Response to Comment on 26 cm Fall Caught on Video Causing Subdural Hemorrhages and Extensive Retinal Hemorrhages in an 8-Month-Old Infant

Abstract

We thank Dr. Shouldice and Dr. Smith for their interest in our case report, “26 cm Fall Caught on Video Causing Subdural Hemorrhages and Extensive Retinal Hemorrhages in an 8-Month-Old Infant” [1].

In their comment [2], Shouldice and Smith assert that “existing literature… supports the predominant opinion that subdural hemorrhages and retinal hemorrhages are highly associated with inflicted injury.” However, this literature has been criticized for its poor methodology, including a lack of appropriate reference standards to classify injuries as inflicted, and frequent use of circular reasoning [3-5]. An alternative interpretation that such findings are markers of the degree of intracranial pathology is supported by the data [4, 6, 7].

Glutaric aciduria type 1 was excluded due to a normal urine amino acid profile. The full blood count showed a slightly elevated white count (13.9 × 10⁹/L), normal hemoglobin (105 g/L), and normal platelets (541 × 10³). Basic coagulation studies (PT, INR, APTT) were normal. An extended coagulation profile showed normal thrombin time, fibrinogen, factor XI and VII assays, and a normal factor XII screen. Factor II, VII, and XI levels were elevated. No abnormalities were detected on von Willebrand studies. Platelet function aggregation studies showed high levels, which the hematology team advised were not significant.

While we did not obtain a coronal FLAIR image, we did obtain an axial FLAIR MRI, which clearly demonstrates the subdural collections as bilateral, involving frontal, parietal, occipital, and middle cranial fossa dura, including extending along a portion of the midline dural fold (falx). As noted in the case report, the collections are holohemispheric, involving both cerebral hemispheres reflecting the ability of subdural blood to track widely in the subdural compartment. They do not involve the infratentorial dura.

For additional context, the sagittal T1 MRI image included in the case report clearly delineates the supratentorial subdural collection as distinct from the subarachnoid cerebral spinal fluid (CSF) which is visible as a darker signal dipping in between the brain sulci.

There was no indication of cerebral edema on the CT scan completed on the day of the described event. There was no clinical or radiographic evidence of increased intracranial pressure. The infant continued to experience projectile vomiting for several days and remained in the hospital for 6 days. No intervention was required, as the symptoms resolved during this time.

Long-term follow-up can likewise be informative. In the months following the injury, what was the child's neurodevelopmental status and follow-up head imaging?

The child is now 4 years old and continues to develop normally. Follow-up head imaging has not been required.

Chris Brook: conceptualization, writing – original draft. Waney Squier: conceptualization, investigation, writing – review and editing. Julie Mack: conceptualization, investigation, writing – review and editing.

The parent gave consent for presenting medical findings in the case of her son. This consent is found in the original Case Report files.