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Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers

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An Erratum to this article was published on 20 September 2014

Abstract

Background

Infants with abusive head trauma (AHT) have diffuse brain damage with potentially fatal brain swelling. The pathogenesis of the brain damage remains unclear. We hypothesize that brain damage in AHT is due to hypoxic-ischemic injury with hypoxic-ischemic encephalopathy (HIE) rather than primary traumatic brain injury (TBI) with traumatic diffuse axonal injury (tDAI).

Methods

We studied brain tissue of AHT victims. Primary outcome measure was the presence of primary traumatic versus hypoxic-ischemic brain injury. The diagnosis of tDAI followed a standardized semiquantitative diagnostic approach yielding a 4-tiered grading scheme (definite, possible, improbable, and none). In addition, results of quantitative immunohistochemical analysis in a subgroup of AHT victims with instant death were compared with matched SIDS controls.

Results

In our cohort of 50 AHT victims, none had definite tDAI (no tDAI in 30, tDAI possible in 2, and tDAI improbable in 18). Instead, all AHT victims showed morphological findings indicative of HIE. Furthermore, the subgroup with instant death showed significantly higher counts of damaged axons with accumulation of amyloid precursor protein (APP) in the brainstem adjacent to the central pattern generator of respiratory activity (CPG) (odds ratio adjusted for age, sex, brain weight, and APP-count in other regions = 3.1; 95 % confidence interval = 1.2 to 7.7; p = 0.015).

Conclusions

AHT victims in our cohort do not have diffuse TBI or tDAI. Instead, our findings indicate that the encephalopathy in AHT is the due to hypoxic-ischemic injury probably as the result of respiratory arrest due to local damage to parts of the CPG in the brainstem.

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Acknowledgements

Mrs Monika Thiel for excellent artwork in Fig. 2. Ms Sandra Deutsch and Ms Kendra Richter for excellent histology and immunohistochemical work.

Ethical standards

As indicated earlier, all studies were in accordance with ethical standards and regulations at the University Medical Center Hamburg-Eppendorf; furthermore, this study was approved by the official ethical institutional review board of the Hamburg medical association (WF 042/12).

Conflict of interest

The authors declare no conflicts of interest

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Authors and Affiliations

  1. Forensic Neuropathology Unit, University Medical Centre Hamburg-Eppendorf, 20246, Hamburg, Germany

    Jakob Matschke

  2. Institute of Neuropathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

    Jakob Matschke, Christian Hagel & Markus Glatzel

  3. Institute of Legal Medicine, Medical Faculty, University of Rostock, Rostock, Germany

    Andreas Büttner

  4. Institute of Clinical Neuropathology, Klinikum Bremen-Mitte, Bremen, Germany

    Markus Bergmann

  5. Institute of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany

    Klaus Püschel

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  1. Jakob Matschke
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Correspondence to Jakob Matschke.

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Matschke, J., Büttner, A., Bergmann, M. et al. Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers. Int J Legal Med 129, 105–114 (2015). https://doi.org/10.1007/s00414-014-1060-7

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