Brief summary of the case for the jury. Both parents are professionals-father is a radiologist and the
mother is a medical malpractice lawyer. They have been married for 2 years, and this was their first
child. Father accused of and charged with assault leading to the death of his 2 month old baby
daughter. Cause of death found to be bilateral subdural haematomas and brain swelling. Charges
against the defendant, what they mean and what is expected of the jury. Introduce QC for the
defence. Witness has been qualified as an expert in child abuse.
Defense attorney (BH): Doctor, you are certainly an eminent expert in this field. I shall try to confine
my questioning to your particular areas of expertise.
2 But first, for the benefit of the jury and to
ensure that I have understood your evidence in chief I shall recap your findings in this case. In this 2
month old baby you have identified the following skeletal findings: multiple rib fractures,3 bilateral
medial clavicle fractures, 4 a left acromion process fracture, a right 5 femoral shaft fracture and
classic metaphysical lesions or CMLs of the distal right femur and distal left tibia and also periosteal
new bone formation along the distal left tibial shaft. Are those your findings?
Expert (PK): Yes, by the way it’s metaphyseal not metaphysical
BH: Thank you for your clarification doctor! You have also very clearly stated how each fracture may
have occurred and the amount and type of force necessary to produce each of them. I understand
that in your opinion these were non-accidental injuries, in other words child abuse.
Doctor, you have testified regarding the fractures in this child. Is it true that you are not an
orthopaedic surgeon?
PK: No, I am not an orthopaedic surgeon, but I…..
BH: And you do not treat patients with fractures?
PK: No, I do not treat them, but…
BH: So it is true that you are not able to diagnose fractures and determine their cause.
PK: No, that is not true. Radiologists regularly diagnose fractures and can make informed judgments
regarding the types and magnitude of forces responsible for the injuries.
BH: But you are not a biomechanical engineer, correct?
PK: Correct.
BH: 6Regarding the rib fractures, could they have occurred at birth?
PK: No
BA: But rib fractures do occur with birth trauma, correct?
PK: Yes
BA: So how can you rule out that possibility in this infant?
PK: The rib fractures initially identified showed no signs of healing in this 2 month old infant.7
BH: But the fact that the rib fractures initially identified were in the mid posterior rib cage and this
baby had what the father described as a very traumatic delivery would be in keeping with birth
injuries, true?
PK: Yes but….
BH: 8 And what about the fact that additional rib fractures occurred when the infant was in the
hospital?
Expert: They may have become evident in the hospital as callus became visible, but we know that
acute fractures are often inconspicuous.
QC: So they MAY have occurred before the hospitalization, but you cannot rule out that they
occurred after the child was admitted?
PK: Well, I guess that is theoretically possible, but…
PK: Let’s move on. I would now like to explore with you the possibility that an underlying medical
condition may have been present, so that these fractures could have occurred as a result of normal,
careful handling of the baby.
The police may not have informed you of some relevant background history in this case. It is
recognised that the mother suffered from severe hyperemesis throughout pregnancy. Also, the
baby was born prematurely at 34 weeks gestation and failed to establish feeding and needed nasogastric feeding and one day of intravenous feeding before discharge at the age of one week.
Now let us consider the possibility that as a result of the hyperemesis, the mother and baby were
deficient in certain nutrients. Would you tell us the X-ray findings you would expect to see if the
baby were deficient in Vitamin C – in other words – was suffering from scurvy?
PK:
9 It is true that in scurvy there may be subphyseal lucency with metaphyseal fragmentation
and fractures, but there is also relative increased density of the zone of provisional calcification and
dense epiphyseal rings. Sub periosteal haemorrhage and mineralization is common.10 The
hallmark of scurvy is severe demineralization.
BH: Just so we are clear – what do you mean by the term demineralization?
PK: Explains....
BH: I presume you are familiar with research that has been done identifying that X-rays are very
imprecise in assessing bone density and that there can be a reduction of 30% of bone mineral
content before this is apparent to radiologists?
PK: Well I am aware that that number has been thrown around, but I am not certain it applies in this
setting.
BH: So, doctor, according to you, the classic findings of scurvy are metaphyseal fractures, periosteal
reactions and possibly fractures as indeed we see in this baby, but you maintain the baby was not
suffering from scurvy!
PK: But you have neglected the critical issue in scurvy of profound demineralization and other critical
clinical and laboratory findings …..
BH: So let us move on. Another possibility given the hyperemesis, is that the baby was deficient in
vitamin D – was suffering from congenital rickets. Would you tell us the X-ray findings you would
expect to see in a case of rickets.
PK:
11 In rickets there is demineralization, loss of the zone of provisional calcification,
widening of the physes with fraying and cupping of the metaphyses. With healing there may be
periosteal reaction.
BH: You have identified metaphyseal fragmentation and periosteal changes with other fractures but
you say the baby was not suffering from rickets! Were you aware that this patient had a vitamin D
level of 32 and her mother showed clinical signs of vitamin D deficiency during her pregnancy
presumably as a result of hyperemesis?
PK: Yes.
BH: Did this influence your thinking regarding the presence of rickets?
PK: Not really, since vitamin D deficiency is quite common, but rickets, particularly the congenital
form is quite rare in otherwise normal infants. Fractures from dietary rickets in otherwise normal
young infants are quite uncommon. 12This infant manifested vitamin D insufficiency, and a recent
paper in Pediatrics from the Children’s Hospital of Philadelphia showed no increase in fracture risk
with vitamin D insufficiency.
BH: Is it possible that this patient was suffering from rickets which was not apparent
radiographically?
PK: Yes, it is possible that the patient might have metabolic alterations, but the absence of any gross
rachitic changes and the pattern of injuries noted in this patient would not be consistent with
fractures occurring purely from metabolic bone disease.
BH: But you would not be able to exclude rickets in this patient, correct?
PK: That is correct.
BH: And you cannot exclude the possibility that the patient's underlying metabolic bone disease
could be contributing to the fractures, correct?
PK: Well, yes that is correct, however that cannot explain all of the findings that we are seeing in this
case.
PK: Doctor, please restrict your response to a yes or no. Doctor, are you aware that there is an
epidemic of confusion between child abuse and rickets?
PK: I am not aware of that.
BH: Doctor, is the journal Pediatric Radiology an authoritative publication.
PK: Yes it is but…
BH: 13Are you familiar with an article appearing in that respected journal, Pediatric Radiology that
describes this epidemic of confusion between rickets and abuse?
PK: I am aware of the commentary which alleges that, but I am not in agreement.
BH: Are you suggesting that this journal publishes papers which are not correct?
PK: I do not believe everything I read.
BH: Would that include your own writings?
PK: I am afraid that would. But, I believe that at the time of publication, the editors of Pediatric
Radiology indicated that this paper was published in order to stimulate conversation on the subject,
which it certainly has. In the same journal issue, the editors found no scientific foundation for the
authors’ allegations in this commentary. 14
Reads from paper: “we find that the connection made by Keller and Barnes between “rickets” and
fractures they consider to be similar in appearance to those seen in child abuse is not based on any
scientific data. Unfortunately, the current scenario is reminiscent of Patersons’ “ temporary brittle
bone disease”. This concept has remained without proof and has been discredited. The work-up of
child abuse considers a differential diagnosis including rickets but, unless there is reasonable
evidence of rachitic bone disease, there is no scientific basis for confusing vitamin D
insufficiency/deficiency with child abuse”
BH: This document is not in evidence and I move that the this testimony be struck. Now Doctor, I
assume that your view that there is no scientific evidence to indicate that rickets is common in
young infants is simply your opinion, and that there is no evidence-based research to support this,
correct?
PK: No, that is not correct. A recent retrospective study examined approximately 100 infants dying
of the sudden infant death syndrome with high-detail skeletal surveys. They found no cases with
rickets.
BH: But is it possible that mild rickets may be present despite normal X-rays?
PK: To exclude that possibility, the authors reviewed the radiographs and also the microscopic
findings in another group of 25 infants dying with multiple skeletal injuries detected at post-mortem
imaging. Not only did they not find any radiologic evidence of rickets, a bone pathologist found no
histologic evidence of rickets.
BH: Has this paper been published?
PK: No, not yet, but it was presented at the highly regarded International Pediatric Radiology
meeting in London, a congress attended by the best and brightest minds in the field of pediatric
radiology.
BH: So Doctor, are you saying that the vitamin D deficiency in this infant was not significant - in this
infant who was breast fed and not supplemented with vitamin D?
PK: I cannot answer that with a simple yes or no.
BH: Well go on then.
PK: Would you please repeat the question?
BH: So Doctor, are you saying that the vitamin D deficiency in this infant was not significant - in this
infant who was breast fed and not supplemented with vitamin D?
PK: I'm not sure I have the expertise to say whether it is significant or not, but we know that a low
vitamin D level is common in this population. However, I can tell you to a reasonable medical
certainty that there are no radiographic findings of rickets. Even if rickets was present, it would not
explain all the imaging findings in this case.
BH: Doctor, did you consider copper deficiency? 15
PK: I did and ruled it out since this was an otherwise normal infant with no significant nutritional
issues and there were no radiologic features to support that diagnosis
BH: What about osteopathy of prematurity?
PK: In an otherwise well infant born at 34 week, I don’t think so.
BH: Let me put this to you. Let us consider the possibility – given the unusual history in this case –
that the baby was suffering from a combination of these problems but not quite sufficient for any
one problem to be clinically evident – do you follow me? – so - a bit of deficiency of vitamins C and D
and of copper and some prematurity. Is it not possible that this combination could account for the
findings we have in this baby?
PK:
Hmmm, a little bit of this and a little bit of that. That’s a novel thought—but since I saw no
evidence of rickets, scurvy, copper deficiency or any other underlying condition, I cannot attribute
the findings to a metabolic disorder, singly or in combination.
BH: Doctor, don’t you think you are being a bit dogmatic!
PK: Well, I would say……
BH: Let’s move on. Did you consider the possibility of osteogenesis imperfecta in this case? 16
PK: Yes I did.
BH: But you chose to ignore that possibility, correct?
PK: Well, not ignore it; I just saw no evidence of it.
BH: Doctor, have you already told us that you are not an orthopaedic surgeon?
PK: Yes I admitted that.
BH: And you are also not a medical geneticist
PK: No I am not, but I do play one on television!
BH: Doctor, kindly answer the question
PK: I saw no evidence of demineralization or other deformity or Wormian bones to suggest this
condition.
BH: But Wormian bones are not always present, true?
PK: That is true. But the infant had metaphyseal corner fractures.
BH: Are you saying that metaphyseal corner fractures do not occur in OI.
PK: Ahhh, yes I am.
BH: 17Doctor don’t you recall publishing a case a number of years ago of Type 1 OI with a corner
fracture pattern.
PK: Ahhhh yes, I do recollect that. I guess it slipped my mind.
BH: I wonder what else has slipped your mind doctor. Is it possible that this patient could still be
suffering from osteogenesis imperfecta, even though the imaging findings are normal?
PK: Well yes it is possible, but….
BH: Please restrict your response to a yes or no. Is it possible that this infant could be suffering from
OI?
PK: Yes, it is possible, but I would rely on a geneticist to make that determination.
BH: Then this patient could have OI and could have sustained these fractures as a consequence of
that terrible disease?
Witness: No.
PK: We know that patients with osteogenesis imperfecta are susceptible to fractures and you said
this patient could have this disease, therefore why couldn’t these fractures be explained by
osteogenesis imperfecta?
BH: The fractures that one sees with OI are generally not the type noted in this case. The degree of
demineralization being so mild as not to be evident on x-ray would strongly weigh against OI as an
explanation of the fractures. Furthermore, it is my understanding that the OI blood test for an
abnormality of type 1 collagen, done in this infant was normal.
BH: Isn't it possible that the child could have this disease and blood testing would be normal?
PK: Yes, that is a possibility, however it is remote. Given the fact that there was no family history of
fractures, the parents were not related to each other, there was no other clinical evidence to
indicate osteogenesis imperfecta, and the fracture patterns noted in this child were not at all typical
of that condition, I decided to exclude osteogenesis imperfecta as a possibility.
BH: But you cannot testify ‘with a reasonable medical certaintly’ that osteogenesis imperfecta is
absent in this case.
PK: No.
BH: Doctor, you indicated that the changes noted within the metaphyses were consistent with
classic metaphyseal lesions, and said they were high specificity indicators of abuse. Is it not possible
that these could represent normal developmental variants?
PK: No.
BH: 18Are you aware of publications by the award winning medical journalist, James Le Fanu in the
Journal of the Royal Society of Medicine and also the respected newspaper, the Daily Telegraph
stating that metaphyseal developmental variants are regularly erroneously diagnosed as inflicted
fractures.
PK: I considered that possibility, but the pattern of these findings was not consistent with
developmental variants. I should mention that you are referring to opinion pieces, not scientific,
peer reviewed articles.
BH: Very well. Could these metaphyseal findings be birth injuries?
PK: Metaphyseal fractures do occur with breech deliveries, but it is my understanding that this infant
was born by caesarean section, so I ruled out birth injury.
BH: Are you suggesting that CMLs do not occur with caesarean sections.
PK: Yes, I certainly am.
BH: 19 Doctor, are you familiar with this paper? (she hands the witness a paper) – and for the
benefit of the jury I shall read the title of this article. ”Can classic metaphyseal lesions follow
uncomplicated caesarean section?” by Drs. Anna Marie O’Connel and Veronica Donoghue.
PK: Uh, I now recall this paper but it describes 3 instances of solitary CMLs with c-sections noted
over a roughly 20 year period in a busy obstetric service, obviously a rare occurrence.
BH: So, you were wrong when you said that CMLs do not occur with caesarean sections.
PK: Yes, but….
BH: So what‘s to say you were not wrong in other matters as well? Now tell me - did you meet the
family in this case?
PK: No.
BH: Are you aware of the testimony here that they are loving, caring parents and are both successful
professionals, not at all typical of child abusers?
PK: No.
BH: Would that fact influence your opinion as to the presence of abuse in this case?
PK: No
BH: But you still contend that abuse occurred to a reasonable medical certainty? Let me remind you
that you are currently under oath.
PK: Yes, abuse occurred.
BH: 20 Are you familiar with the Appeals Court ruling in the Canning case where the presiding
judge stated that ‘the diagnosis of abuse must be “extremely unlikely” in the absence of any
reasonable explanation for why respectable parents, with no history of mental illness or
psychopathology, should seek to inflict these injuries on their children?’
PK: Well, the courtroom is not where scientific matters should be resolved.
BH: Doctor, you mentioned that additional fractures were identified on the skeletal survey done two
weeks after the child was admitted into the hospital. How do you explain the fact that this child
sustained fractures when he was in the hospital? Would that not indicate that the child's bones were
weakened and that they occurred within the normal handling in the hospital environment?
PK: No
BH: 21Doctor, are you aware of the research by Dr. Colin Paterson published in Acta Paediatrica in
2009 in which indicated that some children who are initially felt to be abused develop fractures in
the hospital22, and therefore their condition is not due to abuse, but rather related to ‘temporary
brittle bone disease’? So how would you explain the fact that these fractures occurred while the
child was in the hospital?
PK: As I previously indicated, the fact that the rib fractures appeared in the hospital, does not mean
that they occurred in the hospital. It is well known that certain fractures, in particular classic
metaphyseal lesions and rib fractures may not be visible initially and require a follow-up examination
for them to become evident with healing. Dr. Paterson, is not a radiologist, nor an orthopaedic
surgeon nor a paediatrician, and the papers that you refer to did not have rigorous methodology and
have been widely criticized. The appearance of fracture healing documented while the children
were in the hospital was entirely consistent with injuries occurring prior to admission.
BH:
23 But surely you are impressed by the fact that Dr. Paterson reported that as much as an 18
year follow-up showed no abuse in his cases and that an accompanying commentary by a highly
respected U.S. paediatrician., Marvin Miller applauded this publication?
PK: No, no really
BH: So you would dismiss the possibility of ‘temporary brittle bone disease’, despite the fact that
there have been many articles written on this subject since Dr. Patersons’ seminal article?
PK: Yes
BH: And that some courts have ruled that this is a real disease?
PK: No, I mean yes.
BH: Doctor, are you aware that the mother reported decreased fetal movement during her third
trimester.
PK: No.
BH: If you had been aware of this, would this have influenced your diagnosis?
PK: No.
BH: But you cannot say to a reasonable medical certainty the lack of decreased fetal movement in
this infant did not contribute to the fractures that you're seeing in this case.
PK: There is no evidence-based research to support that idea.
BH: Well Doctor, do you rely entirely on evidence based research in your daily practice and
diagnosis?
PK: I try to, but sometimes we have to rely on what literature is available and the weight of our own
experience and that of trusted colleagues.
BH: I have one further set of questions for this witness, and I want to be sure he responds with
either yes or no. Doctor, is it a fair to say that medicine does not always have an explanation for
what is seen in the clinical setting?
PK: Yes, but…
BH: ..and that you have seen instances where fractures have been noted in otherwise normal
appearing infants, without a medical explanation?
PK: Yes, but…
BH: ..and that in some of these cases, you and others in your medical team did not feel that abuse
definitely explained the findings?
PK: Yes
BH: So you would agree that you do not always have all the answers?
PK: That is true.
BH: I have no further questions for this witness.
QC: Dr Vezina, what are your findings in regards to the central nervous system?
24 On the CT scan obtained at admission, posterior interhemispheric subdural
haemorrhages, 25 focal subarachnoid and subdural haemorrhages at the vertex, and poor greywhite matter contrast suspicious for early cerebral swelling. 26 On a CT scan obtained 12 hours
Expert:
later, increased sedimentation of the subdural haemorrhages posteriorly and development of low
attenuation collections around the anterior cerebral hemispheres.
27 On the MRI of the brain,
obtained at day 4, the sediment of the subdural haemorrhages had bright signal on T1 weighted
images, and dark signal on T2 weighted imaged. The anterior fluid collections had increased in size.
28 Focal mixed subarachnoid and subdural haemorrhages were seen at the vertex. 29 Diffuse
cerebral swelling was evident showing restricted diffusion on diffusion imaging. 30 And MRI of the
cervical spine revealed ligamentous injury and extensive soft tissue swelling.
QC: You have stated that these findings in this child are most likely the result of shaking. Is that
correct?
Expert: Shaking with or without impact.
QC: I understand that in your opinion these were non-accidental injuries, in other words child
abuse. Can you diagnose child abuse based on radiography alone?
Expert: Not alone. Abusive head injury is likely when injuries such as the ones present in this case
are seen; and that clinical, history, laboratory results fail to explain the findings. In addition, in this
case there were retinal haemorrhages and severe encephalopathy at presentation.
QC: Ah, the famous triad. Let us address that later. I first want to discuss the findings on the
radiology studies.
Expert: Fine.
QC: How are you able to determine the age of the bleeds?
Expert: By looking at their density on the CT scans, their intensity on the MR scans, and by analysis
of their evolution on subsequent scans
QC: Isn't it difficult to assess the age of subdural bleeds?
Expert: It can be quite challenging
QC: Isn't there controversy in the radiology literature in the differentiation between subdural
collections that are new and those that are both new and old? Can’t they look alike?
Expert: yes they can. Chronic, old blood is hypodense on CT scans. And in acute collections,
hypodensity can also be present - usually the result of early clot retraction or of admixture of CSF
and blood within the subdural space. So yes, it can be confusing.
QC: So how can you have any idea whether the findings result from a single episode of bleeding or
multiple bleeds occurring at different times?
Expert: In this case, there are no findings to suggest the presence of remote haemorrhage.
31
There are acute haemorrhages, likely less than 1, at most 2 days old based of their density, the
change in appearance – increased sedimentation - and the appearance of hypodense bi-frontal fluid
collections– over the 12 hours between the 2 CT scans. So this is a very dynamic situation, evolving
over hours.
32 In addition, the signal intensity of the sediment on the MR scan done on day 4 is T1
bright, T2 dark – this represents intracellular methemoglobin - also consistent with acute, not
remote bleeding.
33 The MRI confirms that the enlarging anterior fluid collections are subdural in
location, based on the position of the pial vessels against the cerebral surface - so called
hematohygromas . None of these findings look like things that were present for a long time.
QC: can you rule out multiple episodes of bleeding?
Expert: I cannot, but…………
QC: Thank you. Let’s talk about the mechanism that in your opinion lead to the injuries. You stated
that the bleeds were most likely the result of shaking. Are you a biomechanical expert?
Expert: No, I am not
QC: How much force needs to be exerted to cause these bleeds?
Expert: there is quite a bit of debate about that in the biomedical literature, and the exact minimal
force needed is not known.
QC: you do not know how much force is needed?
Expert: There are no biofidelic models, either dummies or computer simulation, which recreate
what happens when an infant is shaken. And no one can obviously experiment on infants. However
there is broad agreement that the force needed is significant.
QC: In other words there is no scientific foundation to support your contention that shaking causes
subdural bleeds?
Expert: the foundation is based on the imperfect models we have; on the imaging findings observed
in infants following witnessed falls and accidents; and on the evidence from cases of abusive head
injury in which there has been reliable confessions.
QC. As if these confessions are reliable! I would suggest to you that most of these are coerced, or
part of plea bargaining agreements, and have no value what so ever.
Could a fall at home create enough force to cause the injuries here?
Expert: The extent of the haemorrhages, the cerebral swelling and the ligamentous cervical injury
are not likely caused by a minor fall at home. And the parents do not report such an episode.
QC: What if the infant had been dropped by someone other than the parents but the accident was
not reported?
Expert: Minor household falls are quite common, and do not lead to the type of injuries seen here.
It takes a greater force.
QC: Ah so you say that a fall at home that is not “minor” could cause the injuries. Good. Now let’s
talk about the cerebral swelling you saw on the films. What is the cause of that swelling?
Expert: Most likely from anoxia, from an episode of apnoea following the inflicted trauma.
QC Do you have any proof of that apnoea?
34 Dr Geddes, a famous British pathologist, has demonstrated that cranio-cervical damage
is present in many cases of inflicted head injury when studied at neuropathology. 35 The cranioExpert:
cervical injuries are thought to cause primary brainstem damage, provoking apnoea, resulting in
global hypoxia and catastrophic secondary brain swelling.
QC: Could a non-traumatic arrest, a near Sudden Infant Death, cause the same swelling?
Expert: yes, but not all the haemorrhages seen, or the cervical ligamentous injuries.
QC:
36 Are you aware of another article by Dr Geddes in which she demonstrates that subdural
haemorrhages can result from an episode of apnoea or arrest? Is this not known as the Geddes
hypothesis?
Expert: Ah yes, the famous unified hypothesis. That paper was an autopsy study in which she
pointed out the vascular nature of the inner dural membrane of the immature brain. She also
demonstrated that severe anoxia, in new-borns and young infants, can lead to intradural
hemorrhage as a secondary result of anoxic injury to meningeal vessels and increased intracranial
pressure. Some of these intradural hemorrhages can spill into the subdural space as thin, film like
subdural haemorrhages. However she did not find subarachnoid haemorrhages or large subdural
haemorrhages.
QC: so you agree that anoxia can lead to subdural haemorrhages?
Expert: Yes, it can, but only…
QC: Thank you. I would now like to explore with you the possibility that an underlying medical
condition may have been present. It is possible that this infant suffered from meningitis?
Expert: I cannot exclude meningitis from the CT or MRI; that would usually be most accurately
diagnosed based on the clinical exam and results of a lumbar puncture.
QC Couldn’t meningitis and its complications cause the brain injuries you describe?
Expert: The patient presented with multiple haemorrhages, which would not occur early in the
course of most meningitis. Meningoencephalitis is characterized by swelling rather than
haemorrhage as an early feature. Also there are no findings of complication such as sinovenous
thrombosis.
QC:
37 How did you exclude the possibility of cortical vein thrombosis or sinus venous thrombosis?
Was a MR venogram or a CT venogram done?
Expert: No
QC: Wouldn’t a competent radiologist have performed a MRV or a CTV to exclude venous
thrombosis?
Expert:
38 In some circumstances, clot within cortical veins or within dural venous sinuses can be
confused with focal subarachnoid or subdural haemorrhages. So, yes, CT venography or MR
venography may be needed to demonstrate venous thrombosis. However, in this case, the findings
are not at all consistent with those of venous thrombosis.
QC: Can venous thrombosis cause subdural bleeds?
Expert: I’ve seen lots of cases with subdural haemorrhages and no venous thrombosis. The reverse –
documented venous thrombosis and subdural haemorrhage – is quite rare. I could not find a single
case from my institution to show to you in court today.
QC: Your Honour, this is pure hear-say, unfounded, and I move that the witness testimony be struck
Judge: Responds
QC: Isn't it possible that this patient was suffering from a bleeding disorder; did you exclude that?
Expert: No, that would be up to the clinicians.
QC:
39 Can you exclude glutaric aciduria?
Expert: There are no imaging findings to support that diagnosis. In glutaric aciduria the sylvian
fissures are abnormally enlarged.
40 Characteristic T2 bright abnormalities are evident in the basal
ganglia, which usually show restricted diffusion.
QC: Can you exclude Menke’s disease?
Expert: There are no imaging findings to support that diagnosis.
of the intracranial vasculature is usually evident.
41
In Menke’s, marked tortuosity
42 These patients can have progressive cerebral
atrophy and multiple episodes of subdural haemorrhage.
43 In some cases the vascular tortuosity
can be subtle, so this can be a tricky radiologic diagnosis – best left to the geneticists.
QC: How about osteogenesis imperfecta?
Expert: There were no skull fractures
QC: The child was found unconscious by her father, who heroically performed cardiopulmonary
resuscitation. Are you aware that this can cause subdural bleeds?
Expert:
44 Cardiopulmonary arrest rarely if ever causes SDH; in a recent study of 50 children
suffering from atraumatic cardiopulmonary arrest, 26 of which were resuscitated, , there were no
significant, macroscopic subdural haemorrhages. In my own experience of many similar situations, I
have not seen a single case of large SDH.
QC: Could the ligamentous neck injuries you saw on the MRI be the result of cardiac resuscitation?
Expert: I’ve never seen that.
QC: is it possible?
Expert: anything is possible, I presume.
QC:
45 Subdural bleeds are often seen following birth, even non-traumatic birth?
Expert: Yes, both subarachnoid and subdural haemorrhages are commonly observed in new-borns
QC: Did you consider the possibility that this child had persistent subdural collections since birth;
and that these collections underwent spontaneous re-bleeding - leading to the current imaging
findings?
Expert:
46 Most SDH identified on post natal imaging resolve by 1 to 2 month of age. A
“spontaneous” re-bleeding, as you say, might cause a small subdural hematoma, but not likely the
pattern of subarachnoid and subdural haemorrhages, the cerebral swelling and the neck injury
evident here.
QC: Don't you know that re-bleeding is common in the presence of subdural bleeds?
Expert: That is very uncommon in children, as compared to adults. The incidence of chronic subdural
hematoma in infants is extremely low as the brain is growing rapidly and this growth acts to
minimize the potential for any material to persist in the subdural space. In paediatrics we see
persistent subdural collections mostly in children with ventricular drains or with cerebral atrophy.
QC: Ah you say cerebral atrophy can predispose to re-bleeding of SDH. Wasn’t she born prematurely
at 34 weeks?
Expert: correct.
QC: Can cerebral atrophy result from premature birth, and therefore enlarged subarachnoid spaces?
Expert: it’s possible
QC:
47 And can enlarged subarachnoid spaces predispose an infant to develop spontaneous
subdural haemorrhages?
Expert: Enlarged subarachnoid spaces may predispose someone to a posttraumatic subdural
haemorrhage, as the bridging veins coursing through the subdural space are stretched and therefore
more vulnerable to injury. In this case however the SA spaces were not enlarged at presentation.
QC. Let’s return to the triad. What is the triad?
Expert: The triad suggests that encephalopathy, subdural hematomas and retinal haemorrhages in
an infant are strongly associated with trauma if there is no clinical, historical or laboratory evidence
to the contrary. And the trauma should be significant, more than a simple fall; therefore if not
explained, it is a strong indicator of abusive head trauma.
QC:
48 Are you aware of the New York Times article, last February - which reports the over
diagnosis of child abuse? In regards to the triad, isn't it true that the article stated that, I quote:
49
“there is fierce disagreement among doctors about the shaken-baby diagnosis”. And, I quote again,
“If the medical community can’t agree about all the conflicting data and research, how is a jury
supposed to reach a conclusion that’s beyond a reasonable doubt?”
Expert: The NYT is not a scientific publication. Peer reviewed scientific publications and scientific
forums with participation of experts from the field such as the International Paediatric Radiology
meeting in London are the appropriate medium to tackle the issues of accurate diagnosis of child
abuse
QC: Isn't the case before us just another case of over diagnosis of child abuse?
Judge: Guilty or not guilty of the charges against the father.