Ruptured Infantile Meningeal Cerebral Arteriovenous Fistula Mimicking Shaken Baby Syndrome: A Cautionary Case Report

This previously healthy 6-month-old boy presented with sudden collapse under the care of his mother while feeding. Despite immediate resuscitation, the infant suffered a prolonged period of hypoxic-ischemic injury. Upon admission to the hospital, a CT head scan revealed a large, mixed-density left frontal subdural hemorrhage causing significant mass effect, as well as features of global hypoxic-ischemic injury. Fundoscopic examination revealed bilateral retinal hemorrhages that were "too numerous to count." Since the articulated clinical history was not deemed to account for the boy's condition, a diagnosis of "abusive head trauma" was suspected, and the parents were removed from the custody of the boy's living twin. Prognosis was considered poor, resulting in care being withdrawn. The infant succumbed 2 days following presentation. Autopsy revealed a large, ruptured, left frontal meningeal arteriovenous fistula. In contrast to the fundoscopic impression, autopsy examination revealed only mild retinal hemorrhage limited to the posterior poles of the globes, suggesting an etiology attributable to raised intracranial pressure. Upon issuance of the autopsy report, the parents regained custody of the second twin. This case adds to the extensive literature arguing against the contention that the so-called "triad" (ie, subdural hemorrhage, retinal hemorrhage, and encephalopathy) is pathognomonic for shaken baby syndrome.