Child abuse: Anatomy and pathogenesis of retinal hemorrhages after abusive head trauma
- Gil Binenbaum, MD, MSCE
Gil Binenbaum, MD, MSCE
- Associate Professor of Ophthalmology
- University of Pennsylvania
- Richard Shafritz Chair of Ophthalmology Research,
- Children’s Hospital of Philadelphia
- Section Editors
- Evelyn A Paysse, MD
Evelyn A Paysse, MD
- Section Editor — Pediatric Ophthalmology
- Professor of Ophthalmology and Pediatrics
- Baylor College of Medicine
- Daniel M Lindberg, MD
Daniel M Lindberg, MD
- Section Editor — Pediatric Psychosocial Emergencies
- Associate Professor of Emergency Medicine and Pediatrics
- University of Colorado Kempe Center
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Abusive head trauma (AHT) is also known as nonaccidental head injury, inflicted head injury, or inflicted childhood neurotrauma. One subset is referred to as shaken baby syndrome, with a constellation of inflicted injuries in young children characterized by repeated acceleration-deceleration injury with or without blunt head impact [1-4]. Characteristic clinical features include retinal hemorrhages (often but not always bilateral, multilayered, and extensive), subdural hematoma, and/or occult fractures (particularly of the ribs and long bone metaphyses). Multiple episodes of trauma may occur before the abuse is detected [5-8]. Early recognition can be lifesaving.
The pathogenesis of retinal hemorrhages in AHT will be reviewed here. Other aspects of AHT and the management of suspected child abuse are discussed separately. (See "Child abuse: Eye findings in children with abusive head trauma (AHT)" and "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children" and "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children" and "Physical child abuse: Diagnostic evaluation and management".)
The retina is comprised of several layers (figure 1). The retinal vessels are contained in the neural portion of the retina . The large vessels course through the nerve fiber and ganglion cell layers. Smaller vessels are located between the nerve fiber and inner nuclear layers. There are three layers of retinal capillaries: those within the nerve fiber and ganglion cell layers, those in the inner nuclear layer, and the radial peripapillary capillaries.
Overview — Several mechanisms have been proposed to play a role in the development of retinal hemorrhages, but none is universally accepted. Different types of retinal hemorrhages may have different mechanisms, and more than one mechanism may operate in any given instance (figure 2 and figure 3 and figure 4 and figure 5).
Autopsy studies demonstrate an increased rate of orbital hemorrhage in abusive head trauma (AHT) victims compared with victims of unintentional (accidental) head injury . Repetitive acceleration-deceleration (shaking) forces appear to play a primary role in the development of orbital and subdural hemorrhage in AHT [10-15]. The role of repetitive acceleration-deceleration forces in the pathogenesis of subdural hemorrhage in AHT is discussed separately. (See "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Mechanisms of injury'.)
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