Abusive head injury is the leading cause of morbidity and mortality in physically abused children. Caffey, in a landmark article published in 1972, described the classic triad associated with inflicted neurotrauma: subdural hemorrhages, retinal hemorrhages, and metaphyseal fractures.17 Over the years, many terms have been used to describe inflicted head injury, including shaken baby syndrome (SBS), shaken-impact syndrome, and abusive head injury. The current recommendation is to refer to the injury with an inclusive term that does not specify the exact mechanism of injury, such as inflicted neurotrauma or abusive head trauma (AHT).
The etiology of AHT is rarely clear because an accurate history is almost always lacking, and the mechanisms of injury vary among patients. Victims of AHT are generally younger than 3 years; most are infants. Perpetrators tend to be men—fathers or a maternal boyfriend.18 The child's symptoms vary from mild lethargy, vomiting, or irritability to apnea and coma. Seizures are common in victims of AHT and are reported in up to 80% of severely injured victims.19
Jenny et al., reported that 31% of patients with inflicted head injury had seen a physician with symptoms of their head injury an average of 2.8 times prior to identification of the abuse. Factors associated with missed diagnosis included age less than 6 months, Caucasian race, both parents living in the home, and presentation with mild, nonspecific symptoms such as vomiting, fever, and irritability.20 Children with fatal or near-fatal injury are symptomatic immediately. In the case of fatal injury, death is usually caused by uncontrollable cerebral edema and increased intracranial pressure. Survivors of inflicted neurotrauma usually suffer moderate-to-severe disabilities, including cognitive delay, visual impairment, seizures, and overall poor developmental outcomes.
Features of AHT seen on physical examination include irritability, lethargy, soft tissue swelling of the scalp, full fontanelle, opisthotonic posturing, or coma. Vomiting is common; when it is accompanied by lethargy, it suggests the possibility of increased intracranial pressure. The hallmark feature of AHT is subdural hemorrhage, which may lie over one or both cerebral convexities but is often found in the posterior interhemispheric fissure (Fig. 144-6). The collection of blood is usually thin and resolves without neurosurgical intervention. CT scan can be done quickly and is highly sensitive in identifying acute bleeding in all intracranial compartments. Magnetic resonance imaging (MRI) is a better means of detecting small subdural hematomas, subacute and chronic intracranial injuries, diffuse axonal injuries, cortical contusions, and posterior interhemispheric subdural hemorrhage (SDH). Injuries associated with AHT include retinal hemorrhages, skeletal injuries, cutaneous injuries, and visceral injuries. When identified, noncranial injuries provide support for the diagnosis of abuse. Approximately 80% of children with AHT have retinal hemorrhages. Dilated, indirect ophthalmoscopy performed by an ophthalmologist is preferred in the evaluation of suspected head injury to identify and document the extent of retinal involvement. All victims with AHT require a skeletal survey to evaluate for further injuries. Extracranial abnormalities are detected in 30% to 70% of abused children with head injuries. Skeletal injuries classically associated with inflicted neurotrauma include rib and metaphyseal fractures.
An 8-month-old child presented to medical care comatose after falling back from a seated position onto the carpeted floor. Examination revealed numerous bruises, severe retinal hemorrhages, and similar injuries in her twin brother.