The emperor has no clothes

Abstract

Sir, The paper by Mack et al. [1] would, by the title, appear to be a straightforward exposition of developmental anatomy and pathophysiology of CSF and extracerebral accumulation of fluid. Instead, the authors raise reasonable doubt regarding the traumatic origin of subdural hematoma (SDH) in infants. The authors present two pillars to support their argument: (1) they include SDH under the rubric of “subdural collection,” implying that a pathogenesis of blood between the dura and arachnoid is similar to effusion, which may result from a variety of causes (e.g., inflammation); and (2) they imply that falcine/tentorial hemorrhages in newborns are the same as SDH later in infancy. Equating dural/subdural hemorrhages in newborns, a phenomenon well-known to pediatricians, neurologists, and pediatric pathologists for decades to be a consequence of birth trauma, with SDH in infancy (a consequence of inflicted or accidental trauma) is blatantly misleading [2]. A similar argument advanced by Geddes et al. that raised doubt regarding the traumatic origin of SDH in infants and that suggested such hemorrhages were a consequence of hypoxia ischemia was later retracted under oath during her testimony before the High Court of Justice of England and Wales in June 2005 [3]. There is a mountain of literature documenting the traumatic origin of greater than 95% of SDH, regardless of age, and to claim that the extraordinarily common problem of hypoxia ischemia is causative contradicts the vast experience of the greater medical community. Hypoxia ischemia alone is not a cause of intra-/subdural hematomas. If it were, the journals and medical textbooks would have documented this phenomenon decades ago. Our forebears were, in fact, astute observers and recorders of clinical–pathological relationships, and it is highly unlikely that such an important correlation would have escaped notice until 2009. To put it bluntly, perinatal subdural/intrafalcine hemorrhages are not equivalent to SDH later in infancy, and hypoxia ischemia does not cause SDH – the emperor has no clothes.