Retinal hemorrhages: evidence of abuse or abuse of evidence?

Arterial dissection and stroke following child abuse: case report and review of the literature

INTRODUCTION

Arterial dissection and stroke following trauma are seen frequently. Although similar mechanisms occur for trauma and child abuse, no reports of stroke have been observed in the literature.

CASE REPORTS

Two patients successively presented to our institution with acute onset of neurological deficit and stroke. Further evaluation disclosed child abuse as an underlying condition leading to the strokes. Child protection services were contacted immediately after admission of the patients and further measures were taken.

CONCLUSIONS

Recognition of potential cases of child abuse is crucial. Early intervention and cessation of interaction between the aggressor and the child are important measures to be taken in all situations when there is strong evidence of suggestive examination of child abuse.

Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in 'shaken baby syndrome'?

A histological review of dura mater taken from a post-mortem series of 50 paediatric cases aged up to 5 months revealed fresh bleeding in the dura in 36/50, the bleeding ranging from small perivascular haemorrhages to extensive haemorrhage which had ruptured onto the surface of the dura. Severe hypoxia had been documented clinically in 27 of the 36 cases (75%). In a similar review of three infants presenting with classical 'shaken baby syndrome', intradural haemorrhage was also found, in addition to subdural bleeding, and we believe that our findings may have relevance to the pathogenesis of some infantile subdural haemorrhage. Recent work has shown that, in a proportion of infants with fatal head injury, there is little traumatic brain damage and that the significant finding is craniocervical injury, which causes respiratory abnormalities, severe global hypoxia and brain swelling, with raised intracranial pressure. We propose that, in such infants, a combination of severe hypoxia, brain swelling and raised central venous pressure causes blood to leak from intracranial veins into the subdural space, and that the cause of the subdural bleeding in some cases of infant head injury is therefore not traumatic rupture of bridging veins, but a phenomenon of immaturity. Hypoxia with brain swelling would also account for retinal haemorrhages, and so provide a unified hypothesis for the clinical and neuropathological findings in cases of infant head injury, without impact or considerable force being necessary.