Pediatric Radiology

, Volume 44, Supplement 4, pp 543–547 | Cite as

Alternate theories of causation in abusive head trauma: What the science tells us

  • Carole JennyEmail author
Special Issue: Abusive Head Trauma


When cases of suspected abusive head trauma are adjudicated in courts of law, several alternative theories of causation are frequently presented. This paper reviews common theories and examines their scientific basis.


Abusive head trauma Alternative theories Evidence Infants 


Conflicts of interest



  1. 1.
    Gabaeff SC (2013) 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) 15:177–192CrossRefGoogle Scholar
  2. 2.
    Looney CB, Smith JK, Merck LH et al (2007) Intracranial hemorrhage in asymptomatic neonates: prevalence on MR images and relationship to obstetric and neonatal risk factors. Radiology 242:535–541PubMedCrossRefGoogle Scholar
  3. 3.
    Holden KR, Titus MO, Van Tassel P (1999) Cranial magnetic resonance imaging examination of normal term neonates: a pilot study. J Child Neurol 14:708–710PubMedCrossRefGoogle Scholar
  4. 4.
    Whitby EH, Griffiths PD, Rutter S et al (2004) Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 363:846–851PubMedCrossRefGoogle Scholar
  5. 5.
    Rooks VJ, Eaton JP, Ruess L et al (2008) Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol 29:1082–1089PubMedCrossRefGoogle Scholar
  6. 6.
    Werner EF, Janevic TM, Illuzzi J et al (2011) Mode of delivery in nulliparous women and neonatal intracranial injury. Obstet Gynecol 118:1239–1246PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Sirgiovanni I, Avignone S, Groppo M et al (2014) Intracranial haemorrhage: an incidental finding at magnetic resonance imaging in a cohort of late preterm and term infants. Pediatr Radiol 44:289–296PubMedCrossRefGoogle Scholar
  8. 8.
    Hymel KP, Jenny C, Block RW (2002) Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies. Child Maltreat 7:329–348PubMedCrossRefGoogle Scholar
  9. 9.
    Rogers CB, Itabashi HH, Tomiyasu U et al (1998) Subdural neomembranes and sudden infant death syndrome. J Forensic Sci 43:375–376PubMedGoogle Scholar
  10. 10.
    Walter T, Meissner C, Oehmichen M (2009) Pathomorphological staging of subdural hemorrhages: statistical analysis of posttraumatic histomorphological alterations. Leg Med (Tokyo) 11:S56–S62CrossRefGoogle Scholar
  11. 11.
    Lonergan GJ, Baker AM, Morey MK et al (2003) From the archives of the AFIP. Child abuse: radiologic–pathologic correlation. Radiographics 23:811–845PubMedCrossRefGoogle Scholar
  12. 12.
    Adamsbaum C, Grabar S, Mejean N et al (2010) Abusive head trauma: judicial admissions highlight violent and repetitive shaking. Pediatrics 126:546–555PubMedCrossRefGoogle Scholar
  13. 13.
    Jenny C, Hymel KP, Ritzen A et al (1999) Analysis of missed cases of abusive head trauma. JAMA 281:621–626PubMedCrossRefGoogle Scholar
  14. 14.
    Geddes JF, Tasker RC, Hackshaw AK et al (2003) Dural haemorrhage in non-traumatic infant deaths: does it explain the bleeding in ‘shaken baby syndrome’? Neuropathol Appl Neurobiol 29:14–22PubMedCrossRefGoogle Scholar
  15. 15.
    Croft PR, Reichard RR (2009) Microscopic examination of grossly unremarkable pediatric dura mater. Am J Forensic Med Pathol 30:10–13PubMedCrossRefGoogle Scholar
  16. 16.
    Richards PG, Berticcu GE, Bonshek RE et al (2006) Shaken baby syndrome. Arch Dis Child 91:205–206PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Scheimberg I, Cohen MC, Zapata Vazquez RE et al (2013) Nontraumatic intradural and subdural hemorrhage and hypoxic ischemic encephalopathy in fetuses, infants, and children up to three years of age: analysis of two audits of 636 cases from two referral centers in the United Kingdom. Pediatr Dev Pathol 16:149–159PubMedCrossRefGoogle Scholar
  18. 18.
    Cohen MC, Sprigg A, Whitby EH (2010) Subdural hemorrhage, intradural hemorrhage and hypoxia in the pediatric and perinatal post mortem: are they related? An observational study combining the use of post mortem pathology and magnetic resonance imaging. Forensic Sci Int 200:100–107PubMedCrossRefGoogle Scholar
  19. 19.
    Geddes JF, Talbert DG (2006) Paroxysmal coughing, subdural and retinal bleeding: a computer modelling approach. Neuropathol Appl Neurobiol 32:625–634PubMedCrossRefGoogle Scholar
  20. 20.
    Rafaat KT, Spear RM, Kuelbs C et al (2008) Cranial computed tomographic findings in a large group of children with drowning: diagnostic, prognostic, and forensic implications. Pediatr Crit Care Med 9:567–572PubMedCrossRefGoogle Scholar
  21. 21.
    Byard RW, Blumbergs P, Rutty G et al (2007) Lack of evidence for a causal relationship between hypoxic encephalopathy and subdural hemorrhage in fetal life, infancy, and early childhood. Pediatr Dev Pathol 10:348–350PubMedCrossRefGoogle Scholar
  22. 22.
    Hurley M, Dineen R, Padfield CJ et al (2010) Is there a causal relationship between the hypoxia–ischaemia associated with cardiorespiratory arrest and subdural hematoma? An observational study. Br J Radiol 83:736–743PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Barnes PD, Galaznik J, Gardner H et al (2010) Infant acute life-threatening event — dysphagic choking versus nonaccidental injury. Semin Pediatr Neurol 17:7–11PubMedCrossRefGoogle Scholar
  24. 24.
    Matsuda M, Matsuda I, Sato M et al (1982) Superior sagittal sinus thrombosis followed by subdural hematoma. Surg Neurol 18:206–211PubMedCrossRefGoogle Scholar
  25. 25.
    Singh SK, Kumar S, Joseph M et al (2005) Cerebral venous sinus thrombosis presenting as subdural hematoma. Australas Radiol 49:101–103PubMedCrossRefGoogle Scholar
  26. 26.
    Akins PT, Axelrod YK, Ji C et al (2013) Cerebral venous sinus thrombosis complicated by subdural hematomas: case series and literature review. Surg Neurol Int 4:85PubMedCentralPubMedCrossRefGoogle Scholar
  27. 27.
    Takahashi S, Shinoda J, Hayashi T (2012) Cerebral venous sinus thrombosis in an adult patient presenting as headache and acute subdural hematoma. J Stroke Cerebrovasc Dis 21:338–340PubMedCrossRefGoogle Scholar
  28. 28.
    Sirin NG, Yesilot N, Ekizoglu E et al (2010) A case report of cerebral venous thrombosis in polycythemia vera presenting with intracranial and spinal subdural hematoma. Case Rep Neurol 2:37–45PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Hedlund G (2013) Cerebral sinovenous thrombosis in pediatric practice. Pediatr Radiol 43:173–188PubMedCrossRefGoogle Scholar
  30. 30.
    McLean LA, Frasier LD, Hedlund GL (2012) Does intracranial venous thrombosis cause subdural hemorrhage in the pediatric population? AJNR Am J Neuroradiol 33:1281–1284PubMedCrossRefGoogle Scholar
  31. 31.
    Stiefel D, Eich G, Sacher P (2000) Posttraumatic dural sinus thrombosis in children. Eur J Pediatr Surg 10:41–44PubMedCrossRefGoogle Scholar
  32. 32.
    Dlamini N, Billinghurst L, Kirkham FJ (2010) Cerebral venous sinus (sinovenous) thrombosis in children. Neurosurg Clin N Am 21:511–527PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Scheibner V (1999) Shaken baby syndrome: the vaccination link. Nexus Mag 5:79Google Scholar
  34. 34.
    Buttram HE (2001) Shaken baby syndrome or vaccine-induced encephalitis? Med Sentinel 6:83–89Google Scholar
  35. 35.
    Stratton K, Ford A, Rusch E et al (2012) Committee to Review Adverse Effects of Vaccines, Board on Population Health and Public Health Practice, Institute of Medicine. Adverse effects of vaccines: evidence and causality. National Academies Press, Washington, DCGoogle Scholar
  36. 36.
    Zahl SM, Egge A, Helseth E et al (2011) Benign external hydrocephalus: a review, with emphasis on management. Neurosurg Rev 34:417–432PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Ghosh PS, Ghosh D (2011) Subdural hematoma in infants without accidental or nonaccidental injury: benign external hydrocephalus is a risk factor. Clin Pediatr (Phila) 50:897–903CrossRefGoogle Scholar
  38. 38.
    Mori K, Sakamoto T, Nishimura K et al (1993) Subarachnoid fluid collection in infants complicated by subdural hematoma. Childs Nerv Syst 9:282–284PubMedCrossRefGoogle Scholar
  39. 39.
    Laubscher B, Deonna T, Uske A et al (1990) Primitive megalencephaly in children: natural history, medium term prognosis with special reference to external hydrocephalus. Eur J Pediatr 149:502–507PubMedCrossRefGoogle Scholar
  40. 40.
    Ravid S, Maytal J (2003) External hydrocephalus: a probable cause for subdural hematoma in infancy. Pediatr Neurol 28:139–141PubMedCrossRefGoogle Scholar
  41. 41.
    Morad Y, Kim YM, Armstrong DC et al (2002) Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome. Am J Ophthalmol 134:354–359PubMedCrossRefGoogle Scholar
  42. 42.
    Bechtel K, Stoessel K, Leventhal JM et al (2004) Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics 114:165–168PubMedCrossRefGoogle Scholar
  43. 43.
    Munger CE, Peiffer RL, Bouldin TW et al (1993) Ocular and associated neuropathologic observations in suspected whiplash shaken infant syndrome. A retrospective study of 12 cases. Am J Forensic Med Pathol 14:193–200PubMedCrossRefGoogle Scholar
  44. 44.
    Friendly DS (1971) Ocular manifestations of physical child abuse. Trans Am Acad Ophthalmol Otolaryngol 75:318–332PubMedGoogle Scholar
  45. 45.
    Bhardwaj G, Chowdhury V, Jacobs MB et al (2010) A systematic review of the diagnostic accuracy of ocular signs in pediatric abusive head trauma. Ophthalmology 117:983–992PubMedCrossRefGoogle Scholar
  46. 46.
    Agrawal S, Peters MJ, Adams GG et al (2012) Prevalence of retinal hemorrhages in critically ill children. Pediatrics 129:e1388–e1396PubMedCrossRefGoogle Scholar
  47. 47.
    Levin AV (2005) Retinal haemorrhage and child abuse. In: David TJ (ed) Recent advances in paediatrics, vol 22. Royal Society of Medicine Press Limited, London, pp 151–219Google Scholar
  48. 48.
    Watts P, Maguire S, Kwok T et al (2013) Newborn retinal hemorrhages: a systematic review. J AAPOS 17:70–78PubMedCrossRefGoogle Scholar
  49. 49.
    Plunkett J (2001) Fatal pediatric head injuries caused by short-distance falls. Am J Forensic Med Pathol 22:1–12PubMedCrossRefGoogle Scholar
  50. 50.
    Chadwick DL, Bertocci G, Castillo E et al (2008) Annual risk of death resulting from short falls among young children: less than 1 in 1 million. Pediatrics 121:1213–1224PubMedCrossRefGoogle Scholar
  51. 51.
    Duhaime AC, Gennarelli TA, Thibault LE et al (1987) The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 66:409–415PubMedCrossRefGoogle Scholar
  52. 52.
    Prange MT, Coats B, Duhaime AC et al (2003) Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg 99:143–150PubMedCrossRefGoogle Scholar
  53. 53.
    Coats B, Margulies SS (2008) Potential for head injuries in infants from low-height falls. J Neurosurg Pediatr 2:321–330PubMedCrossRefGoogle Scholar
  54. 54.
    Thibault KL, Margulies SS (1998) Age-dependent material properties of the porcine cerebrum: effect on pediatric inertial head injury criteria. J Biomech 31:1119–1126PubMedCrossRefGoogle Scholar
  55. 55.
    Kochanek PM (2006) Pediatric traumatic brain injury: quovadis? Dev Neurosci 28:244–255PubMedCrossRefGoogle Scholar
  56. 56.
    Dias MS (2010) The case for shaking. In: Jenny C (ed) Child abuse and neglect: diagnosis, treatment, and evidence. Elsevier Saunders, Philadelphia, pp 364–372Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  1. 1.Department of PediatricsUniversity of Washington School of MedicineSeattleUSA

Personalised recommendations