Optic Nerve Sheath Hemorrhage Research Articles

Magnetic resonance imaging of optic nerve and optic sheath hemorrhages in child abuse.

In abusive head trauma victims, optic nerves and optic sheath hemorrhages are commonly associated with retinal hemorrhages. Until now, optic nerve and optic nerve sheath hemorrhages related to abusive head trauma have been identified by exenteration and soft-tissue sectioning during postmortem examination. In 2013, we proposed the use of tailored high-resolution susceptibility-weighted imaging (SWI) MRI sequences to depict retinal hemorrhages in lieu of the gold standard dilated fundus exam, in select patients, and in 2017 we showed how the same high-resolution sequences used in the coronal plane can depict ruptured bridging veins in abusive head trauma. This paper describes the new potential diagnostic application of high-resolution axial and coronal SWI in the diagnosis of optic nerve and optic sheath hemorrhages.

Novel in vivo depiction of optic nerves hemorrhages in child abuse: a 3D-SWI pilot study

PurposeUntil now, the diagnosis of optic nerves hemorrhages in abusive head trauma (AHT) has been obtained only in the postmortem setting. The aim of the IRB-approved study was to assess the presence of optic nerves hemorrhages in AHT patients using 3D-SWI.MethodsThirteen children with a final confirmed multidisciplinary diagnosis of AHT underwent coronal and axial 3D-SWI imaging of the orbits. The presence of optic nerve sheath (ONS) hemorrhages was defined by thickening and marked 3D-SWI hypointensity of the ONS, resulting in mass effect upon the CSF space. Optic nerve (ON) hemorrhages were defined by areas of susceptibility artifacts in the ON parenchyma. Superficial siderosis was defined by susceptibility artifact coating the ON. Furthermore, data about post-traumatic deformity of the ONS at the head of the optic nerve were collected.ResultsThe average age of the population was 7.9 ± 5.9 months old. The average GCS was 11.8 ± 4.5. The male to female ratio was 7:6. ONS hemorrhages were identified in 69.2% of cases. Superficial siderosis and ON hemorrhages were identified in 38.5 and 76.9% of cases, respectively. 3D-SWI also depicted traumatic deformity of the ONS at the level of the optic nerve head in 10 cases (76.9%). No statistical correlations were identified between RetCam findings and 3D-SWI findings or GCS and ON hemorrhages.ConclusionThis research shows that dedicated MRI with volumetric SWI of the orbits can depict hemorrhages in the ON, ONS, and ONS injury, in AHT victims.

The importance of optic nerve sheath hemorrhage as a postmortem finding in cases of fatal abusive head trauma: A 13-year study in a tertiary hospital

Fatal abusive head trauma is a major cause of death in children and toddlers who suffer from cruel physical abuse. Postmortem differentiation of fatal abusive head trauma from accidental head trauma can be a complicated process. This consecutive case series study aimed to determine the role of subdural optic nerve sheath hemorrhage (ONSH) in 70 autopsy cases of children ≤3 years old in making this differentiation. The study took place over a 13 year period (between August 1st 2003 and July 31st 2016) at a tertiary hospital in Thailand. Eleven cases were diagnosed with fatal abusive head trauma and 10 were identified as being accidental closed head trauma cases. Bilateral retinal hemorrhage was noted in antemortem medical records in every hospitalized abusive head trauma case (n=10). Upon autopsy, ONSH was observed in all 11 fatal cases of abusive head trauma (bilateral=10 and unilateral=1) but not in any cases of accidental head trauma (0/5). Subdural hemorrhage was found in 10 out of 11 abusive head trauma victims but not in any of the 10 with accidental head trauma. Other postmortem findings in abusive head trauma included subarachnoid hemorrhage (5/11), marked brain swelling (3/11), skull fracture (4/11) and brain contusion (1/11). This study suggests that ONSH, together with subdural hemorrhage, plays an essential role in an accurate postmortem diagnosis of fatal abusive head trauma. Therefore, an ocular investigation should be performed in all autopsy cases where child abuse is suspected and where there is no reliable history/witnesses, confession or antemortem ophthalmologic examination.

Diffuse bilateral retinal hemorrhages in an infant with a coagulopathy and prolonged cardiopulmonary resuscitation

We report a case of diffuse bilateral retinal and optic nerve sheath hemorrhages in an 8-week-old boy who was found unresponsive. The child underwent prolonged cardiopulmonary resuscitation andwas noted on admission to have a coagulopathy. An autopsy determined the cause of death to be a myocardial infarct in the distribution of an anomalous coronary artery. This case demonstrates the difficulty that may occur in establishing whether child abuse caused death in the setting of another potential cause of mortality.

The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse

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.

Distinguishing accidental from inflicted head trauma at autopsy.

This article will discuss accidental and inflicted head injuries in infants and young children and how forensic pathologists distinguish between these types of injuries. The article begins with a consideration of the special and unique features of the anatomy and development of the child's head and neck and then relates these features to the mechanisms of traumatic brain injury and how these unique features influence the mechanisms of injury. The article very specifically notes that accidental head injuries in young children that occur in and around the home are focal head injuries in distinction to inflicted head injuries, which are diffuse brain injuries. The article discusses the mechanisms by which traumatic brain injury causes loss of consciousness and relates those mechanisms to the differences in the clinical features that occur in both accidental and inflicted head injury. The article discusses and illustrates the pathological findings in accidental head injuries consisting of the crushing head injuries and the head injuries sustained in short falls including epidural hemorrhage and focal subdural hemorrhage. The article discusses and illustrates the pathological findings that occur in inflicted head trauma, including subdural and subarachnoid hemorrhages and retinal and optic nerve sheath hemorrhages.

Shaken Adult Syndrome

To establish that the intracranial and ophthalmologic findings present in victims of abusive head trauma can also be seen in shaken adults. We report 2 cases of shaken adults with intracranial and ophthalmologic findings that resulted from repetitive acceleration-deceleration injury. These findings included intracranial hemorrhages, hemorrhages involving the optic nerve sheath, intraretinal and subretinal hemorrhages, and macular folds. The intracranial and ophthalmologic findings that are characteristic of abusive head trauma--subdural hemorrhages, optic nerve sheath hemorrhages, and retinal hemorrhages--are generally thought to be limited to young children and infants. Adults may also be victims of shaking abuse, and an ophthalmic examination may be beneficial when shaking is suspected.

Extramedullary Hematopoiesis in Abusive Head Trauma

was observed in an otherwise clear cut case of abusive head trauma with bilateral retinal hemorrhage, optic nerve sheath hemorrhage and peripapillary intrascleral hemorrhage. Review of 60 archival cases of suspected abusive head trauma identified two more examples of extramedullary hematopoiesis in abusive head trauma that initially had been diagnosed as uveitis. Extramedullary hematopoiesis of the choroid may have a relation to premature birth, possible anemia or may be a reaction to intraocular bleeding due to earlier trauma. Choroidal extramedullary hematopoiesis may easily be confused for choroiditis and interpreted as a sign of infectious disease. Awarenes of the possibiliy of extramedullary hematopoiesis of the choroid should prevent misdiagnosis.

Are Peripapillary Intrascleral Hemorrhages Pathognomonic for Abusive Head Trauma?*

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.

Craniocerebral Trauma Inflicted by Television Falls*

Accidents and inflicted trauma account for 33% and 5-8% of childhood deaths, respectively. Injuries secondary to falling televisions have been reported in the clinical literature. However, descriptions of such injuries at autopsy are limited. The severity and patterns of injury may mimic those considered ''typical'' of inflicted trauma. Thus, integration of data from clinical, scene investigation, and autopsy is necessary for determination of the cause and manner of death. We present autopsy findings from two cases which illustrate injuries sustained from falling televisions. Findings common to both cases include subscalpular hemorrhages, skull fractures, subdural hemorrhages, brain injuries, and optic nerve sheath hemorrhages. The first case showed postsurgical changes secondary to evacuation of a posterior fossa hematoma; three-dimensional reconstruction of the admission computed tomography scan demonstrated the extent of the preintervention skull fractures. In addition, the second case showed a right epidural hematoma. Only case two showed retinal hemorrhage.

Ocular Findings in Raised Intracranial Pressure

We present the case of a 7-month-old female infant who was found crying and limp. She was transported to a hospital where a possible subarachnoid hemorrhage was diagnosed radiologically. Before further studies could be pursued, her condition worsened and she died. The autopsy demonstrated diffuse subarachnoid hemorrhage of the brain and along the spinal cord. The brain, spinal cord, and eyes were retained and examined postfixation. An aneurysm of the middle cerebral artery was identified. Examination of the eyes demonstrated bilateral optic nerve sheath hemorrhage and extensive retinal hemorrhages extending to the ora serrata. A rapid increase in intracranial pressure secondary to subarachnoid hemorrhage following rupture of an aneurysm can result in sequelae similar to those found in inflicted traumatic brain injury. In this case, the rise in intracranial pressure resulted in marked hemorrhage within the optic nerve sheaths as well as intra- and preretinal hemorrhages. Patients with subarachnoid hemorrhage, or other causes of rapidly increased intracranial pressure, may develop ocular hemorrhage (Terson syndrome). This case illustrates the importance of ruling out natural disease before attributing the autopsy findings to trauma, as well as the importance of postmortem fixation of pediatric brains and eyes prior to examination.

Fatal spontaneous subdural bleeding due to neonatal giant cell hepatitis: a rare differential diagnosis of shaken baby syndrome

A 7-week-old girl showed vomiting after feeding, facial pallor, loss of muscle tone and respiratory depression. An emergency doctor performed successful resuscitation and after arrival in hospital, cranial ultrasound showed left-sided subdural hemorrhage, cerebral edema with a shift of the midline, and a decrease in cerebral perfusion. Ophthalmologic examination showed retinal hemorrhage. In view of this, the doctors suspected shaken baby syndrome and approached the parents with their suspicions, but they denied any shaking or trauma. Despite surgery for the subdural hemorrhage the girl died a few hours later with a severe coagulopathy. Autopsy verified subdural hemorrhage, cerebral edema and retinal hemorrhage, but also revealed intact bridging veins and a lack of optic nerve sheath hemorrhage, therefore shaken baby syndrome could not be proven by autopsy. Histological examination showed severe neonatal giant cell hepatitis as the cause of the severe coagulopathy and the associated spontaneous subdural bleeding. Neonatal giant cell hepatitis may be responsible for unexpected deaths in infancy and, although rarely associated with subdural bleeding, must be considered as a potential differential diagnosis of shaken baby syndrome.

A Systematic Review of the Diagnostic Accuracy of Ocular Signs in Pediatric Abusive Head Trauma

To review systematically the diagnostic accuracy of various ocular signs for pediatric abusive head trauma (AHT). Intraocular hemorrhages (IOH), perimacular retinal folds, traumatic retinoschisis and optic nerve sheath hemorrhages have been reported as cardinal signs of AHT. The evidence base supporting the accuracy of this interpretation, however, has not been systematically reviewed. A systematic keyword search of MEDLINE, EMBASE, and Evidence-Based Medicine Reviews was conducted for original studies reporting ocular findings in AHT. Articles were graded using a checklist for systematic reviews of diagnostic accuracy. The initial search yielded 971 articles, of which 55 relevant studies were graded, and 20 studies met inclusion criteria and were included in the review. The overall sensitivity of IOH for AHT was 75% and their specificity was 94%. Intraretinal hemorrhage at the posterior pole was the most common finding, although extensive, bilateral, and multilayered IOH were the most specific for AHT. Optic nerve sheath hemorrhages had a sensitivity and specificity for AHT of 72% and 71%, respectively. Traumatic retinoschisis and perimacular retinal folds were reported in 8% and 14% of AHT, respectively, but were not reported in other conditions. Prospective, consecutive studies confirm that IOH in infants-particularly bilateral, extensive, and multilayered-are highly specific for AHT. Optic nerve sheath hemorrhages are significantly more common in AHT than in other conditions, in autopsy studies. Traumatic retinoschisis and perimacular folds are present in a minority of AHT, but rarely seen in other conditions.

Optic Nerve Sheath Hemorrhages, Increased Intracranial Pressure, and Retinal Hemorrhages in Central Nervous System Trauma

Optic Nerve Sheath Hemorrhages, Increased Intracranial Pressure, and Retinal Hemorrhages in Central Nervous System Trauma

Ocular pathology in shaken baby syndrome and other forms of infantile non-accidental head injury

Retinal and optic nerve sheath hemorrhages are an essential part of the various forms of inflicted neurotrauma in infants, especially in its most common variant, the shaken baby syndrome (SBS). Clinically, ophthalmologists play an important part for the diagnosis and further management of patients with SBS. For the forensic pathologist, a thorough understanding of the basic principles behind the morphological phenomena commonly encountered in the orbita is required. This review summarizes the present knowledge of ocular pathology in inflicted infantile neurotrauma, focusing strongly on SBS. Furthermore, a review of the most recent literature on the subject is given.

Terson Syndrome With Bilateral Optic Nerve Sheath Hemorrhage

A 53-year-old man presented with an acute headache and mental status changes due to rupture of an anterior choroidal artery aneurysm. A preoperative CT scan demonstrated subarachnoid hemorrhage, bilateral optic nerve sheath hemorrhage, and bilateral intraocular hemorrhage. Ophthalmoscopy and B-scan ocular ultrasound disclosed vitreous hemorrhages, features consistent with Terson syndrome. This is the first CT report of Terson syndrome showing bilateral optic nerve sheath hemorrhage.

Postmortem Orbital Findings in Shaken Baby Syndrome

To compare postmortem orbital findings in pediatric accidental head injury to Shaken Baby Syndrome (SBS). Retrospective study. Institutional. Thirty-six patients underwent postmortem modified exenteration with sectioning of the orbital contents; 18 victims of SBS and 18 cases of fatal accidental head trauma. In all cases of children who died from accidental head trauma, the orbital tissues were separated to expose the optic nerve sheath. Patients with gross evidence of hemorrhage within the sheath were included. All cases of SBS were included. After accidental head injury, exenteration was performed only if optic nerve sheath hemorrhage was suspected on gross examination. All children younger than 18 years old with head injury as primary cause of death were included. SBS is defined as having at least two of the following: (1) typical abnormal findings on neuroimaging, (2) typical skeletal injury, (3) retinal hemorrhages, (4) history of abusive shaking with or without blunt head trauma, or (5) an inadequate history to explain the observed injuries. Presence or absence of orbital hemorrhage. Orbital tissue injury is more common in SBS than accidental head trauma without orbital fracture. In addition, optic nerve sheath and optic nerve intradural hemorrhage are also significantly more common in SBS (P < .0001). Our study reports new evidence of injury to orbital tissues in SBS and supports the concept that these finding are due to unique acceleration-deceleration forces of this type of abusive head injury.

Findings in Older Children With Abusive Head Injury: Does Shaken-Child Syndrome Exist?

Shaken-baby syndrome (SBS) has been hypothesized to occur after shaking by an adult during the first 2 years of life. We wondered whether it is possible to achieve rotational forces sufficient to cause SBS-like injuries in children >2 years of age. The present study describes cases of child abuse in older children who presented with the classic ophthalmologic and intracranial findings of SBS. In this case series, 4 cases of older children (2.5-7 years old; 11.8-22 kg) who died from abusive head injuries and who had diffuse retinal hemorrhages identified antemortem were selected for review. The cases were abstracted from hospital charts, records from autopsies, coroners' and district attorneys' offices, and court transcripts. In all 4 cases the history provided by the primary caregiver did not match the severity of the injuries. Three case subjects presented with patterned bruises. Multilayered retinal hemorrhages and acute subdural hematoma were observed in all 4 cases. At autopsy, diffuse axonal injury was evident in 3 of the 4 cases; all 4 cases had optic nerve sheath hemorrhages. None of the victims had skeletal fractures on radiologic examination or at autopsy. This case series demonstrates that it is possible to observe SBS-like retinal and central nervous system findings in the older and heavier child. Our findings underscore the need for providers to consider intentional shaking as a mechanism of injury in the evaluation of abusive head injury in older children.

An Overview of Inflicted Head Injury in Infants and Young Children, With a Review of β-Amyloid Precursor Protein Immunohistochemistry

Abstract Context.—Inflicted traumatic brain injury of infants and young children results in a complex array of autopsy findings. In many cases, immunostains for β-amyloid precursor protein are used to detect axonal injury. Interpretation of the gross, microscopic, and immunostaining results requires the integration of the many facets of the individual case. Objective.—In this article we review the gross and microscopic findings associated with inflicted traumatic brain injury. The application and interpretation of β-amyloid precursor protein immunostains are discussed and photomicrographs are used to illustrate immunostaining patterns. Data Sources.—The pertinent literature is integrated into a review of the subject. Conclusions.—Inflicted traumatic brain injury often results in subdural, subarachnoid, retinal, and optic nerve sheath hemorrhage. These findings must be interpreted within the entire context of the case. β-Amyloid precursor protein immunostains may be helpful in illustrating the traumatic nature of the injuries in some cases.

The spectrum of postmortem ocular findings in victims of shaken baby syndrome

Background: Ophthalmologists and ocular pathologists are called on to help identify children who have undergone violent shaking. The objective of this study was to describe the spectrum of postmortem ocular findings in victims of shaken baby syndrome and to correlate the ocular findings with the nonocular features found at autopsy.Methods: The ocular pathology registry at the University of Ottawa Eye Institute was reviewed to identify all victims of fatal shaken baby syndrome whose eyes had been submitted for examination between Apr. 1, 1971, and Dec. 31, 1995. Autopsy reports were accessed from the hospital charts of the identified patients.Results: Six patients, aged I to 34 months, were identified. Intraocular findings ranged from a focal globular hemorrhage at the posterior pole to extensive intraocular hemorrhage involving the entire retina with perimacular folds. All the children had evidence of optic nerve sheath hemorrhage. Nonocular findings included intracranial hemorrhage (in all cases), skull fracture (in two), rib fractures (in three) and high spinal cord hemorrhage (in four). The extent of the intraocular hemorrhage was not consistent with the nonocular findings.Interprétation: Abused children may display a range of postmortem ocular findings, with intraocular hemorrhage varying from minimal to severe. These findings may not correlate with the severity of the child's other injuries. The presence of any retinal or optic nerve sheath hemorrhage in an infant, in the absence of an appropriate explanation for these findings, should raise suspicion of child abuse.