Children who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.
The authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.
Of 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.
The high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.
ABBREVIATIONSAHT = abusive head trauma; BESS = benign enlargement of the subarachnoid spaces; CAP = Child Abuse Pediatrics; CSI = concomitant suspicious injury; SDH = subdural hematoma.
GabaeffSC: Investigating the possibility and probability of perinatal subdural hematoma progressing to chronic subdural hematoma, with and without complications, in neonates, and its potential relationship to the misdiagnosis of abusive head trauma. Leg Med (Tokyo)15:177–1922013
LooneyCBSmithJKMerckLHWolfeHMChescheirNCHamerRM: Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology242:535–5412007
MillerDBarnesPMillerM: The significance of macrocephaly or enlarging head circumference in infants with the triad: further evidence of mimics of shaken baby syndrome. Am J Forensic Med Pathol36:111–1202015
VinchonMDelestretIDeFoort-DhellemmesSDesurmontMNouléN: Subdural hematoma in infants: can it occur spontaneously? Data from a prospective series and critical review of the literature. Childs Nerv Syst26:1195–12052010