Important new data for legal cases involving child abuse: elevated intracranial pressure doesn’t cause retinal hemorrhages

Like many pediatric intensivists, I care from time to time for victims of child abuse in the form of what is often called “shaken baby syndrome.” This syndrome is a characteristic constellation of finds that happen when a strong person grasps a child around the chest and aggressively shakes the infant. It was first describe by Caffey, a pediatric radiologist, fifty years ago. The baby may have broken ribs from being grabbed tightly, but what really causes severe damage is the act of shaking. An infant’s head is floppy on the neck and the whiplash effect of snapping the head back and forth often causes bleeding in or around the brain and brain swelling. The skull may also be fractured if the infant’s head strikes a hard surface. Severe residual injury or death are a common result. The effect of the brain bouncing around inside the skull is illustrated in this image:

One of the hallmarks of shaken baby syndrome are retinal hemorrhages — areas of bleeding in the back of the eye. These result from the same pressure changes during the shaking that induce bursting small blood vessels in and around the brain. So one of the key things we look for when we suspect this form of child abuse are the presence of such hemorrhages.

Defense attorneys know this, and there is a small industry of crackpot “experts” going around the country testifying (for money, of course) in child abuse cases that these characteristic retinal hemorrhages may be from other things, particularly increased pressure inside the skull. I have been involved with and testified in several legal cases of this sort involving patients I have cared for. A jury, of course, consists of non-experts and they may be confused by such claims and counter-claims. So this new study is extremely useful to lay that bogus claim to rest.

The investigators asked a simple question: Can elevated pressure inside the skull (intracranial hyptension) cause retinal hemorrhages, or is that claim made by defenders of child abusers just nonsense? To answer the question they did detailed examinations of the retina, the back of the eye, in 56 children ranging in age from 1 to 46 months who had known, documented elevated pressure inside the head. None of the subjects were suspected to have been abused and all had conditions known to cause elevated intracranial pressure. These included hydrocephalus, intraventricular hemorrhage, congenital malformations, malfunctioning shunts, and the presence of intracranial space-occupying lesions (masses or tumors).

The authors couched their conclusions in the usual soft language of medical research, but the answer is clear — elevated intracranial pressure does not cause retinal hemorrhages. This new information will be very useful to those who deal with the tragic cases of child abuse.


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