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Published on: November 3, 2016
Delayed homicides due to infant head injury initially reported as natural (cerebral palsy) deaths
James R Gill1, Raffaella A Morotti, Vincent Tranchida
1New York City Office of Chief Medical Examiner, 520 First Avenue, New York, NY 10016, USA. jgill@ocme.nyc.gov
Insights
Delayed deaths in infants with traumatic brain injury may be misclassified as natural causes. Autopsies revealed chronic hypoxic-ischemic injury from remote head trauma, underscoring the need for thorough investigation.
Area of Science:
- Forensic Pathology
- Pediatric Neurology
- Neurotrauma
Background:
- Traumatic brain injury (TBI) in infants can lead to delayed neuropathology.
- Prolonged survival intervals after infant head injury may obscure trauma as the cause of death.
Observation:
- A review of 5 delayed fatalities in New York City involved infants with nonaccidental head injuries.
- Injuries occurred at 2-3 months of age, with deaths occurring 2.5 to 17 years later.
- Initial reports often classified these deaths as natural, despite evidence of remote subdural hematomas.
Findings:
- Autopsies revealed remote subdural hemorrhages and chronic hypoxic-ischemic injury (atrophy, infarcts, cystic encephalomalacia).
- Children succumbed to delayed effects of secondary hypoxic-ischemic encephalopathy following the initial injury.
- All 5 deaths were ultimately certified as homicides.
Implications:
- Highlights the need for independent investigation of medical histories in deaths attributed to "cerebral palsy."
- Emphasizes that initial trauma, even years prior, can be the proximate cause of death.
- Underscores the importance of recognizing delayed consequences of infant head trauma in forensic investigations.
Abstract:
A spectrum of neuropathology occurs in infants who sustain traumatic brain injury. Because of a prolonged survival interval, there is a risk that these deaths may not be recognized as a sequel of trauma. We reviewed the records in New York City of 5 delayed fatalities due to nonaccidental infant head injury that had survival intervals from 2.5 to 17 years. The head injuries occurred at 2 to 3 months of age, and death occurred at 2.5 to 17 years of age. Initially, they were reported as natural deaths by treating physicians, families, and/or police. All 5 infants had unexplained or poorly explained remote traumatic head injury that included subdural hematomas. At autopsy, the neuropathologic exam demonstrated remote subdural hemorrhages and lesions related to chronic hypoxic-ischemic injury including atrophy, arterial infarcts, border-zone infarcts, and cystic encephalomalacia. Each child survived the initial injury but later succumbed to the delayed effects of secondary hypoxic-ischemic encephalopathy. These 5 deaths highlight the need to investigate independently the medical history of any child (or adult) who dies with a clinical diagnosis of "cerebral palsy." The term cerebral palsy often is used as a catchall for any patient who has had neurologic impairment since infancy or childhood. If there is a direct link between the initial injury and the death, even if the injury occurred many years before death, then the injury is the proximate cause of death and dictates the manner of death. All 5 deaths were certified as homicides.
