Key Clinical Message:
This Letter to the Editor comments on and aims to clarify details
regarding the case, 26 cm fall caught on video causing subdural
hemorrhages and extensive retinal hemorrhages in an 8-month-old infant .
The findings in this case are rarely reported in accidental injury
events and are therefore, important to understand.
We read with interest the case report by Brook et al. of an 8-month-old
with subdural and retinal hemorrhages following a fall from a couch with
inertial rotational forces and possible previous head
injury1. We thank the authors for the details
provided, which are important in considering the differential diagnosis
in a particular case, including the possibilities of accidental and
inflicted head trauma, and any possible contributing factors. The
existing literature, including systematic reviews from Canada, Australia
and the UK supports the predominant opinion that subdural hemorrhages
and retinal hemorrhages are highly associated with inflicted
injury2-6. As a result, this case report is expected
to be of interest and importance to others as they assess cases with
findings which may raise concern for inflicted injury. We therefore are
requesting further details regarding this case.
The authors appropriately note previous falls and the possibility that
these contributed to the symptoms and findings. The pattern of head
circumference increase can be helpful clinically in understanding the
sequence of events and underlying contributors to bleeding. The authors
noted that the head circumference was large at the
99th percentile one month prior to presentation to
hospital. It was reported that one month prior to presentation, a fall
from a trampoline occurred and there was an episode of shoulder and arm
twitching. Could the authors clarify the timing of the fall from the
trampoline, relative to the timing of the twitching symptoms and the
date of the head circumference? Additionally, is the previous pattern of
head circumference growth known to the authors?
The authors describe symptoms of vomiting and poor eating two days prior
to the fall from the couch. We note that these can be symptoms of
traumatic head injury, in addition to other possible etiologies. Could
the authors clarify the clinical assessment regarding the cause of these
symptoms?
Abnormalities of coagulation are typically considered in the
differential diagnosis of infants presenting with bleeding (subdural
hemorrhages and retinal hemorrhages). Could the authors clarify whether
a bleeding disorder work-up was completed and if so, it would be helpful
to understand which tests were completed and the results?
We are interested in the details of the head imaging. Were the subdural
hemorrhages all supratentorial, or were there also infratentorial
hemorrhages? Would it be possible to share an axial or coronal MRI FLAIR
image, which may provide improved visualization of the subdural and
subarachnoid spaces?
We note the ophthalmology comment that the optic nerves in each eye were
mildly swollen, suggesting possible increase in intracranial pressure.
Was there indication of cerebral edema on the CT scan completed on the
day of the described event? It would also be helpful to understand the
clinical course of symptoms following the day of the fall from the couch
and during hospitalization.
Case reports of this nature are critical to deepening our understanding
of potential mechanisms for subdural hemorrhages and retinal hemorrhages
in infants. We read this case report with interest and appreciate the
authors’ efforts in responding to our questions.