SIR–Your editorial overview of the diagnostic dilemmas in non-accidental injury is both welcome and timely.1 As noted, there are many misunderstood factors in the pathogenesis and mechanisms of infant brain injury.

As far as spinal cord bleeding is concerned, this is seen commonly at autopsy in any infant with intracranial subdural bleeding, whatever the cause. Koumellis et al.2 saw spinal bleeding only in infants thought to have been abused as this was their study population; they did not look at infants with subdural haemorrhage of any other cause. While a local origin remains a possibility, and indeed bleeding from the spinal dura is often seen, the typically crescentic collection of blood over the posterior cord (Fig. 1) indicates a gravitational sedimentation of blood, as does the common finding of spinal blood in the most dependent levels of the cord, thoracic, and lumbar. Relocation and sedimentation of blood within the subdural compartment is well recognized.3


Figure 1.  Transverse section through the spinal cord stained with Perl’s stain. Three-month-old male infant with fresh bleeding into chronic subdural collection around the spinal cord. Infant spent 2 weeks on a ventilator; fresh bleeding occurred during this time.

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The editorial noted that choking and coughing are common features in the clinical history of infants with the ‘accepted diagnostic triad’ and questions the effects of prolonged crying. However, it did not question the cause of the crying. Many infants with the triad have a history of being irritable, crying, and vomiting and are often diagnosed with gastro-oesophageal reflux; some also have a history of prolonged neonatal jaundice. In these infants a chronic subdural haemorrhage is common and is rarely diagnosed in life before the infant presents in acute collapse.

Subdural bleeding occurs in almost half of asymptomatic neonates7 but follow-up studies are so few – only 27 infants have been followed-up worldwide to date7,8– that we have no meaningful data regarding the outcome of most neonatal subdural haemorrhages. We have little understanding of the mechanisms of formation or resorption of subdural blood in infants and even less of the reasons why blood in the subdural compartment, not causing mass effect, may be responsible for the clinical symptoms including vomiting, lethargy, failure to thrive, apnoea, and seizures.9

Raised awareness of the possibility of a chronic subdural collection as the cause of these symptoms and early investigation may prevent many infants from suffering additional brain damage and their families from the potential of wrongful accusations of abuse.


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  2. References
  • 1
    Baxter P. Non-accidental brain injury: mechanisms and imponderables. Dev Med Child Neurol 2009; 51: 575.
  • 2
    Koumellis P, McConachie NS, Jaspan T. Spinal subdural hematomas in children with non accidental head injury. Arch Dis Child 2009; 94: 2169.
  • 3
    Vinchon M, Noule N, Tchofo PJ, Soto-Ares G, Fourier C, Dhellemmes P. Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse. J Neurosurg 2004; 1 (Suppl.): 4452.
  • 4
    Lee JI, Hong SC. Spinal subdural haematoma as a complication of cranial surgery. Acta Neurochir (Wien) 2003; 145: 4114.
  • 5
    Yamaguchi S, Kurisi K, Arita K, Takeda M, Tani I, Araki O. Simultaneous cranial and spinal subdural hematoma. Neurol Med Chir (Tokyo) 2005; 45: 6459.
  • 6
    Vinchon M. Differentiating accidental from abusive injuries: intracranial findings and mechanisms. Second International Conference on Pediatric Abusive Head Trauma, Jackson Hole, Wyoming, 25 June 2009.
  • 7
    Rooks VJ, Eaton JP, Ruess L, Petermann GW, Keck-Wherley J, Pedersen RC. Prevalence and evolution of intracranial hemorrhage in asymptomatic term infants. AJNR Am J Neuroradiol 2008; 29: 10829.
  • 8
    Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363: 84651.
  • 9
    Swift DM, McBride L. Chronic subdural hemtoma in children. Neurosurg Clin N Am 2000; 11: 43946.