Dating the abusive head trauma episode and perpetrator statements: key points for imaging

Abstract

Shaken baby syndrome/abusive head trauma is a leading cause of morbidity and mortality in infants. The presence of a diffuse subdural hematoma without evidence of accident is a key diagnostic clue. The hematoma is typically attributed to rupture of the cerebral bridging veins due to violent shaking, with or without impact. Dating the incident, however, remains controversial. The aim of this article is to review the most reliable features used for dating the incident, based on both legal statements by perpetrators and medical documentation. The key points are: 1) The high (yet likely underestimated) frequency of repeated shaking is around 50%, 2) Children do not behave normally immediately after shaking, and the time of onset of even mild symptoms appears to be the best clue for dating the incident and 3) Brain imaging provides strong indicators of "age-different" injuries but the ranges for dating the causal event are wide. The density pattern in a single subdural hematoma location provides no reliable clues for assessing repeated violence. Only the finding of different density in two distant subdural hematomas argues in favor of "age-different" injuries, i.e. repeated violence. MRI is difficult to interpret in terms of dating subdural hemorrhages and must be analyzed in conjunction with CT. Most importantly, all of the child's previous clinical and radiological data must be carefully studied and correlated to provide accurate information on the date and repetition of the trauma.

Modern post-mortem imaging: an update on recent developments

“…It is also useful in child abuse cases, in particular to diagnose shaken baby syndrome, where it can document peri-cerebral lesions [ 81 ]. A precise datation of those lesions is a myth and dating the incident, however, remains controversial [ 82 ]. Recent publications have emphasized that MRI of the spinal column should be considered in any child with suspected abuse and head trauma [ 83 , 84 ] as there is clear evidence of spinal involvement in a proportion of cases of abusive head trauma.…”

Reply:

“…Repeated shaking, of course, may definitely cause corresponding injuries such as seen in the "agedifferent" pattern described by Adamsbaum et al 2,3 In regard to the case example shown in Fig 3 of our article 1 however, we can exclude, due to the child's medical history, a previous subdural hematoma (SDH) being present 4 weeks earlier. The infant had been clinically examined at relatively short intervals since birth, and the clinical records did not reveal any abnormalities 1 month before the MR imaging, in either cranial sonography or clinically.…”

Reply to Bilo et al.

“…Dear Editor, We thank Bilo et al [1] for commenting on our paper, "Dating the abusive head trauma episode and perpetrator statements: key points for imaging" [2].…”

“…We fully agree that it's important not to overinterpret radiologic patterns. In the paper's abstract, we stressed the need to analyze all of the medical data to obtain accurate information on the date and repetition of the trauma [2]: "Brain imaging provides strong indicators of 'age-different' injuries but the ranges for dating the causal event are wide. The density pattern in a single subdural hematoma location provides no reliable clues for assessing repeated violence.…”