination and histopathologic step sections disclosed bilateral intrascleral hemorrhages around both optic nerves. In addition, bilateral diffuse multilayered retinal, vitreous, and sublaminar (beneath the internal limiting membrane) hemorrhages were present.

CONCLUSION

Periopticointrascleral hemorrhages are characteristic of blunt head trauma and may constitute important forensic evidence in cases of suspected child abuse.

Bruising in non-accidental head injured children; a retrospective study of the prevalence, distribution and pathological associations in 24 cases

Non-accidental head injury, be it shaking, impact(s) or a combination of the two, is characterised by subdural and/or subarachnoid haemorrhages with retinal haemorrhages, but minimal or absent external cranio-facial trauma. The classical assault scenario depicts the infant being gripped around the head, face, chest and abdomen and shaken or being gripped by a limb and swung. This gripping might be expected to leave physical evidence in the form of bruising. A study was undertaken to establish the prevalence, distribution and pathological association of external bruising in 24 cases of fatal non-accidental head injury in children. At autopsy, 17 cases had new external bruises, 15 old external bruises and 13, a combination of both. However, seven (29%) cases showed no fresh external bruising and five (21%) showed no external bruising at all. Thus, external bruising may be absent in children with fatal intracranial injury. The face was shown to be the commonest site of bruising followed by the forehead and buttocks. Limb, chest and abdominal bruising were found to be uncommon. Retinal haemorrhages were confirmed in 23 (96%) cases. It is hypothesised that bruising, when present, may be a result of abuse in the form of punches and slaps rather than due to gripping during the assault. We discuss why gripping does not necessarily result in external bruising.