Retinal findings in children with intracranial hemorrhage

doi:10.1016/S0161-6420(02)01086-2

Ophthalmology

Volume 109, Issue 8, August 2002, Pages 1472-1476

Presented in part at Department of Surgery Annual Research Competition, The Hospital for Sick Children, Toronto, Ontario, Canada, May 1997; the Thirty-ninth Annual Research Day, Department of Ophthalmology, University of Toronto, Toronto, Ontario, Canada, May 1998; the Eleventh Annual Jack Crawford Day, The Hospital for Sick Children, Toronto, Ontario, Canada, April 1999; and the American Professional Society on the Abuse of Children, Chicago, Illinois, July 2000.

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Abstract

Purpose

To identify the incidence of Terson’s syndrome in children.

Design

Prospective, observational case series.

Participants

Fifty-seven consecutive children with known intracranial hemorrhage from nonabuse causes.

Methods

Dilated fundus examination to detect intraretinal hemorrhages or other abnormalities.

Main outcome measures

Presence or absence of intraretinal hemorrhages or other abnormalities.

Results

Fifty-five patients (96%) had no evidence of intraretinal or vitreous hemorrhage. Two patients had abnormal retinal examinations. One patient had a single dot hemorrhage associated with presumed infectious white retinal lesions. The second patient had three flame and two deeper dot intraretinal hemorrhages after a motor vehicle accident (1.5% incidence of retinal hemorrhage).

Conclusions

Retinal hemorrhage is uncommon in children with intracranial hemorrhage not resulting from shaken baby syndrome. The maximal incidence of intraretinal hemorrhage in children with nonabuse intracranial hemorrhage is 8%.

Section snippets

Materials and methods

All children 6 weeks of age or older with intracranial hemorrhage documented by computerized tomography (CT) from any cause other than abuse were considered eligible for the study. Exclusion criteria were age less than 6 weeks or duration of intracranial hemorrhage more than 72 hours. The former was designed to eliminate the possible confounding effect of retinal hemorrhage resulting from birth.10, 17 The latter was to avoid accidental exclusion of a patient whose hemorrhages had cleared

Results

Fifty-seven patients met the inclusion criteria. The patients were 5 months to 16.1 years of age (mean, 10.3 years). Seventeen children (30%) were 4 years of age or younger. There were 30 males and 27 females.

Table 1 shows the mechanism for intracranial hemorrhage. Twenty-seven (47%) were the result of trauma. Of these, 15 (55%) were motor vehicle accidents. Sports or hobbies accounted for 6 (22%), whereas falls from a height made up the remaining 6 trauma cases (22%). Our sample size prevented

Discussion

We undertook this prospective study to report retinal findings in children with intracranial blood from any cause other than abuse. Although prospective studies in adults have demonstrated Terson’s syndrome at a rate of 16% to 27%,7, 8, 12 our study suggests that the incidence is much lower in children.

Shaking is a violent act. It is now believed that shaking alone can cause most of the intraretinal and intracranial findings.10, 19, 20 Death can also occur from shaking alone. Shaken baby

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It may occur after fatal head injuries, in crashes such as motor vehicle accidents (MVA), and in unusual scenarios, such as when a television set topples over, and in one case of a stairway fall.22–28 It is extremely rare to find ONSH and RH accompanying TS in infants,29–34, The occurrence of ONSH in an infant with TS has been described in only three infant cases.35–37 RH may accompany infectious diseases 38, but little is known about the incidence of ONSH in conjunction with infectious conditions.
In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.
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A total of 168 children (104 males) were included. Of these, 103 were classified as cases and 65 as controls. The mean age (with standard deviation) was 9.3 ± 8.3 months (range, 1 day-36 months). Of the 103 cases, 22 (21%) had subretinal hemorrhage, 9 (9%) had retinoschisis, and 1 (1%) had vitreous hemorrhage. Children presenting with lethargy or altered mental status (P < 0.0001), subdural hemorrhage (P < 0.0001), and other radiologic findings (eg, cerebral ischemia, diffuse axonal injury, hydrocephalus, or solid organ injury; P = 0.01546) were likely to have RH. All 23 children with skull or nonskull fracture without intracranial hemorrhage did not have RH (P < 0.0001 both categories).
Retinal hemorrhages were almost never found in the absence of intracranial hemorrhage and not found in the setting of fracture without intracranial hemorrhage.
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In the absence of any other cause, these classical retinal hemorrhages suggest an inflicted injury, but they are neither pathonomonic98 nor universal.2,78 Short falls,21,91 stairwell falls,65 road traffic accidents,98 and crush injuries66 have in exceptional cases been the likely cause of retinal or intraocular hemorrhages, usually in the context of intracranial hemorrhage. Any retinal hemorrhages, particularly in the context of other unexplained trauma, should raise the suspicion of abuse.62

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¹: The authors have no financial interest in any aspect of this paper.

View full text

Retinal findings in children with intracranial hemorrhage1

Abstract

Purpose

Design

Participants

Methods

Main outcome measures

Results

Conclusions

Section snippets

Materials and methods

Results

Discussion

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Am J Ophthalmol

Ophthalmology

Ophthalmology

Ophthalmology

Ann Emerg Med

Ann Emerg Med

Ophthalmology

Ophthalmology

De l’hémorrhagie dans le corps vitré au cours de l’hémorrhage cérébrale

Clin Ophtalmol

Intraocular and optic nerve sheath hemorrhage in cases of sudden intracranial hypertension

J Neurosurg

Terson’s’s syndromea reversible cause of blindness following subarachnoid hemorrhage

J Neurosurg

Terson’s’s syndrome in spontaneous subarachnoid hemorrhagea prospective study of 60 consecutive patients

J Neurosurg

Retinal haemorrhages and child abuse

A propos de syndrome de Terson’s et d’un cas post-tramatique chez le nourrisson

Bull Soc Ophtalmol Fr

Ocular clues to child abuse

J Pediatr Ophthalmol

Retinal findings in children with intracranial hemorrhage¹