I was delighted to get such prompt interest in the case report of an infant with an abnormal in utero expansive intracranial process who was diagnosed at 3 months of age with a chronic subdural hematoma (SDH)/effusions.1 As single case reports are meant to provoke thought in a relevant community and bring to light new potentials for differential diagnosis and stimulate a re-examination of long held presumptions and beliefs, I am pleased that this case offering found at least one target audience.
In their commentary, Dr van Rijn, Dr Hobbs and Dr Bilo concluded with the statement, ‘this case report has insufficient information to conclude that this is a true exception’.2 As for their concerns for the adequacy of the abuse work up, the evaluation for abuse was under the direction of a well-credentialed child abuse consultant pediatrician and team with input from a full spectrum of specialists. In addition to the studies already mentioned in the case report, the infant had one magnetic resonance imaging (MRI) and five computerized tomography scans of his head. The skeletal survey was negative for acute or healing fractures. The electroencephalographywas normal. The nursing notes documented ‘bulging, tense’ fontanel over a 48-h period before the ophthalmology examination and surgical drainage of his subdural spaces. The ophthalmologist noted a retinal hemorrhage in one eye and hemorrhages along the vascular arcades in the other. The neurosurgeon's operative note indicated that the fluid was ‘xanthochromic, with fresh blood.…under very high pressure’. After drainage, neurosurgery notes stated, ‘child looks great… he is playful comfortable…interactive, feeding well.’ The psychosocial evaluation by the child abuse consultant pediatrician and social services turned up nothing suspect and evaluations of all the siblings found no evidence of abuse. The principal diagnosis in the medical chart was shaken infant syndrome. It would appear that this diagnosis was a presumption based on a seizure presentation, chronic SDH/effusions and some hemorrhages along the vascular arcades. This resulted in the initiation of legal proceedings with a shift of the burden of proof to the parents to convince the court the infant was not abused. From my experience, this work up would appear to be very much in line with work ups across this country. If it were deficient, this deficiency would represent a systemic inadequacy in investigation in many of these cases in this country.
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