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Distinguishing accidental from inflicted head trauma at autopsy

  • Special Issue: Abusive Head Trauma
  • Published:
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Abstract

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.

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References

  1. Raghupathi R, Margulies SS (2002) Traumatic axonal injury after closed head injury in the neonatal pig. J Neurotrauma 19:843–885

    Article  PubMed  Google Scholar 

  2. Gean AD (1994) Head trauma. Raven, New York

    Google Scholar 

  3. Cantu RC (2000) Biomechanics of head trauma. In: Cantu RC (ed) Neurologic athletic head and spine injuries. WB Saunders, Philadelphia, pp 2–5

    Google Scholar 

  4. Graham DI, McIntosh TK, Maxwell WL et al (2000) Recent advances in neurotrauma. J Neuropathol Exp Neurol 59:641–651

    CAS  PubMed  Google Scholar 

  5. Margulies SS, Thibault LE (1989) An analytic model of traumatic diffuse brain injury. J Biomech Eng 111:241–249

    Article  CAS  PubMed  Google Scholar 

  6. Ommaya AK (1985) Biomechanics of head injury: experimental aspects. In: Ommaya AK (ed) The biomechanics of trauma. Appleton-Century, Norwalk, pp 245–269

    Google Scholar 

  7. Ommay AK, Gennareli TA (1974) Cerebral concussion and traumatic unconsciousness: correlation of experimental and clinical observations on blunt head injuries. Brain 97:633–654

    Article  Google Scholar 

  8. Stalhammer D (1986) Experimental models of head injury. Acta Neurochir Suppl (Wien) 36:33–46

    Google Scholar 

  9. Wilkins RH, Rengachary SS (1985) In: Wilkins RH, Rengachary SS (eds) Biomechanics of head injury. McGraw-Hill, New York, pp 1531–1536

    Google Scholar 

  10. Case ME (2008) Accidental traumatic head injury in infants and young children. Brain Pathol 18:583–589

    Article  PubMed  Google Scholar 

  11. Russell WR, Schiller F (1949) Crushing injuries of the skull: clinical and experimental observations. J Neurol Neurosurg Psychiatry 12:52–60

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  12. Duhaime AC, Eppley M, Margulies S et al (1995) Crush injuries to the head of children. Neurosurgery 37:401–407

    Article  CAS  PubMed  Google Scholar 

  13. Prasad M (1999) Crush head injuries in infants and young children: neurologic and neuropsychiatric sequelae. J Child Neurol 14:496–501

    Article  CAS  PubMed  Google Scholar 

  14. McClelland CQ, Rekate H, Kaufman B et al (1980) Cerebral injury in child abuse: a changing profile. Childs Brain 7:225–235

    CAS  PubMed  Google Scholar 

  15. Chadwick DL, Chin S, Salerno CS et al (1991) Deaths from falls in children: how far is fatal? J Trauma 13:1353–1355

    Article  Google Scholar 

  16. Chadwick DL, Salerno C (1993) Likelihood of the death of an infant or young child in a short fall of less than 6 feet. J Trauma 35:968

    Article  CAS  PubMed  Google Scholar 

  17. Helfer RE, Slovis TL, Black M (1977) Injuries resulting when small children fall out of bed. Pediatrics 60:533–535

    CAS  PubMed  Google Scholar 

  18. Hymel KP, Bandak FA, Portington MD et al (1998) Abusive head trauma? A biomechanics–based approach. Child Maltreat 3:116–128

    Article  Google Scholar 

  19. Kravitz H, Driessen F, Gomberg KA (1969) Accidental falls from elevated surfaces in infants from birth to one year of age. Pediatrics 44:869–876

    PubMed  Google Scholar 

  20. Lyons JL, Oates RK (1993) Falling out of bed: a relatively benign occurrence. Pediatrics 92:125–127

    CAS  PubMed  Google Scholar 

  21. Nimitiyongskul DL, Anderson L (1987) The likelihood of injuries when children fall out of bed. J Pediatr Orthop 7:184–186

    Article  Google Scholar 

  22. Williams RA (1991) Injuries in infants and small children resulting from witnessed and corroborated free falls. J Trauma 31:1350–1352

    Article  CAS  PubMed  Google Scholar 

  23. Chadwick DL, Bertocci G, Castillo E et al (2008) Annual risk of death resulting from short falls among children: less than 1 in 1 million. Pediatrics 121:1213–1224

    Article  PubMed  Google Scholar 

  24. Denton S, Milusenic D (2003) Delayed sudden death in an infant following an accidental fall: a case report with review of the literature. J Forensic Med Pathol 24:371–376

    Article  Google Scholar 

  25. Maxwell WL, Povlishock JT, Graham DL (1997) A mechanistic analysis of nondisruptive axonal injury: a review. J Neurotrauma 14:419–440

    Article  CAS  PubMed  Google Scholar 

  26. Meythaler JM, Peduzzi JD, Eleftheriou E et al (2001) Current concepts: diffuse axonal injury—associated traumatic brain injury. Arch Phys Med Rehabil 82:1461–1471

    Article  CAS  PubMed  Google Scholar 

  27. Ommaya A, Goldsmith W, Thibault L (2003) Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg 16:220–242

    Article  Google Scholar 

  28. Rivas JJ, Lobato RD, Sarabia R et al (1988) Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 23:44–51

    Article  CAS  PubMed  Google Scholar 

  29. Servadei F (1997) Prognostic factors in severely head injured patients with epidural hematomas. Acta Neurochir 139:273–278

    Article  CAS  PubMed  Google Scholar 

  30. Overpeck MD, Brenner RA, Trumble AC et al (1998) Risk factors for infant homicide in the United States. N Engl J Med 339:1211–1216

    Article  CAS  PubMed  Google Scholar 

  31. Di Maio VJ, Di Maio D (2001) Neonatocide, infanticide and child homicide. In: DiMaio D (ed) Forensic pathology, vol 2. CRC Press, Boca Raton, p 338

    Google Scholar 

  32. Case ME, Graham MA, Handy TC et al (2001) Position paper on fatal abusive head injuries in infants and young children. Am J Forensic Med Pathol 22:112–122

    Article  CAS  PubMed  Google Scholar 

  33. Salehi-Had H, Brandt JD, Rosas AJ et al (2006) Findings in older children with abusive head injury: does shaken-child syndrome exist? Pediatrics 117:e1039–1044

    Article  PubMed  Google Scholar 

  34. King WJ, MacKay M, Sirnick A et al (2003) Shaken baby syndrome in Canada: clinical characteristics and outcomes of hospital cases. CMAJ 168:155–159

    PubMed Central  PubMed  Google Scholar 

  35. Duhaime AC, Gennarelli TA, Thibault LE et al (1987) The shaken baby syndrome: a clinical, pathological and biomechanical study. J Neurosurg 66:409–415

    Article  CAS  PubMed  Google Scholar 

  36. Gilles EE, Nelson MD (1998) Cerebral complications of nonaccidental head injury in childhood. Pediatr Neurol 19:119–128

    Article  CAS  PubMed  Google Scholar 

  37. Kleinman PK (1990) Diagnostic imaging in infant abuse. Am J Radiol 156:703–712

    Google Scholar 

  38. Dias MS, Backstom J, Falk M et al (1998) Serial radiographs in the infant shaken impact syndrome. Pediatr Neurosurg 29:77–85

    Article  CAS  PubMed  Google Scholar 

  39. Vowles GH, Scholtz CL, Cameron JM (1987) Diffuse axonal injury in early infancy. J Clin Pathol 40:185–189

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Yason D, Jane JA, White RJ et al (1986) Traumatic subdural hematoma of infancy: long-term follow-up of 92 patients. Arch Neurol 18:370–377

    Article  Google Scholar 

  41. Gago L, Wegner R, Capone A et al (2003) Intraretinal hemorrhages and chronic subdural effusions: glutaric aciduries type 1 can be mistaken for shaken baby syndrome. Retina 23:724–726

    Article  PubMed  Google Scholar 

  42. Bacopoulou F, Henderson I, Philip SG (2006) Menkes disease mimicking non-accidental trauma. Arch Dis Child 91:919

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  43. Suzuki K, Fukushima T, Meguro K et al (1999) Intracranial hemorrhage in an infant owing to vitamin K deficiency despite prophylaxis. Childs Ner Syst 15:292–294

    Article  CAS  Google Scholar 

  44. Mishra P, Naithani R, Dolai T et al (2008) Intracranial hemorrhage in patients with congenital haemostatic defects. Haemophilia 14:1–4

    Article  Google Scholar 

  45. Weissgold DJ, Budenz DL, Hood I et al (1995) Ruptured vascular malformation masquerading as battered/shaken baby syndrome: a near tragic mistake. Surv Ophthalmol 39:509–512

    Article  CAS  PubMed  Google Scholar 

  46. Prahlow JA, Rushing EJ, Bernard JJ (1998) Death due to a ruptured berry aneurysm in a 3.5 year old child. Am J Forensic Med Pathol 19:391–394

    Article  CAS  PubMed  Google Scholar 

  47. Hymel KP, Makoroff KL, Laskey AL et al (2006) Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. Pediatrics 119:922–929

    Article  Google Scholar 

  48. Duhaime AC, Christian C, Armonda R et al (1996) Disappearing subdural hematomas in children. Pediatric Neurosurg 25:116–122

    Article  CAS  Google Scholar 

  49. Gilliland MGF, Levin AV, Enzenauer RW et al (2007) Guidelines for postmortem protocol for ocular investigation of sudden unexplained infant death and suspected physical child abuse. Am J Forensic Med Pathol 28:323–329

    Article  CAS  PubMed  Google Scholar 

  50. Tzioumi D (1998) Subdural hematomas in children under 2 years. accidental or inflicted? A 10-year experience. Child Abuse Negl 22:1105–1112

    Article  CAS  PubMed  Google Scholar 

  51. Levin AV (2000) Retinal hemorrhages and child abuse. In: David TJ (ed) Recent advances in paediatrics No 18. Churchill Livingstone, London, pp 151–219

    Google Scholar 

  52. Morad Y, Kim YM, Armstrong DC et al (2002) Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol 34:354–359

    Article  Google Scholar 

  53. Schloff S, Mullaney PB, Armstrong DC et al (2002) Retinal findings in children with intracranial hemorrhage. Ophthalmology 109:1472–1476

    Article  PubMed  Google Scholar 

  54. Lueder GT, Turner JW, Paschall R (2006) Perimacular retinal folds simulating nonaccidental injury in an infant. Arch Ophthalmol 124:1782–1783

    Article  PubMed  Google Scholar 

  55. Greenwald M, Weiss A, Oesterle C et al (1986) Trauamtic retinoschisis in battered babies. Ophthalmology 93:618–625

    Article  CAS  PubMed  Google Scholar 

  56. Lantz PE, Sinal SH, Stanton CA et al (2004) Perimacular retinal folds from childhood head trauma. BMJ 328:754–756

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  57. Duhaime AC, Alario AJ, Lewander WJ et al (1992) Head injury in very young children: mechanisms, imjury types, and ophthalmological findings in 100 hospitalized patients younger than 2 years of age. Pediatrics 90:179–185

    CAS  PubMed  Google Scholar 

  58. Wilbur LS (1992) Magnetic resonance imaging evaluation of neonates with retinal hemorrhages. Pediatrics 89:332–333

    Google Scholar 

  59. Wilbur LS (1994) Abusive head injury. APSAC Advisor 7:16–19

    Google Scholar 

  60. Gilliland MGF, Luckenback MW (1993) Are retinal hemorrhages found after resuscitation attempts? Am J Forensic Med Pathol 14:187–192

    Article  CAS  PubMed  Google Scholar 

  61. Goetting MG, Sow B (1990) Retinal hemorrhage after cardiopulmonary resuscitation in children: an etiological reevaluation. Pediatrics 85:585–588

    CAS  PubMed  Google Scholar 

  62. Johnson DL, Braun D, Friendly D (1993) Accidental head trauma and retinal hemorrhage. Neurosurgery 33:231–234

    Article  CAS  PubMed  Google Scholar 

  63. Fraser S, Horgan S, Bardavio J (1995) Eye 9:659–660

    Article  PubMed  Google Scholar 

  64. Douherty W, Trubeck M (1931) Significant retinal lesions in bacterial endocarditis (roth’s spots). JAMA 97:308–313

    Article  Google Scholar 

  65. Levin A (1986) Retinal hemorrhages after cardiopulmonary resuscitation: literature review and commentary. Pediatr Emerg Care 2:269–274

    Article  Google Scholar 

  66. Kramer K, Goldstein B (1993) Retinal hemorrhages following cardiopulmonary resuscitaton. Clin Pediatr 32:366–368

    Article  CAS  Google Scholar 

  67. Kanter R (1986) Retinal hemorrhages after cardiopulmonary resuscitation or abuse. J Pediatr 180:430–432

    Article  Google Scholar 

  68. Pham H, Enzanauer RW, Elder JE et al (2013) Retinal hemorrhage after cardiopulmonary resuscitation with chest compressions. Am J Forensic Med Pathol 34:122–124

    Article  PubMed  Google Scholar 

  69. Elner S, Elner V, Arnall M et al (1990) Ocular and associated systemic findings in suspected child abuse: a necropsy study. Arch Ophthalmol 108:1094–1101

    Article  CAS  PubMed  Google Scholar 

  70. Gilliland M, Luckenbach M, Chenier T (1994) Systemic and ocular findings in 169 prospectively studied child deaths: retinal hemorrhages usually mean child abuse. Forensic Sci Int 68:117–132

    Article  CAS  PubMed  Google Scholar 

  71. Budenz D, Farber M, Mirchandani H et al (1994) Ocular and optic nerve hemorrhages in abused infants with intracranial injuries. Ophthalmology 101:559–565

    Article  CAS  PubMed  Google Scholar 

  72. Adams JH, Doyle D, Ford I et al (1989) Diffuse axonal injury in head injury: definition, diagnosis, and grading. Histopathology 15:49–59

    Article  CAS  PubMed  Google Scholar 

  73. Adams JH, Graham DI, Scott G et al (1980) Brain damage in fatal nonmissile head injury. J Clin Pathol 33:1132–1145

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  74. Lindenberg R, Frietag E (1969) Morphology of brain lesions from blunt trauma in early infancy. Arch Pathol 87:298–305

    CAS  PubMed  Google Scholar 

  75. Sheriff FE, Bridges LR, Sivaloganthan S (1994) Early detection of axonal injury after human head trauma using immunocytochemistry for Beta amyloid precursor protein. Acta Neuropathol 87:55–62

    Article  Google Scholar 

  76. Geddes JF, Hackshaw AK, Vowles GH et al (2001) Neuropatholgoy of inflicted head injury in children I. Patterns of brain damage. Brain 124:1290–1298

    Article  CAS  PubMed  Google Scholar 

  77. Geddes JF, Vowles GH, Hackshaw AK et al (2001) Neuropathology of inflicted head injury in children II. Microscopic brain injury in infants. Brain 124:1299–1306

    Article  CAS  PubMed  Google Scholar 

  78. Case ME (2008) Inflicted traumatic brain injury in infants and young children. Brain Pathol 18:571–582

    Article  PubMed  Google Scholar 

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Case, M.E. Distinguishing accidental from inflicted head trauma at autopsy. Pediatr Radiol 44 (Suppl 4), 632–640 (2014). https://doi.org/10.1007/s00247-014-3061-6

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  • DOI: https://doi.org/10.1007/s00247-014-3061-6

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