Evaluations for abuse in young children with subdural hemorrhages: findings based on symptom severity and benign enlargement of the subarachnoid spaces

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.</jats:p></jats:sec>

Consensus statement on abusive head trauma in infants and young children

“…Accidental trauma or abuse was reported in 5/12 (41.7%) of subdural collections which were hemorrhagic. Besides, up to 50% of children with BESS and SDH may display concomitant important injuries [167].…”

Har et «filleristet spedbarn» alltid vært filleristet?

“…Triaden består av tre medisinske funn: subduralt hematom, utbredte øyebunnsblødninger og encefalopati. Min erfaring, og også vist i litteraturen (2,3), er at encefalopati ikke lenger er nødvendig for diagnosen «shaken baby». Kombinasjonen av subduralt hematom og øyebunnsblødninger synes tilstrekkelig.…”

Thrombosis is not a marker of bridging vein rupture in infants with alleged abusive head trauma

“…Disagreement still exists as to whether BEH is a risk factor or not. 76,77 A recent review investigated the similarities between SDH and BEH, and presented a unifying theory of pathophysiology behind these subdural collections 78 Few neuroimaging studies have reported findings of ruptured bridging veins, except the ones reviewed above. Findings such as the tadpole or lollipop signs lack pathologic verification of bridging vein injuries.…”