This case was originally published in 2017. The information provided in this case was accurate and correct at the time of initial program release. Any changes in terminology since the time of initial publication may not be reflected in this case.
A 5-month-old girl was admitted to the hospital after being discovered unresponsive. Brain death was pronounced the day after admission, and care was withdrawn. Hospital diagnoses included skull fractures, subdural hemorrhage, brain edema, and retinal hemorrhages. The caregiver said he had “gently shaken” the infant “back and forth about four or five times” when she was discovered unresponsive. Autopsy revealed bilateral subdural hemorrhage (75 mL total). The brain, dura, spinal cord, and eyes were retained for neuropathologic consultation.
Brain, dura mater, eyes, spinal cord
Whole Slide Image
The whole slide image provided is an H&E stained slide of cervical spine and cord.
Which of the following is the MOST appropriate cause of death?
Blunt impact and hyperflexion/extension injuries of head/neck
Shaken baby syndrome
Sharp force injuries of head/neck
Traumatic respiratory failure
Which of the following findings would support shaking as a mechanism of injury?
Cervical spinal nerve root/ganglia hemorrhage
What is the MOST appropriate manner of death classification in this case?
Discussion and Diagnosis
Cause of death is defined as the injury or disease which, in a natural sequence, produces death; but for the injury or disease, death would not have occurred. The head injuries seen in this case are blunt impact injuries sustained by direct contact between the head and an object that lacks a cutting edge. The scalp contusions (Image A) and skull fractures (Image B and Image C) are the result of direct impact(s) to the head, as is the acute subdural hemorrhage (Image G and Image H). Another significant finding in this case is hemorrhage in the cervical spinal nerve roots/ganglia (Image F). En bloc
resection of the cervical spinal column aids in visualization of this important finding and supports a mechanism of injury involving hyperflexion/extension of the neck, as can be seen in rapid acceleration/deceleration (ie, whiplash) or violent shaking of an infant. Although this infant likely developed respiratory failure due to her head and neck injuries, traumatic respiratory failure is properly categorized as a mechanism of death, not a cause of death.
Nonaccidental head trauma is a leading cause of death in homicides of children under two years of age. Discrimination between accidental and nonaccidental lethal head trauma can be difficult, and potential mechanisms of injury must be considered as part of a forensic neuropathologic examination. In this case, the child was reportedly “gently shaken” one day prior to death, and no explanation was initially provided for the blunt impact injuries of the head. After the death of the infant, the caregiver remembered the infant had “rolled” off the sofa onto a carpeted floor several days prior to hospitalization. Further investigation resulted in discovery of home security video recordings which showed the caregiver violently and repeatedly shaking the infant and forcefully throwing her into a wall. The caregiver subsequently gave a written confession and admitted the story about the short fall from the sofa was a fabrication he created when he learned the baby had skull fractures.
Accidental short falls are sometimes offered as potential mechanisms of injury in cases such as that described here. Linear skull fractures in infants have been associated with short-distance falls, such as those from a sofa or bed onto a floor, or other direct blunt impacts to the skull with impact energy spread over a wide area of the skull. Studies have shown that skull fractures in infants and small children from falls from heights of less than three to five feet are rare, and complications such as brain injury or intracranial hemorrhage are exceedingly uncommon. Skull fractures in accidental short falls are typically linear, nondisplaced, nondiastatic fractures and commonly involve the parietal bone. Falls from greater heights allow for greater acceleration due to gravity, and hence the potential for significant injury is greater. Inflicted injuries and falls from greater heights with greater velocity at impact are more likely to result in complex, displaced, or depressed skull fractures that are more likely to involve the occipital bone and the foramen magnum.
Injury of cervical spinal nerve roots/ganglia is thought to effectively disrupt innervation of the diaphragm resulting in respiratory compromise and anoxic brain injury. Acute intraparenchymal hemorrhage in the cervical spinal nerve roots/ganglia may be linked to trauma, neoplasm, infection, hydrocephalus, and increased intracranial pressure, among other etiologies. Given the investigative information substantiated by the home security video recordings in this case, the hemorrhage seen in Image F is likely due to hyperflexion/extension injury.
Blunt impacts to the head or anoxic brain injury can result in vasogenic and/or cytotoxic brain edema which subsequently act to increase intracranial pressure. Transmission of increased pressure along the optic nerve sheaths can effectively compromise circulation through the central retinal vessels and result in retinal and optic nerve sheath hemorrhages (Image D and Image E). Hemorrhages in the inner retina (Image I) are a nonspecific finding and, although commonly associated with subdural hematoma and increased intracranial pressure, may be caused by a multitude of etiologies including infection, coagulopathy, vasculitis/vasculopathy, or hematologic malignancy.
In this case, purported mechanisms of injury initially included “gentle shaking” and a short fall from a sofa onto a carpeted floor. Neither of these proffered mechanisms is adequate to explain the constellation of findings seen at postmortem neuropathologic examination. The injuries in this case are consistent with nonaccidental, inflicted injuries, and, as such, the manner of death is properly classified as homicide.
Take Home Points
- Nonaccidental head trauma is a leading cause of death in homicides of children under two years of age.
- Skull fractures in accidental short falls are typically linear, nondisplaced, nondiastatic fractures, commonly involve the parietal bone, and are rarely complicated by brain injury or intracranial hemorrhage.
- Inflicted injuries and falls from greater heights with greater velocity at impact are more likely to result in complex, displaced, or depressed skull fractures that are more likely to involve the occipital bone and the foramen magnum.
- En bloc resection of the cervical spinal column aids in visualization of spinal nerve root/ganglia hemorrhage.
- Cerebral edema and increased intracranial pressure of a variety of origins including blunt impact(s) and anoxic brain injury can be associated with retinal and optic nerve sheath hemorrhages. Retinal hemorrhages are not specific for shaking.
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- Geddes JF, Hackshaw AK, Vowles GH, Nickols CD, Whitwell HL. Neuropathology of inflicted head injury in children: I. Patterns of brain damage. Brain. 2001;124:1290-8.
- John SM, Jones P, Kelly P, Vincent A. Fatal pediatric head injuries: a 20-year review of cases through the Auckland Coroner’s Office. Am J Forensic Med Pathol. 2013;34:277-82.
- Leestma JE. Child abuse: neuropathology perspectives. In: Leestma JE, ed. Forensic Neuropathology. 3rd ed. Boca Raton, FL: CRC Press; 2014:595-642.
- Matshes EW, Evans RM, Pinckard JK, Joseph JT, Lew EO. Shaken infants die of neck trauma, not of brain trauma. Acad Forensic Pathol. 2011;1:82-91.
- Unterberg AW, Stover J, Kress B, Kiening KL. Edema and brain trauma. Neuroscience. 2004;129:1021-9.
- Which of the following is the MOST appropriate cause of death?
- A. Blunt impact and hyperflexion/extension injuries of head/neck
- B. Shaken baby syndrome
- C. Sharp force injuries of head/neck
- D. Traumatic respiratory failure
- E. Undetermined
- Which of the following findings would support shaking as a mechanism of injury?
- A. Brain edema
- B. Cervical spinal nerve root/ganglia hemorrhage
- C. Retinal hemorrhage
- D. Subarachnoid hemorrhage
- E. Subdural hemorrhage
- What is the MOST appropriate manner of death classification in this case?
- A. Accident
- B. Homicide
- C. Natural
- D. Suicide
- E. Undetermined