International Journal of Legal Medicine

, Volume 129, Issue 1, pp 105–114 | Cite as

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

  • Jakob Matschke
  • Andreas Büttner
  • Markus Bergmann
  • Christian Hagel
  • Klaus Püschel
  • Markus Glatzel
Original Article



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).


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.


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).


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.


Abusive head trauma Non-accidental head injury Shaken baby syndrome Child abuse Diffuse axonal injury Neuropathology 



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

Supplementary material

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414_2014_1060_MOESM2_ESM.pdf (84 kb)
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Online Resource 3 (PDF 72 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Jakob Matschke
    • 1
    • 2
  • Andreas Büttner
    • 3
  • Markus Bergmann
    • 4
  • Christian Hagel
    • 2
  • Klaus Püschel
    • 5
  • Markus Glatzel
    • 2
  1. 1.Forensic Neuropathology UnitUniversity Medical Centre Hamburg-EppendorfHamburgGermany
  2. 2.Institute of NeuropathologyUniversity Medical Centre Hamburg-EppendorfHamburgGermany
  3. 3.Institute of Legal Medicine, Medical FacultyUniversity of RostockRostockGermany
  4. 4.Institute of Clinical NeuropathologyKlinikum Bremen-MitteBremenGermany
  5. 5.Institute of Legal MedicineUniversity Medical Centre Hamburg-EppendorfHamburgGermany

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