Re-evaluation of medical findings in alleged shaken baby syndrome and abusive head trauma in Norwegian courts fails to support abuse diagnoses.

AIM: The criteria for diagnosing abusive head trauma (AHT) are not well defined and this condition might be diagnosed on failing premises. Our aim was to review criminal AHT cases in Norwegian courts by scrutinising the underlying medical documentation. METHODS: Cases were identified in the data registry for Norwegian courts from 2004 to 2015. Documentation was obtained from relevant health institutions. The medical co-authors first made independent evaluations of the documentation for each child, followed by a consensus evaluation. RESULTS: A total of 17 children (11 boys) were identified, all diagnosed as AHT by court appointed experts, 15 were infants (mean age 2.6 months). A high proportion (41.2%) was born to immigrant parents and 31.3% were premature. The medical findings could be explained by alternative diagnoses in 16 of the 17 children; 8 boys (7 infants - mean age 2.9 months) had clinical and radiological characteristics compatible with external hydrocephalus complicated by chronic subdural haematoma. Six children (five infants with mean age 2.1 months) had a female preponderance and findings compatible with hypoxic ischaemic insults. CONCLUSION: The medical condition in most children had not necessarily been caused by shaking or direct impact, as was originally concluded by the court experts.

Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

BACKGROUND: Criteria for diagnosing abusive head trauma (AHT) or "shaken baby syndrome" are not well defined; consequently, these conditions might be diagnosed on failing premises. METHODS: The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)-mean age 5.1 month, without age difference between genders. RESULTS: Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH). CONCLUSIONS: BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors' experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

Retinal haemorrhage in infants investigated for suspected maltreatment is strongly correlated with intracranial pathology.

AIM: To test the two prevailing hypotheses regarding the aetiology of infant retinal haemorrhage: (a) traction forces exerted by the lens and/or corpus vitreum on the retina during infant shaking or (b) retinal vessel leakage secondary to intracranial pathology and raised intracranial pressure. METHODS: Comparison of medical findings and reported type of trauma in infants investigated for suspected physical abuse with presence (n = 29) or non-presence of retinal haemorrhage (RH) (n = 119). RESULTS: Intracranial pathology was recorded in 15 (13%) of the non-RH cases and in 27 (97%) of the RH cases (p < 0.0001). All 18 infants with bilateral RH had intracranial pathology. Of 27 infants subjected to witnessed or admitted shaking, two were in the group with RH. One had a single unilateral RH and no intracranial pathology. The other had bilateral RH and intracranial pathology with non-specific white matter changes, acute subdural and subarachnoid haemorrhages, and suspected cortical venous thrombosis. In 15 RH cases, there was no trauma reported and no findings other than RH and intracranial pathology. Accidental blunt head trauma was reported in 7 RH cases. CONCLUSION: The present study indicates that RH in infants is secondary to intracranial pathology of non-specific aetiology.

External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused.

BACKGROUND: Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population. PURPOSE: The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse. MATERIAL AND METHODS: Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated. RESULTS: Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC. CONCLUSION: A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Thrombosis is not a marker of bridging vein rupture in infants with alleged abusive head trauma.

AIM: Thrombosis of bridging veins has been suggested to be a marker of bridging vein rupture, and thus AHT, in infants with subdural haematoma. METHODS: This is a non-systematic review based on Pubmed search, secondary reference tracking and authors' own article collections. RESULTS: Radiological studies asserting that imaging signs of cortical vein thrombosis were indicative of traumatic bridging vein rupture were unreliable as they lacked pathological verification of either thrombosis or rupture, and paid little regard to medical conditions other than trauma. Autopsy attempts at confirmation of ruptured bridging veins as the origin of SDH were fraught with difficulty. Moreover, microscopic anatomy demonstrated alternative non-traumatic sources of a clot in or around bridging veins. Objective pathological observations did not support the hypothesis that a radiological finding of bridging vein thrombosis was the result of traumatic rupture by AHT. No biomechanical models have produced reliable and reproducible data to demonstrate that shaking alone can be a cause of bridging vein rupture. CONCLUSION: There is no conclusive evidence supporting the hypothesis that diagnostic imaging showing thrombosed bridging veins in infants correlates with bridging vein rupture. Hence, there is no literature support for the use of thrombosis as a marker for AHT.

Medical findings and symptoms in infants exposed to witnessed or admitted abusive shaking: A nationwide registry study.

BACKGROUND: Many physicians regard the combination of encephalopathy, subdural haemorrhage (SDH), retinal haemorrhage (RH), rib fractures, and classical metaphyseal lesions (CML) as highly specific for abusive head trauma (AHT). However, without observed abuse or other criteria that are independent of these findings, bias risk is high. METHODS: Infants subjected for examination under the suspicion of maltreatment during the period 1997-2014 were identified in the National Patient Registry, International Classification of Diseases (ICD-10 SE). The medical records were scrutinized for identification of cases of witnessed or admitted physical abuse by shaking. The main outcome measures were occurrence of SDH, RH, fractures and skin lesions. RESULTS: All identified 36 infants had been shaken, and for 6, there was information indicating blunt force impact immediately after shaking. In 30 cases, there were no findings of SDH or RH, rib fractures, or CMLs. Six infants had finding(s) suggestive of physical abuse, two with possible acute intracranial pathology. One infant with combined shaking and impact trauma had hyperdense SDH, hyperdense subarachnoid haemorrhage, suspected cortical vein thrombosis, RH, and bruises. Another infant abused by shaking had solely an acute subarachnoid haemorrhage. Both had pre-existing vulnerability. The first was born preterm and had non-specific frontal subcortical changes. The other had bilateral chronic SDH/hygroma. CONCLUSIONS: The present findings do not support the hypothesis that acute SDH or RH can be caused by isolated shaking of a healthy infant. However, they do suggest that abuse by shaking may cause acute intracranial haemorrhage with RH in infants with certain risk factors.

Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures.

AIM: Specific birth-related fractures have been studied; underestimates might be a problem. We aimed to assess all fractures diagnosed as birth-related as well as other neonatal fractures. METHODS: A population-based study on all infants born in Sweden 1997-2014; data were retrieved from the Swedish Health Registers (10th version of International Classification of Diseases. Outcome measures were birth-related fractures (ICD-10 P-codes) and other neonatal fractures (ICD-10 S-codes). RESULTS: The overall fracture incidence was 2.9 per 1000 live birth (N = 5336); 92.6% had P-codes and 7.4% (S-codes). Some birth-related fractures were diagnosed beyond the neonatal period. Other neonatal fractures could have been birth-related. Clavicle fracture (88.8%) was associated with adverse maternal and infant anthropometrics and birth complications. The few neonates with rib fractures all had concomitant clavicle fracture. For skull fractures, a minor part was birth-related and most were associated with accidents. Half of the long bone fractures were associated with accidents. Birth-related femur fractures were associated with bone fragility risk factors. Five infants with abuse diagnoses had fractures: skull (4), long bone (2) and rib (1). CONCLUSION: Birth-related and other neonatal fractures are rarely diagnosed. Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures.

Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma.

AIM: Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants. METHODS: Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature. RESULTS: Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children. CONCLUSION: Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.

Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study.

BACKGROUND AND AIMS: Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out-of-home care. The objective of this study was to analyse infants placed in out-of-home care in Sweden by incidence, medical diagnoses, and perinatal factors. METHODS: This was a population-based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out-of-home care categories: (a) "Problems Related to Social Environment/Upbringing", (b) "Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture", and (c) "SDH, RH, rib fracture, or long bone fracture." As a reference population, we randomly selected infants without medical diagnoses born the same year. RESULTS: Overall incidence of out-of-home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out-of-home care, children in category (c), "SDH, RH, rib fracture, or long bone fracture", had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08-2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32-0.75) and a smoker (aOR 0.60; 95% CI, 0.37-0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small-for-gestational age (5.2% versus 2.1%). CONCLUSION: SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out-of-home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.

Anxiety and Depression in Patients with Intracranial Arachnoid Cysts-A Prospective Study.

BACKGROUND: Arachnoid cysts yield cognitive deficits that are normalized after surgical cyst decompression. OBJECTIVE: The present study aimed to investigate whether arachnoid cysts also affect symptoms of anxiety and depression, and if surgical cyst decompression leads to reduction of these symptoms. METHODS: Twenty-two adult patients (13 men and 9 women) with symptomatic temporal or frontal cysts were included in this questionnaire (Hospital Anxiety and Depression Scale [HADS])-based prospective study. The mean time between answering the preoperative questionnaire and surgery was 37 days. The patients answered the same HADS questionnaire 3-6 months postoperatively. RESULTS: Preoperatively, both patients with frontal (N = 4) and patients with temporal (N = 18) cyst had higher mean HADS anxiety scores than those found in the general population. For patients with temporal cyst, there was a significant or near-significant difference in anxiety and depression scores and the combined scores between those with right-sided cysts and those with left-sided cysts. Postoperatively, the HADS scores normalized and were no longer different from those of the general population. The difference in scores between patients with right and left temporal cyst also disappeared. CONCLUSIONS: Patients with arachnoid cyst have higher levels of anxiety and depression than do the general population and these scores were normalized after decompressive cyst surgery. We further found a hemispheric asymmetry: patients with a right temporal cyst showed higher anxiety, depression, and combined scores than did patients with a left temporal cyst. Also, this disparity normalized after cyst decompression. Thus, arachnoid cysts seem to affect not only cognition but also the level of affective symptoms.

Surgical decompression of arachnoid cysts leads to improved quality of life: a prospective study-long-term follow-up.

BACKGROUND: In a previous study, we reported a short-term (6 months) postoperative improvement of health-related quality of life (Qol) in patients operated for an arachnoid cyst (AC). The aim was to investigate whether this initial improvement was permanent. METHODS: A long-term (5 ± 2 years) prospective study comparing Qol and complaints before and 5 ± 2 years after surgical fenestration for AC in 76 adult patients, using the Short Form 36 (SF-36) scores, Glasgow Benefit Inventory (GBI) questionnaires, and Visual Analogue Scales (VAS) for headache and dizziness, similarly to what they did at short-term follow-up. RESULTS: At short-term and long-term follow-ups, 73.4% and 82%, respectively, of the patients were better from their headache compared with preoperative scores. The corresponding improvement rates for dizziness were 61.7% (short-term) and 67.9 (long-term). Preoperatively, the mean headache VAS score was 45.6; at short-term follow-up, this was reduced to 25.7, and at long-term follow-up, this further reduced to 24.8. The preoperative mean VAS score for dizziness (35.2) was reduced to 12.2 (short-term) and 13.9 (long-term). The significant postoperative improvement of patient-reported Qol at short-term follow-up remained at long-term follow-up across seven out of eight SF-36 dimensions and three out of four GBI subscale scores. Similar to at short-term follow-up, the Qol improvement is correlated to improvement in headache and/or dizziness. CONCLUSIONS: The previously reported postoperative, short-term improvement in Qol and complaints appears stable, as the improvement remains at long-term follow-up. This suggests that the beneficial effects of surgical treatment are long-lasting.

Clinical, Radiological, and Demographic Details of Benign External Hydrocephalus: A Population-Based Study.

BACKGROUND: Benign external hydrocephalus has an incidence of about 0.4 per 1000 live births. It affects infants and is characterized by an increasing head circumference and typical neuroimaging findings. Previously published studies on benign external hydrocephalus often contain groups of few and selected patients. METHODS: This is a follow-up of a recently published article reporting the incidence of benign external hydrocephalus. This retrospective and population-based study covers two large health regions in Norway, over a 10-year period (1994 to 2003). Infants with increasing head circumference, combined with typical radiological findings of enlarged subarachnoid spaces, were included. Information about head circumference development, neuroimaging findings, and birth delivery methods, as well as demographic details, was retrieved from the hospital medical records. RESULTS: A total of 176 children with benign external hydrocephalus were included, 86.4% being boys. At birth, the head circumference was close to normal. Mean age for when the head circumference reached abnormal values, i.e., crossing two percentiles or reaching the 97.5 percentile, was 3.4 months; none was older than seven months. Around four of five children had dilated lateral ventricles in addition to enlarged subarachnoid spaces. The neuroimaging findings tended to normalize after age 12 months. About half of the patients ended up with head circumferences at or above the 97.5 percentile. CONCLUSIONS: Most infants with benign external hydrocephalus are born with a normal head circumference that increases too fast and reaches abnormally high values before age six months. This age and gender distribution is very similar to that described for infant subdural hemorrhage.