Restricting the time of injury in fatal inflicted head injuries

doi:10.1016/S0145-2134(97)00054-9

Child Abuse & Neglect

Volume 21, Issue 10, October 1997, Pages 929-940

https://doi.org/10.1016/S0145-2134(97)00054-9 Get rights and content

Abstract

Objective: To determine the normal clinical progression of fatal head injuries in children. Such information can then be used to estimate the time of injury in cases with obscure histories and will thus aid investigations of nonaccidental trauma.

Method: A retrospective chart review design was used. One hundred and thirty eight accidental fatalities involving head injury were identified and 95 of these were used as the study group. Details of the cases were reviewed and cases in which a child either had a Glasgow Coma Scale (GCS) of 14–15 or was described as having a “lucid interval” or as being “conscious” were further studied.

Results: One “lucid interval” case was identified. This case involved an epidural hematoma. Three other cases that partially met the criteria for a lucid interval were also identified; one of these cases did not meet the criteria for inclusion in the study group. Review of head CTs revealed that brain swelling could be detected as early as 1 hour and 17 minutes post injury.

Conclusions: The children studied were in obvious serious medical condition from the time of injury until death. If a history purports a lucid interval in a fatal head injury case that does not involve an epidural hematoma, that history is likely false and the injury is likely inflicted. The time of most fatal head injury events can be restricted to the time period after the last confirmed period of wellness for the child. In addition, the presence of brain swelling on a head CT scan is not helpful in restricting the time of injury

Résumé

But: Déterminer la progression clinique normale des lésions crâniennes fatales chez les enfants. Cette information peut alors être utilisée pour évaluer le moment du traumatisme dans les cas, présentant de sombres histoires, ce qui facilitera les enquêtes des traumatismes non-accidentels.

Méthode: Une revue rétrospective de dossiers a été utilisée. Cente trente huit morts d'enfants accidentelles incluant un traumatisme crânien ont été identifiées, dont 95 ont été utilisées comme groupe d'étude. Les détails des dossiers ont été passés en revue et les cas où l'enfant présentaient un GCS de 14–15 ou avait été décrit comme ayant eu “un intervalle lucide” ou ayant été “conscient” ont été appeofondis.

Resultats: Un cas d'“intervalle lucide” présentait des haematomes épiduraux. Il n'y avait pas de cas où un enfant avait présenté un “intervalle lucide” avant de mourir d'un traumatisme crânien, excepté dans ces cas sélectés. Le passage en revue des CT de la tête a révélé que l'oedème cérébral pouvait être détecté aussi tôt qu'une heure et 17 minutes après le traumatisme.

Conclusions: Mis à part ces cas sélectés d' “intervalle lucide”, les enfants étudiés présentait une condition médicale grave évidente depuis le traumatisme jusqu'à la mort. Quand une histoire contient un “intervalle lucide” dans un cas fatal de traumatisme crânien, qui n'implique pas un haematome épidural, cette histoire est probablement fausse et le traumatisme probablement infligé. Dans la plupart des cas, le moment où le traumatisme crânien fatal a été infligé, peut être attribuéà la période après la dernière période confirmée de bien-être de l'enfant. En plus, la présence d'un oedème cérébral sur un CT scan n'est pas utile pour déterminer le moment où le traumatisme a été infligé.

Resumen

Objetivo: Determinar cuál es la progresion clinica normal de lesiones mortales en la cabeza producidas en ninos/as. Esta información podrá utilizarse entonces para estimar el momento en el que se produjo la lesión en casos con historias poco claras, y ayudará en la investigación de lesiones no accidentales.

Método: Se utilizó un diseno retrospectivo de revisión de expedientes. Se identificaron 138 casos de muertes accidentales provocadas por lesiones en la cabeza; 95 de ellos formaron el grupo objeto de estudio. Se revisaron las circunstancias de cada caso, y se estudiaron más detenidamente aquéllos en los cuales el nino/a habia tenido un GCS de 14–15, o se describia que habia tenido un “período de lucidez” o había estado “consciente”.

Resultados: Hubo un caso con “período de lucidez” entre los casos con hematomas epidurales. No hubo ningún caso en el que el nino/a tuviera un período de lucidez antes de morir a causa de la lesión en la cabeza, exceptuando esos casos elegidos. La revision de los CT de la cabeza reveló que, una hora y diecisiete minutos después de producirse la lesion, ya se podia detectar una tumefacción cerebral.

Conclusiones: Excepto en los casos seleccionados con “intervalo de lucidez”, los ninos/as estudiados estuvieron en un estado médico claramente grave desde el momento de la lesion hasta su fallecimiento. Cuando una historia clinica de una lesion mortal en la cabeza incluya un período de lucidez, los hechos pueden situarse en el período de tiempo posterior al último momento en que se haya confirmado que el nino/a estaba bien. Por otra parte, la presencia de una tumefacción cerebral en un examen CT de la cabeza, no sirve de ayuda para precisar el momento en que se produjo la lesión.

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There are more references available in the full text version of this article.

Cited by (72)

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2021, Neurochirurgie
Good practice guidelines help clinicians to establish a suspected diagnosis of non-accidental head injury (NAHI) and help forensic experts to establish a level of certainty for the diagnosis.
The objective of this study was to assess how the French Health Authority (HAS) guidelines contribute to the process of producing an expert assessment, on causation and certainty in cases of suspected NAHI.
A retrospective study was conducted of the expert assessments that were conducted by a paediatric surgeon and forensic expert attached to our local court between 2002 and 2018, with the aim of determining the causal mechanism of the lesions and express a degree of certainty regarding the diagnosis.
In our study, we found that, despite the HAS guidelines, a number of documents deemed essential for the forensic expert were sometimes missing, and that, by applying these guidelines, the decisions reached in some expert assessments could been reclassified and certain factors formerly described as risk factors for injury could be excluded. A precise dating of the traumatic event was proposed in half of cases.
Our study highlights the vital role of the HAS guidelines, not only for patient management but also to ensure high-quality expert assessments. Unfortunately, guidelines were not yet being properly adhered to by medical teams.
A verified period of normal neurologic status in a young victim of abusive head trauma
2020, Journal of Forensic and Legal Medicine
Citation Excerpt :
Studies involving perpetrator admissions demonstrate immediate and persistent symptoms in cases with sufficient details.17,18 Other studies evaluating for possible delayed neurologic decompensation typically involve subjects older than most victims of AHT and/or subjects who suffer permanent neurologic damage or death.10–16 However, there is also a degree of agreement that, in some cases, particularly those in which the child eventually returns to neurologic baseline, a period of normal neurologic appearance is possible.7–9
Abusive head trauma (AHT) is the leading cause of child physical abuse fatalities, and survivors frequently face life-long consequences. Victims of AHT are typically infants, and many are subjected to repeat AHT if not accurately identified and protected. Identifying the timing of AHT is often a medical-forensic process, and investigative personnel use the determination of timing of AHT to guide safety decisions for the child victim. If the medical-forensic timing of AHT is incorrect, a child could be inappropriately placed and/or an innocent caregiver could be subject to prosecution. Victims of AHT who suffer severe/permanent injury are felt to demonstrate symptoms immediately after the trauma, and AHT victims with milder injury are thought to generally have persistent or recurrent clinical signs shortly after the trauma. Periods of normal neurologic appearance, in which a victim of AHT is completely asymptomatic for an extended time after the trauma, are felt to be rare and have not been well characterized in the literature. This case involves a 2-month-old infant victim of AHT who presented to medical care with mild neurologic symptoms that resolved without intervention from medical personnel. While hospitalized, the infant had an asymptomatic period of approximately 38 hours prior to more severe neurologic decompensation, then later returned to neurologic baseline. This case highlights the challenges in accurately timing AHT in very young victims who return to neurologic baseline by characterizing a verifiable prolonged period of normal neurologic appearance and function after AHT.
Histological dating of subarachnoid hemorrhage and retinal hemorrhage in infants
2019, Forensic Science International
Citation Excerpt :
Among the information resulting from medical and police questioning of the parents, the first criterion to be taken into account is the moment at which the first clinical sign is reported to have appeared. This moment is described as being very close to the traumatic event [19,20]. The median age of our population was 3.8 months, which is in line with the median ages (3 and 5 months) of pediatric intracranial hemorrhages described in the literature [21].
Dating the traumatic event is usually done on subdural hematoma (SDH). After infant deaths due to Abusive head trauma (AHT) without SDH available, the magistrates still ask experts to date the traumatic event. To do so, the expert only has tools based on adult series of AHT. We aimed to develop a subarachnoid hemorrhage (SAH) and retinal hemorrhage (RH) dating system applicable to infants aged under 3 years.
We studied a retrospective multicenter collection of 235 infants who died between the ages of 0 and 36 months, diagnosed with SAH and/or RH by forensic pathological examination and with known posttraumatic interval (PTI). Two pathologists assessed blindly and independently 12 histomorphological features in 83 infants (35 girls, 48 boys) whose median age was 3.8 months. For SAH, histopathological changes were significantly correlated with PTI for the appearance of red blood cells, of fibrino-plaquetted organization, the quantity of lymphocytes and macrophages and the presence or absence of siderophages, collagen and fibroblast formation and presence or absence of neovascularization. For RH, histopathological changes were significantly correlated with PTI for the appearance of red blood cells, the presence or absence of siderophages and sclerosis of the retina.
Our HAS dating system improves the precision and reliability of forensic pathological expert examination of AHT, when SDH are not available, for age estimation in infants. The study of RH histomorphological changes does not allow for reliable dating.
The epidemiology of fractures in infants - Which accidents are preventable?
2016, Injury
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As stated, the rate of cases of maltreatment seems to be low in our patient cohort. Warlock et al. found 1 of 8 fractures in children less than 18 months of age to be non-accidental [19], while others report that up to 60% of fractures in infants younger than one year might be non-accidental [20]. In 1794 abuse cases, Loder and Feinberg found 50% of the victims to be younger than one year of age [21].
In children, fractures have a huge impact on the health care system. In order to develop effective prevention strategies exact knowledge about the epidemiology of fractures is mandatory. This study aims to describe clinical and epidemiological data of fractures diagnosed in infants.
A retrospective analysis of all infants (children < 1 year of age) presenting with fractures in an 11 years period (2001–2011) was performed. Information was obtained regarding the location of the fractures, sites of the accident, circumstances and mechanisms of injury and post-injury care.
248 infants (54% male, 46% female) with a mean age of 7 months presented with 253 fractures. In more than half of the cases skull fractures were diagnosed (n = 151, 61%). Most frequently the accidents causing fractures happened at home (67%). Falls from the changing table, from the arm of the care-giver and out of bed were most commonly encountered (n = 92, 37%). While the majority of skull fractures was caused from falls out of different heights, external impacts tended to lead to fractures of the extremities. 6 patients (2%) were victims of maltreatment and sustained 10 fractures (2 skull fractures, 4 proximal humeral fractures, 2 rib fractures, and 2 tibial fractures).
Falls from the changing table, the arms of the caregivers and out of bed caused the majority of fractures (especially skull fracture) in infants. Therefore, awareness campaigns and prevention strategies should focus on these mechanisms of accident in order to decrease the rate of fractures in infants.
Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes
2015, World Neurosurgery
Citation Excerpt :
Previous data reporting higher NAHT mortality after 6 hours and treatment guidelines in stroke suggest delay in arrival, in part, may help in recognizing those with an increased chance of survival >24 hours. Despite the initial history and confession generally observed to be limited or erroneous (1, 18) and the unreliability of computed tomography (CT) scans in predicting the time of injury, Willman et al. (21) determined the time of injury to be restricted to the immediate time after the last observed “period of wellness” (21). In 1995 report, Starling et al. (18) found 97% of identified perpetrators were present at symptom onset.
Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation.
Extent of delay in seeking medical attention may be related to patient outcome.
A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6–12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case.
All children were 3 years of age or younger (2.1–34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay.
Patients presenting to medical care 6–12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.
Speed of development of cerebral swelling following blunt cranial trauma
2013, Journal of Forensic and Legal Medicine
Citation Excerpt :
The significance of this in forensic terms is that individuals who suffer severe blunt cranial trauma which leads to death (not involving the slowly developing extradural haematoma) are unlikely to exhibit normal behaviour after impact, given that intracranial pressure increases rapidly with the associated reduction in arterial perfusion and brain parenchymal oxygenation. In humans the speed of brain swelling has been shown to be quite rapid on cerebral imaging with computerized tomography (CT) showing cerebral swelling as early as 1 h and 17 min following trauma.6 Clinical studies are, however limited by the time in which it takes to bring an injured individual to a hospital, to be stabilized and then to be available for radiological studies.
A 22-year-old male suffered severe injuries to the head, chest and abdominal cavities in a vehicle crash, with death occurring at the scene. At autopsy, the cranial cavity was opened and markedly disrupted with compound and comminuted fracturing of all bones of the skull and facial skeleton. The brain showed extensive lacerations with almost complete parenchymal disruption. However, a preserved fragment of right frontal lobe exhibited marked swelling with gyral flattening. This case could provide further evidence for prompt cerebral swelling after blunt head trauma, and is supportive of animal studies that have demonstrated rapid swelling that is most likely is related to reactive vasodilation rather than to vasogenic oedema.

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Restricting the time of injury in fatal inflicted head injuries

Abstract

Résumé

Resumen

Annals of Emergency Medicine

Brain damage in fatal non-missile head injury

Destructive brain disorders of childhood

Diffuse cerebral swelling following head injuries in children: The syndrome of “malignant brain edema”

Journal of Neurosurgery