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Correlation between retinal abnormalities and intracranial abnormalities in the shaken baby syndrome
Yair Morad1, Yuri M Kim, Derek C Armstrong
1Department of Ophthalmology, The Hospital for Sick Children, University of Toronto, Ontario, Canada.
Insights
The severity of retinal and intracranial injuries are correlated in shaken baby syndrome (SBS). Retinal hemorrhages in SBS are likely caused by mechanical shaking forces, not direct impact or pressure changes.
Area of Science:
- Pediatric Ophthalmology
- Neurology
- Forensic Pathology
Background:
- Shaken baby syndrome (SBS) is a severe form of abusive head trauma in infants.
- Retinal hemorrhages are a common finding in SBS, but their exact pathogenesis remains debated.
Purpose of the Study:
- To investigate the correlation between retinal and intracranial abnormalities in SBS.
- To evaluate the pathogenesis of retinal hemorrhages in SBS.
Main Methods:
- Retrospective case series of 75 children with SBS.
- Correlation analysis of ophthalmoscopic and neuroimaging findings (CT/MRI).
- Assessment of various intracranial injuries and retinal abnormalities.
Main Results:
- All 75 children had abnormal neuroimaging, with subdural hematoma being the most common finding (93%).
- 85% of children presented with retinal abnormalities, predominantly multiple, confluent hemorrhages.
- No correlation was found between specific intracranial findings or impact trauma and retinal hemorrhages, but severity scores of cranial and retinal injuries were correlated.
Conclusions:
- The severity of retinal and intracranial injuries in SBS is correlated.
- The findings do not support theories of retinal bleeding due to elevated intracranial pressure, intrathoracic pressure, direct tracking of blood, or direct impact.
- Mechanical shaking forces are suggested as the primary cause of retinal abnormalities in SBS.
Purpose:
To report correlation between retinal and intracranial abnormalities and to evaluate pathogenesis of retinal hemorrhages in the shaken baby syndrome (SBS).
Design:
Observational case series.
Methods:
Seventy-five children with apparent nonaccidental head trauma consistent with SBS had complete physical examination, complete ophthalmologic examination, neuroimaging by CT or MRI, or both, and skeletal radiographic survey. In this retrospective review, ophthalmoscopic and intracranial abnormalities were correlated.
Results:
The age of patients ranged from 2 to 48 months (mean - SD, 10.6 +/- 10.4 months). Neuroimaging was abnormal in all 75 cases. Findings included subdural hematoma (70 children, 93%), cerebral edema (33 children, 44%), subarachnoid hemorrhage (12 children, 16%), vascular infarction (nine children, 12%), intraparenchymal blood (six children, 8%), parenchymal contusion (six children, 8%), and epidural hemorrhage (one child, 1%). Sixty-four (64/75, 85%) children had retinal abnormalities, mostly (53/64, 82%) confluent multiple hemorrhages that were subretinal, intraretinal, and preretinal in 47/64 (74%) and bilateral in 52/64 (81%). No association was found between anatomic site (left, right, or bilateral) of intracranial and retinal findings (McNemar test kappa = -0.026-0.106) or between any of the intracranial findings mentioned above and the following retinal findings: normal or abnormal retinal examination, multiple (>10) or few retinal hemorrhages (< or =10), symmetric or asymmetric retinal findings, or retinoschisis (kappa = -0.127-0.104). Signs of possible increased intracranial pressure were not correlated with any retinal abnormality (kappa = -0.03-0.073). There was no correlation between evidence of impact trauma to the head and retinal hemorrhages (kappa = 0.058). Total Cranial Trauma Score and Total Retinal Hemorrhage Score, both indicating the severity of injury, were correlated (P =.032).
Conclusions:
Our study supports previous observations that the severity of retinal and intracranial injury is correlated in SBS. We cannot support the suggestions that in most children with SBS retinal bleeding is caused by sustained elevated intracranial, elevated intrathoracic pressure, direct tracking of blood from the intracranial space, or direct impact trauma. The correlation in severity of both eye and head findings may suggest, however, that retinal abnormalities are the result of mechanical shaking forces.
