New Insights into the Diagnosis and Age Determination of Retinal Hemorrhages from Abusive Head Trauma: A Systematic Review
Diagnostics · 8 authors, 3 centres
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This systematic review synthesizes recent evidence on diagnosing and dating retinal hemorrhages (RH) in abusive head trauma (AHT). Key findings include that unilateral RH may be more common in infants under 6 months, and that histopathological features such as siderophages (appearing after 3 days) and retinal sclerosis (after 1 week) are reliable for timing. The review proposes an operational framework integrating clinical, radiological, autopsy, and immunohistochemical methods to improve forensic accuracy.
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**Background**
Retinal hemorrhage (RH) is a critical finding in abusive head trauma (AHT), present in about 85% of cases. Despite its importance, misdiagnosis occurs in about 30% of abused children at first medical contact, and 25% suffer further abuse before correct diagnosis. The classic diagnostic triad—subdural hematoma, encephalopathy, and RH—has been criticized for potential circular reasoning and selection bias. This systematic review aims to clarify the current gold standard for diagnosing and timing RH in fatal AHT, covering clinical, radiological, autopsy, and histopathological approaches.
**Methods**
A systematic literature search was conducted in PubMed, ScienceDirect, and Web of Science from 1 January 2016 to 15 August 2022. The search terms were: ["Abusive Head Trauma" OR "Abusive Trauma" OR "Shaken Baby Syndrome"] AND "Retinal Hemorrhage" AND "Forensic". Inclusion criteria: infant victims of AHT with RH, clinical/radiological evaluation and/or judicial autopsy with histopathology, comparison with prior evidence, and outcome accuracy of methods for RH diagnosis and dating. Exclusion criteria: publication before 2016, non-forensic focus, insufficient innovation, no English abstract, non-impacted journal articles. Two reviewers independently screened articles; 16 studies were included for qualitative analysis.
**Key Results**
The 16 studies (2016–2021) came from eight countries and included 296 infant victims (age range 10 days to 34.7 months). Study types: 6 case reports/series, 2 reviews, 1 technical note, and 7 original articles with statistical validation. Key findings include:
- **Laterality and age**: Moskwa et al. (2022) analyzed 133 infants and found that subjects >6 months more frequently had bilateral RH; unilateral RH was more common in those <6 months. Barth et al. (2020) reported two cases of unilateral RH in infants under 3 months, supporting age-related anatomical predisposition.
- **Imaging**: Oliva et al. (2021) combined RETcam (DWFFP) and OCT in 6 infants, achieving 100% sensitivity and 85.7% specificity for RH detection. Yusuf et al. (2017) used non-contact ultra-widefield scanning laser ophthalmoscope (Optos P200MA) in 5 infants, obtaining 200° field of view without sedation. Zuccoli et al. (2020) applied 3D-SWI MRI in 13 AHT victims, grading optic nerve sheath hemorrhages (ONSH) from grade 1 (moderate deformation) to grade 3 (loss of anatomical demarcation).
- **Autopsy and histopathology**: Puanglumyai et al. (2017) reported 100% specificity for ONSH in 11 AHT cases. Delteil et al. (2019) studied 83 AHT victims and constructed a timing chart: intact RBCs within first 24 h, lysed RBCs from 2 to 24 days, siderophages from 4 days, retinal sclerosis from 8 days. Del Bigio and Phillips (2017) found hemosiderin deposits in optic nerve up to 36 months post-trauma.
- **Immunohistochemistry**: Bais et al. (2016) showed β-APP and ubiquitin as valid markers for retinal axonal injury in 21 AHT cases vs. 16 controls, with positivity from 2.5 h to 8 days. Bulirsch et al. (2021) found CD44 immunoreactivity specific to AHT (p < 0.05) in 5 AHT cases. Maiese et al. (2021) proposed glycophorin-A immunolabeling for detecting hemorrhagic areas.
**Clinical Implications**
The review provides an operational framework for forensic practice: (1) In living subjects, use indirect ophthalmoscopy integrated with DWFFP and OCT; consider age when interpreting laterality. (2) In post-mortem cases, use PMIO with smartphone for low-suspicion cases, but enucleation via intracranial approach is preferred for definitive diagnosis. (3) MRI with GRE T2-w and 3D-SWI protocols is the best radiological method for detecting RH and ONSH. (4) Histopathological timing relies on RBC morphology, siderophages (≥3 days), and retinal sclerosis (≥8 days). (5) Immunohistochemical markers (β-APP, ubiquitin, glycophorin-A, CD44) are promising but not yet validated for routine use. The proposed framework aims to reduce misdiagnosis and improve legal evidence in AHT cases.