Fatal acute intracranial injury, subdural hematoma, and retinal hemorrhages caused by stairway fall

We describe an infant with an acute subdural hematoma, a fatal head injury, and severe hemorrhagic retinopathy caused by a stairway fall. His cerebral and ocular findings are considered diagnostic of abusive head trauma by many authors. Our literature search of serious injuries or fatalities from stairway or low-height falls involving young children yielded 19 articles of primary data. These articles are discrepant, making the classification of a young child's death following a reported short fall problematic. This case report contradicts the prevalent belief of many physicians dealing with suspected child abuse that low-height falls by young children are without exception benign occurrences and cannot cause fatal intracranial injuries and severe retinal hemorrhages. The irreparable harm to a caregiver facing an erroneous allegation of child abuse requires physicians to thoroughly investigate and correctly classify pediatric accidental head injuries.     

Are Peripapillary Intrascleral Hemorrhages Pathognomonic for Abusive Head Trauma?*

Abstract: The American Academy of Pediatrics’ Committee on Child Abuse and Neglect, Section on Ophthalmology, acknowledges that searching for retinal hemorrhages (RHs) in infants only in cases of suspected of abuse creates selection bias. However, they also recommend that postmortem eye removal might not be indicated “in children who have clearly died from witnessed severe accidental head trauma or otherwise readily diagnosed systemic medical conditions.” Although infrequently described in the child abuse literature, peripapillary intrascleral hemorrhages (bleeding in the sclera at the optic nerve insertion)—putatively from severe repetitive acceleration/deceleration forces with or without blunt head trauma—have been considered essentially pathognomonic for abusive head trauma (shaken baby syndrome). We present two neonates who sustained accidental, severe in utero head injuries and had associated extensive RHs and optic nerve sheath hemorrhages with peripapillary intrascleral hemorrhages detected at autopsy. Neither neonate had a documented clinical fundal examination in the intensive care unit.     

大鼠视神经损伤后Bad蛋白表达与视网膜神经细胞观察

目的观察大鼠视神经钳夹伤后视网膜神经节细胞(RGCs)和Bad蛋白表达变化。方法建立大鼠视神经钳夹伤动物模型,伤后1,3,5,7,9,14,28d处死,HE染色观察RGCs的改变,免疫组化方法检测Bad蛋白的表达水平。结果视神经损伤后1d节细胞开始减少,7d内呈快速减少,14d后呈慢速减少期,28d后趋于稳定;伤后3dBad蛋白表达明显增加,5d时达到高峰,7d后开始下降,14d后变化不明显。结论视神经损伤Bad蛋白的表达诱发RGCs丧失,是伤后视功能下降的重要原因,视功能评价应在损伤28d以后进行。     

Ocular findings in pediatric deaths under 2 years of age (1994-2004)

Abstract:  Our purpose is to highlight novel ocular findings of 102 forensic pediatric cases under 2 years of age who die suddenly. Forensic information, grossing, and microscopic eye protocol was followed. The most common diagnosis was Sudden Infant Death Syndrome (SIDS) (57/102). Novel cytoid bodies were present in the retina of 72/102 cases and they were located predominantly 90% (65/72) at the anterior part of the retina ( p  < 0.001). Of the SIDS cases, 85% (47/57) showed the presence of cytoid bodies, and among all diagnosis, SIDS was the most associated with cytoid bodies ( p  = 0.003). A second observation was extramedullary hematopoiesis (EMH) identified in 35/102 cases and 22 of the 57 SIDS cases. The most frequent EMH location was the choroids (29/35). This study is the first to demonstrate the presence of cytoid bodies and extramedullary hematopoiesis in the retinas of SIDS cases and children who die suddenly from other causes.     

眼球钝挫伤后视网膜脱离的司法鉴定

目的分析眼球钝挫伤后视网膜脱离在法医临床学眼损伤及伤残鉴定中的致伤原因及因果关系。方法研究112例眼球钝挫伤后视网膜脱离案例,对其中视网膜裂孔类型、外伤至视网膜脱离时间、合并其他损伤或疾病进行分析。结果本组案例锯齿缘离断4.28%,黄斑裂孔12.50%,其他部位的裂孔(<90°)56.25%,巨大裂孔(>90°)5.00%,未发现裂孔的增殖性玻璃体视网膜病变(PVR)性视网膜脱离11.6%,其中45眼有不同程度的PVR。外伤至视网膜脱离的时间以1周～2个月为常见(61.60%)。合并中高度近视者83.93%,合并玻璃体混浊者52.68%。外伤与视网膜脱离存在直接因果关系者41.07%,存在间接因果关系者52.68%,外伤与视网膜脱离难以联系者6.25%。结论视网膜脱离与多种危险因素有关,外伤与视网膜脱离之间因果关系的分析是法医学眼损伤及伤残鉴定的重要内容。     

大鼠视神经横断伤后视网膜形态学改变及Bcl-2/Bax表达

目的观察大鼠视神经横断伤后,视网膜细胞(RGCs)形态学变化、Bcl-2/Bax蛋白不同时间的表达变化,并探讨其与视神经损伤经过时间的关系。方法采用大鼠球后视神经横断伤动物模型,用Bcl-2和Bax免疫组织化学和HE染色方法观察伤后不同时间RGCs的动态变化。应用图像分析技术,对Bcl-2及Bax免疫反应阳性细胞进行统计学分析。结果视神经横断伤后RGCs数目严重下降,2周内RGCs快速减少,2周以后缓慢减少;伤后Bcl-2、Bax表达随时间不同程度的增加,Bax对损伤反应较Bcl-2稍晚,两者表达均呈现先升后降的趋势,并维持一定的时间。Bcl-2/Bax蛋白表达比率与RGCs存活数目有一定的相关性。结论视神经横断伤后Bcl-2和Bax的表达在伤后不同时间呈现一定的规律性变化,可为损伤时间的推断提供一定依据。     

A Simple Model for Teaching Postmortem Monocular Indirect Ophthalmoscopy

Abstract:  Although the ophthalmoscope was invented by Hermann von Helmholtz in 1851, pathologists until recently have relied almost exclusively on ocular enucleation to identify and describe postmortem fundal abnormalities. An inexpensive but valuable tool for forensic pathologists, the postmortem monocular indirect ophthalmoscope consists of a light source attached to a headband along with a hand-held lens. This permits a wide view of the fundus after death but the technique can be challenging to master for pathology residents and forensic pathology fellows. To facilitate skill acquisition in monocular indirect ophthalmoscopy, a simple and inexpensive teaching model can be constructed from hinged, cylindrical plastic containers. An artificial pupil created in the lid and a removable color fundal image placed in the bottom of the opaque container allows the pathologist-in-training to practice the technique of monocular indirect ophthalmoscopy and correctly identify, localize, and describe fundal abnormalities such as retinal hemorrhages.     

Severe Retinal Hemorrhages with Retinoschisis in Infants are Not Pathognomonic for Abusive Head Trauma

The combination of subdural hemorrhage (SDH), retinal hemorrhage (RH), and encephalopathy, or the presence of severe retinal hemorrhages alone in infants, is often attributed to and has been stated to be pathognomonic for abusive head trauma (AHT) or shaken baby syndrome. These beliefs have been challenged, because the same constellation of findings has been identified in accidental head injuries and natural diseases, and most if not all of the studies that support the concept of diagnostic specificity have serious flaws in their methodology. Presented here are two cases of severe retinal hemorrhages with retinoschisis associated with subdural hemorrhage in a natural disease and with severe cerebral edema in an accidental head injury. These cases challenge the dogma that severe retinal hemorrhages with retinoschisis are pathognomonic for AHT.     

Hemorrhagic Retinopathy and Optic Nerve Sheath Hemorrhage Associated With Fatal Subarachnoid Hemorrhage from a Ruptured Intracranial Aneurysm Due to Segmental Fibromuscular Dysplasia

Fibromuscular dysplasia is an idiopathic, nonatheromatous, and noninflammatory arterial disease that most commonly affects the renal and carotid arteries. We report a child with subarachnoid and ocular hemorrhage associated with an aneurysm due to fibromuscular dysplasia. Computed tomography following a witnessed collapse revealed diffuse subarachnoid hemorrhage and severe cerebral edema. An autopsy confirmed the radiographic findings and detected bilateral retinal hemorrhages, optic nerve sheath hemorrhages, and a ruptured saccular aneurysm due to focal fibromuscular dysplasia involving the intracranial right vertebral artery. This case documents a fatal subarachnoid hemorrhage in a child with an intracranial saccular aneurysm caused by fibromuscular dysplasia. The associated retinal hemorrhages are easily detected by postmortem monocular indirect ophthalmoscopy.     

外伤性黄斑裂孔法医学鉴定16例分析

目的 分析总结外伤性黄斑裂孔的特点,探讨法医学鉴定的要点及注意事项.方法 对2004-2009年在中国医科大学法医司法鉴定中心鉴定的16例外伤性黄斑裂孔案例进行回顾性分析.结果 16例外伤性黄斑裂孔均为闭合性眼球钝挫伤所致,以青年男性多见.裂孔可于伤后立即出现或间隔一段时间出现.伤后6个月,2例黄斑裂孔自发性闭合,12...