Determining Causation For SDH

Subdural Hematoma in Children

Guy N. Rutty and M.V. Waney Squier

Introduction
There are few areas within medicolegal practice at present that generate as much controversy as the interpretation of findings upon which mechanisms of injury to children, living and deceased, are based. High-profile cases within the English legal system highlight the difficulty of diagnosing the cause of pathologic findings “beyond reasonable doubt.” The pathologist may be faced with a panel of experts clinging to “mainstream thinking” backed by anecdotal and personal experience rather than considering peer-reviewed research and literature. This is one area where evidence-based medicine is an absolute requirement, particularly when evidence is being put before a court.

In recent times the question of who should be undertaking these examinations has been raised. Should it be a forensic pathologist who may have little, if any, formal pediatric training, or a pediatric pathologist who equally may have little, if any, forensic training? The solution seems obvious: have both pathologists present at the autopsy, especially when the pathologic findings may have both a natural and/or an unnatural causation. Ultimately, the pathologist’s duty is to the court, as an unbiased witness to present and interpret the findings within his or her limits of expertise.

This chapter addresses a single pathology from an area of contentious medicolegal practice, that is, the subdural hematoma (SDH), which is regarded by some as highly indicative of nonaccidental injury. Whereas most SDH in infants is caused by trauma, many other natural and unnatural causes have been described. We review all causes that could be identified from the world literature as possible causes of SDH and consider the ages when they occur, the associated medical or pathologic findings, and the hypothesized mechanisms of causation. Only by considering all of the causes examined within this chapter can we start to plan the investigations required to determine the causation of SDH in childhood.

Incidence
Subdural hemorrhage occurs in 10.9 per 100,000 infants aged 0 to 2 years, 20.8 per 100,000 infants younger than 1 year.1 Most SDH occurs in infants aged 0 to 4 months.2 The age distribution is similar for all causes of traumatic SDH, indicating that pathogenesis is dependent on age and independent of cause.3

Source:

http://www.springerlink.com/content/vnnx29066n8q2j34/

http://www.springerlink.com/content/vnnx29066n8q2j34/fulltext.pdf?page=1