Inflicted traumatic brain injury in infants and young children

Abstract

This article will discuss the subject of inflicted or abusive head injury in infants and young children. Inflicted neurotrauma is a very common injury and a frequent problem in attempting to distinguish between inflicted and accidental injury. Inflicted head injury occurs usually in the home in the presence of the individual who has inflicted the injury outside the view of unbiased witnesses. Distinguishing between inflicted and accidental injury may be dependent upon the pathological findings and consideration of the circumstances surrounding the injury. The most common finding in an inflicted head injury is the presence of subdural hemorrhage. Subdural hemorrhage may occur in a variety of distributions and appearances. The natural history of subdural bleeding and the anatomy of the "subdural" will be considered. The anatomy of the dura and its attachment to the skull and to the arachnoid determines how subdural bleeding evolves into the cleaved dural border cell layer and as well as how bridging veins are torn and anatomically where bleeding will occur. Different biomechanical mechanisms result in different distributions of subdural blood and these differences will be discussed.

Figure 1

A 7‐month‐old male with inflicted head trauma with thin layer of subdural blood over cerebral convexities.

Figure 2

A 5‐month‐old female with inflicted neurotrauma with subdural blood over both cerebral convexities greater on the left than right.

Figure 3

A. A 3‐month‐old male with inflicted head injury with fracture of right parieto‐occipital skull. B. Subdural blood over left cerebral convexity. C. Subarachnoid hemorrhages over left cerebral convexity.

Figure 4

Eye transected through pupil‐optic nerve plane of a 2‐month‐old male with inflicted head injury showing multiple retinal hemorrhages extending far into the periphery to the ora serrata.

Figure 5

Eye of a 2‐month‐old male with inflicted head trauma showing multiple hemorrhages throughout all layers of retina (40× magnification).

Figure 6

Coronal section of brain of a 6‐month‐old female with inflicted head trauma showing contusion tear of right inferior parietal lobe.

Figure 7

Beta‐amyloid precursor protein expression in a vascular axonal injury pattern with large clusters of axons distributed around a vessel (100× magnification).

Figure 8

Beta‐amyloid precursor protein expression in a diffuse traumatic axonal injury pattern with small numbers of scattered axons in the corpus callosum (100× magnification).

Figure 9

Posterior dissection of the spine to demonstrate extensive blood within the epidural space in a 3‐month‐old female infant dying from causes unrelated to head trauma.

Figure 10

A. A 4‐month‐old male with distraction injury showing hemorrhagic lesions within the caudal medulla and upper cervical spinal cord. B. Sections of brainstem and cervical cord demonstrating the hemorrhagic lesions within the central portions of caudal medulla and upper cervical cord.