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Histological dating of subdural hematoma in infants

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Abstract

Background

After infant deaths due to non-accidental head injury (NAHI) with subdural hematoma (SDH), the magistrates ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of NAHI. We aimed to develop an SDH dating system applicable to infants aged under 3 years.

Methods and results

We studied a retrospective multicenter collection of 235 infants who died between the ages of 0 and 36 months, diagnosed with SDH by forensic pathological examination and with known posttraumatic interval (PTI). Two pathologists assessed blindly and independently 12 histomorphological criteria relating to the clot and 14 relating to the dura mater in 73 victims (31 girls, 42 boys) whose median age was 3.8 months. Histopathological changes were significantly correlated with PTI for the appearance of red blood cells (RBCs) and the presence or absence of siderophages, and regarding the dura mater, the quantity of lymphocytes, macrophages, and siderophages; presence or absence of hematoidin deposits; collagen and fibroblast formation; neomembrane thickness; and presence or absence of neovascularization. Dating systems for SDH in adults are not applicable to infants. Notably, neomembrane of organized connective tissue is formed earlier in infants than in adults.

Conclusion

Our dating system improves the precision and reliability of forensic pathological expert examination of NAHI, particularly for age estimation of SDH in infants. However, the expert can only define a time interval. Histopathology is indispensable to detect repetitive trauma.

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Abbreviations

NAHI:

Non-accidental head injury

PTI:

Posttraumatic interval

SDH:

Subdural hematoma

RBCs:

Red blood cells

PMNs:

Polymorphonuclear neutrophils

References

  1. Haute Autorité de Santé - Recommandation : Syndrome du bébé secoué [Internet]. 2011 Mai [cited 2016 Nov 22]. Available from: http://www.has-sante.fr/portail/jcms/c_1095929/fr/recommandation-syndrome-du-bebe-secoue

  2. Barlow KM, Minns RA (2000) Annual incidence of shaken impact syndrome in young children. Lancet 356(9241):1571–1572

    Article  CAS  Google Scholar 

  3. Jayawant S, Rawlinson A, Gibbon F, Price J, Schulte J, Sharples P, Sibert JR, Kemp AM (1998) Subdural haemorrhages in infants: population based study. BMJ 317(7172):1558–1561

    Article  CAS  Google Scholar 

  4. Mireau E (2005) Syndrome du bébé secoué, hématome sous-dural du nourrisson et maltraitance a propos d’une série de 404 cas. [Paris]: Paris V Rene Descartes

  5. Duckett S (1995) Pediatric neuropathology. Williams and Wilkins, Pennsylvania

    Google Scholar 

  6. Leestma JE (2014) Forensic neuropathology, 3rd edn. CRC Press, Bosa Roca

    Google Scholar 

  7. Adamsbaum C, Rambaud C (2012) Abusive head trauma: don’t overlook bridging vein thrombosis. Pediatr Radiol 42(11):1298–1300

    Article  Google Scholar 

  8. Munro D, Merritt HH (1936) Surgical pathology of subdural hematoma : based on a study of one hundred and five cases. Arch Neurol Psychiatr 35(1):64–78

    Article  Google Scholar 

  9. Pearl GS (1998) Traumatic neuropathology. Clin Lab Med 18(1):39–64

    Article  CAS  Google Scholar 

  10. Oehmichen M, Auer RN, König HG (2006) Forensic neuropathology and associated neurology. Springer Science & Business Media, Berlin

    Book  Google Scholar 

  11. DiMaio VJM, Dana SE (2007) Handbook of forensic pathology, 2nd edn. Taylor & Francis, Boca Raton, United States

  12. Walter T, Meissner C, Oehmichen M (2009) Pathomorphological staging of subdural hemorrhages: statistical analysis of posttraumatic histomorphological alterations. Leg Med Tokyo Jpn 11(Suppl 1):S56–S62

    Article  Google Scholar 

  13. van den Bos D, Zomer S, Kubat B (2014) Dare to date: age estimation of subdural hematomas, literature, and case analysis. Int J Legal Med 128(4):631–640

    Article  Google Scholar 

  14. Leary T (1934) Subdural hemorrhages. J Am Med Assoc 103(12):897–903

    Article  Google Scholar 

  15. Andrew M, Paes B, Milner R, Johnston M, Mitchell L, Tollefsen DM et al (1987) Development of the human coagulation system in the full-term infant. Blood 70(1):165–172

    Article  CAS  Google Scholar 

  16. Andrew M, Vegh P, Johnston M, Bowker J, Ofosu F, Mitchell L (1992) Maturation of the hemostatic system during childhood. Blood 80(8):1998–2005

    Article  CAS  Google Scholar 

  17. Toulon P, De Pooter N (2013) Hemostase en pediatrie. 42ème Colloque National des Biologistes des Hopitaux 2013 Oct 2, Strasbourg

  18. Haute Autorité de Santé - Recommandation : Syndrome du bébé secoué [Internet]. 2017 Sep [cited 2016 Nov 22]. Available from: http://www.has-sante.fr/portail/jcms/c_1095929/fr/recommandation-syndrome-du-bebe-secoue

  19. Gilliland MG (1998) Interval duration between injury and severe symptoms in nonaccidental head trauma in infants and young children. J Forensic Sci 43(3):723–725

    Article  CAS  Google Scholar 

  20. Starling SP, Patel S, Burke BL, Sirotnak AP, Stronks S, Rosquist P (2004) Analysis of perpetrator admissions to inflicted traumatic brain injury in children. Arch Pediatr Adolesc Med 158(5):454–458

    Article  Google Scholar 

  21. Adamsbaum C, Morel B, Ducot B, Antoni G, Rey-Salmon C (2014) Dating the abusive head trauma episode and perpetrator statements: key points for imaging. Pediatr Radiol 44(Suppl 4):S578–S588

    Article  Google Scholar 

  22. Willman KY, Bank DE, Senac M, Chadwick DL (1997) Restricting the time of injury in fatal inflicted head injuries. Child Abuse Negl 21(10):929–940

    Article  CAS  Google Scholar 

  23. Fortin G, Stipanicic A (2010) How to recognize and diagnose abusive head trauma in infants. Ann Phys Rehabil Med 53(10):693–710

    Article  CAS  Google Scholar 

  24. Rao MG, Singh D, Vashista RK, Sharma SK (2016) Dating of acute and subacute subdural haemorrhage: a histo-pathological study. J Clin Diagn Res 10(7):HC01–HC07

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Feldman KW, Sugar NF, Browd SR (2015) Initial clinical presentation of children with acute and chronic versus acute subdural hemorrhage resulting from abusive head trauma. J Neurosurg Pediatr 16(2):177–185

    Article  Google Scholar 

  26. Adamsbaum C (2013) Maltraitance chez l’enfant. Lavoisier MSP, Paris

Download references

Author information

Authors and Affiliations

  1. Forensic Department, APHM, La Timone, 264 rue St Pierre, 13385, Marseille, Cedex 05, France

    Clémence Delteil, Georges Leonetti, Lucile Tuchtan & Marie-Dominique Piercecchi

  2. Aix-Marseille University, CNRS, EFS, ADES, Marseille, France

    Clémence Delteil, Georges Leonetti, Lucile Tuchtan & Marie-Dominique Piercecchi

  3. Pathology Department, University Hospital of Lille, 2 Avenue Oscar Lambret, 59000, Lille, France

    Sarah Humez

  4. Public Health Research Unit EA 3279, Aix-Marseille University, 3005, Marseille, France

    Mohamed Boucekine

  5. Pathology Department, University Hospital of Lyon-Est, 59 Boulevard Pinel, 69677, Bron, France

    Anne Jouvet

  6. Forensic Department and Social Medicine, Faculty of Medicine of Lille, 59045, Lille Cedex, France

    Valery Hedouin

  7. Forensic Department, 12 Avenue Rockefeller, 69437, Lyon 03, France

    Laurent Fanton

Authors
  1. Clémence Delteil
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  2. Sarah Humez
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  9. Marie-Dominique Piercecchi
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Correspondence to Clémence Delteil.

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Electronic supplementary material

ESM 1

(DOCX 19 kb)

ESM 2

Qualitative classification of RBCs, from left to right: HES × 40. a Intact (discoid shape with a distinct contour and uniform staining); b Lysed cells (blurred contours, non-uniform staining): minimal lysis; c Distinct lysis; d Mixed. (PNG 8587 kb)

High Resolution Image (TIFF 18688 kb)

ESM 3

Semi-quantitative classification of PMNs: a No or very rare neutrophils, HES × 20; b Up to three clumps, HES × 20; c More than three clumps, HES × 20; d: Diffuse, HES × 20. (PNG 8941 kb)

High Resolution Image (TIFF 20518 kb)

ESM 4

Qualitative classification of neovascularization: a Capillary proliferation, HES × 10; b Giant capillaries, HES × 10; c Arterioles, HES × 20 (PNG 20735 kb)

High Resolution Image (TIFF 61491 kb)

ESM 5

Most important histological features over time. a Lysed red cells from 2 days onward, HES × 10; b Siderophages at 3 days in the dura mater and the clot, HES × 10; c Hemosiderin deposit from 12 days onward in the dura mater, Perls stain × 40, fibrinous organization; d Presence of fibroblasts and collagen from 3 days onward, HES × 30; e Neomembrane formation from 4 days onward, HES × 5; f neovascularization from 6 days onward, HES × 10. (PNG 3756 kb)

High Resolution Image (TIFF 8366 kb)

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Delteil, C., Humez, S., Boucekine, M. et al. Histological dating of subdural hematoma in infants. Int J Legal Med 133, 539–546 (2019). https://doi.org/10.1007/s00414-018-1980-8

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  • DOI: https://doi.org/10.1007/s00414-018-1980-8

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