H Maxeiner1. 1. Institut für Rechtsmedizin, Freie Universität Berlin, FB Humanmedizin, Hittorfstrasse 18, 14195 Berlin. maxrmed@zedat.fu-berlin.de
Abstract
QUESTIONING: Recently the discussion concerning the causes of infantile subdural bleedings (SDB) has become quite controversial. The wide-spread interpretation that most of these cases are the result of abuse, especially by the shaken-baby-syndrome, was doubted, and the role of (even minor) accidental events was emphasized. METHODS: This situation should be analyzed basing on the official statistics of the causes of death in the city of Berlin (1978-1998) and the autopsy material of our institute (1978-1999). RESULTS: In this period, approximately 440.000 children lived their first year of life in our city. Only 80 violent deaths of infants (up to 1 year old) were recorded in the official statistics, including 27 deaths due to blunt forces, with 24 lethal head injuries as the main group. Only two cases were attributed to "falls under unclear conditions"; all other accidental cases were the results of traffic accidents or falls from a height. No death due to an undoubted minor fall was recorded, nor was any in our autopsy material. We investigated 10 cases of infantile SDB, all without skull fractures and gross brain injuries. Only 1 victim had a SDB of a significant volume; in all other cases only small amounts of blood were present in the subdural space. Bridging vein ruptures were directly demonstrated in 8 cases and were bilaterally in most instances; recently their detection has been simplified by postmortem x-ray using contrast material. All 10 cases were interpreted as typical acceleration-deceleration injuries (as in shaking), although only in 2 cases a confession of this procedure could be obtained. CONCLUSION: Comparing cases of accidental and non-accidental SDB in the literature, infantile SDB obviously cannot be looked at as a homogeneous entity: two quite different types should be kept separate: the patients suffering from an accidental SDB due to a minor fall mostly do not deteriorate immediately after the trauma, develop SDB of some volume, up to a space-occupying mass lesion, and have often a good prognosis. A lethal outcome is extremely uncommon; we have not observed a single case of an infantile lethal SDB resulting from such a minor injury for more than 20 years. The source of the SDB in those cases currently is unknown in most instances. The second group of infantile SDB includes the well-known group of shaken-baby-syndrome: no adequate history, infants dead or nearly dead on clinical presentation, often a poor outcome if the event is survived, typically no significant volume of SDB, and--according to our experiences--in all cases BV ruptures. This combination of several BV ruptures with no significant subdural bleeding is not compatible with a supposition of a minor fall causing this.
QUESTIONING: Recently the discussion concerning the causes of infantile subdural bleedings (SDB) has become quite controversial. The wide-spread interpretation that most of these cases are the result of abuse, especially by the shaken-baby-syndrome, was doubted, and the role of (even minor) accidental events was emphasized. METHODS: This situation should be analyzed basing on the official statistics of the causes of death in the city of Berlin (1978-1998) and the autopsy material of our institute (1978-1999). RESULTS: In this period, approximately 440.000 children lived their first year of life in our city. Only 80 violent deaths of infants (up to 1 year old) were recorded in the official statistics, including 27 deaths due to blunt forces, with 24 lethal head injuries as the main group. Only two cases were attributed to "falls under unclear conditions"; all other accidental cases were the results of traffic accidents or falls from a height. No death due to an undoubted minor fall was recorded, nor was any in our autopsy material. We investigated 10 cases of infantile SDB, all without skull fractures and gross brain injuries. Only 1 victim had a SDB of a significant volume; in all other cases only small amounts of blood were present in the subdural space. Bridging vein ruptures were directly demonstrated in 8 cases and were bilaterally in most instances; recently their detection has been simplified by postmortem x-ray using contrast material. All 10 cases were interpreted as typical acceleration-deceleration injuries (as in shaking), although only in 2 cases a confession of this procedure could be obtained. CONCLUSION: Comparing cases of accidental and non-accidental SDB in the literature, infantile SDB obviously cannot be looked at as a homogeneous entity: two quite different types should be kept separate: the patients suffering from an accidental SDB due to a minor fall mostly do not deteriorate immediately after the trauma, develop SDB of some volume, up to a space-occupying mass lesion, and have often a good prognosis. A lethal outcome is extremely uncommon; we have not observed a single case of an infantile lethal SDB resulting from such a minor injury for more than 20 years. The source of the SDB in those cases currently is unknown in most instances. The second group of infantile SDB includes the well-known group of shaken-baby-syndrome: no adequate history, infants dead or nearly dead on clinical presentation, often a poor outcome if the event is survived, typically no significant volume of SDB, and--according to our experiences--in all cases BV ruptures. This combination of several BV ruptures with no significant subdural bleeding is not compatible with a supposition of a minor fall causing this.