Brain, Vol. 125, No. 3, 677,
March 2002
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Letters to the Editor |
Retinal haemorrhages in infant head injury
1 Moorfields Eye Hospital, London and Institute of Ophthalmology, University College London, UK
Correspondence to: Dr Brian J. Clark, Department of Pathology, Institute of Ophthalmology, University College London, 11–43 Bath Street, London EC1V 9EL, UK
We would like to congratulate Dr Geddes et al. and Brain for publishing their recent valuable contributions to the field of infant head injury/shaken baby syndrome (Geddes et al., 2001
a, b). It is unacceptable for malicious child abuse to go undetected and there is an obligation on those looking after children to protect them. However, a refusal to study alternative explanations should not be allowed to unjustly destroy the lives of the accused and their families (Wilkins, 1997). We believe that these papers have important implications for the understanding of retinal haemorrhages in shaken infants.
Prior to Geddes’ papers, consensus strongly supported the hypothesis that in cases of shaking injury, severe shearing forces caused diffuse axonal injury, tears in bridging veins with subdural haemorrhage and retinal hemorrhages (Duhaime et al., 1998; Ophthalmology Child Abuse Working Party, 1999). The mechanical nature of the suggested mechanism of injury has contributed to the belief that extreme angular accelerational forces are required to generate retinal haemorrhages. These notions are, however, hypothesis and not established fact. The Geddes’ investigations have challenged the importance of diffuse axonal injury and hence shearing forces in the brain and by implication also at the vitreoretinal interface. To date, experimental studies, biomechanical modelling and extrapolations from adult or other forms of paediatric injury have without exception been open to criticism over their relevance to young infants. Biological variation in pathological responses is also rarely given consideration (Wilkins, 1997).
The notion that shearing forces underlie the genesis of retinal haemorrhages is further brought into question by observations of similar or identical patterns of haemorrhage in situations where no shearing is implicated. Rapidly increasing intracranial pressure and a number of other conditions are well-documented causes of retinal haemorrhage. It seems entirely feasible, therefore, that in shaking with brainstem injury and diffuse cerebral hypoxia with oedema, the retinal haemorrhages arise as a consequence of intracranial pathology alone and are not a result of traumatic damage to the vitreoretinal interface. Whilst acknowledging that retinal haemorrhages are associated with cases of non-accidental injury we would urge caution in assuming that all children with retinal haemorrhages have been violently shaken.
Professionals seeing large numbers of these infants repeatedly encounter cases that do not comfortably fit current dogma. There may be no other suspicion of abuse or other features of physical trauma and minimal unequivocal evidence of traumatic brain injury. Some accused adults consistently relate histories of no significant trauma or show bewilderment about the cause of the child’s condition. Not infrequently they face conviction for murder rather than admit to manslaughter. Nevertheless, the current, prevailing view is against them. It is perhaps surprising that we have only one widely accepted hypothesis—a scenario very unusual in pathology, where multiple routes to a single outcome are the norm.
If one thing is clear now, it is that we do not understand the pathophysiology of infant brain injury nearly as well as we thought.
References
Duhaime AC, Christian CW, Rorke LB, Zimmerman RA. Nonaccidental head injury in infants—the ‘shaken-baby syndrome’. [Review]. New Engl J Med 1998; 338: 1822–9.
Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain 2001a; 124: 1290–8.
Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 2001b; 124: 1299–306.
4 Ophthalmology Child Abuse Working Party. Child abuse and the eye. [Review]. Eye 1999; 13: 3–10.
Wilkins B. Head injury—abuse or accident? [Review]. Arch Dis Child 1997; 76: 393–6
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