[A postmortem view on "pure" subdural hemorrhages in infants and toddlers].
In the last years, the discussion concerning the causes of infantile subdural hemorrhages became controversial. Many authors still suppose that child abuse is the predominant cause of such cases. On the other hand, reports presenting series of accidental cases were published, and the fear of an overdiagnosis of the shaken baby syndrome has been expressed. Our autopsy material concerning all lethal head injuries of infants and toddlers from 2 decades was reviewed. 17 of these 64 cases were characterized by the following: history of no trauma or only an insignificant event; children found dead or apnoic or in coma; no skull fractures; no focal brain injury; ruptures of several bridging veins but only minimal subdural bleeding. 11 victims were infants (1st year of life) and either 3 were 2 years resp. 3 - 6 years old; 50 % off all lethal head injuries of infants were of this type, while only 25 % resp. 10 % of the following age groups. None of these 17 cases was a result of a minor accident witnessed by unrelated persons. Abuse could be ascertained with a high degree of probability in most cases and remained quite likely in the others. Two different types of subdural hemorrhages should be kept from another: a) patients suffering a moderate head injury from a minor accident which results in a subdural bleeding (from a small intracranial lesion) often do not deteriorate soon after the impact, develop a hemorrhage of significant volume, respond well to therapy and have a good prognosis. b) cases with a history of no or only of an insignificant trauma, infants dead or nearly dead on clinical presentation, often a poor outcome in cases of survival. There is typically no significant subdural bleeding despite multiple bridging vein ruptures in the majority of these cases: the subdural hemorrhage is here only a visible sign of a much more serious and general cerebral alteration, resulting in a rapid increase of intracranial pressure (often complicated by respiratory arrest) which prevents a signifant bleeding into the subdural space. This combination of findings is typically found in victims of massive events (car occupants in high-velocity crashes) and not compatible with a supposition of a minor fall causing this.
Maxeiner
H
H
Freie Universität Berlin, FB Humanmedizin, UK Benjamin Franklin, Institut für Rechtsmedizin, Berlin. maxrmed@zedat.fu-berlin.deq
D000058:Accidental Falls; D001497:Battered Child Syndrome / Q000473:pathology*; D001924:Brain Concussion / Q000473:pathology*; D002423:Cause of Death; D002649:Child Abuse / Q000175:diagnosis / Q000331:legislation & jurisprudence; D002675:Child, Preschool; D003937:Diagnosis, Differential; D004388:Dura Mater / Q000098:blood supply / Q000473:pathology; D005260:Female; D006408:Hematoma, Subdural / Q000473:pathology*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D013345:Subarachnoid Hemorrhage / Q000473:pathology; D013398:Sudden Infant Death / Q000473:pathology; D014680:Veins / Q000293:injuries / Q000473:pathology