                                                              WR 59,201-03
                                                COURT OF CRIMINAL APPEALS
                                                                AUSTIN, TEXAS
                                              Transmitted 4/20/2015 12:00:00 AM
                                                 Accepted 4/20/2015 8:11:52 AM
                                                                 ABEL ACOSTA
              WR 59,201-03                                               CLERK

                                                 RECEIVED
                                          COURT OF CRIMINAL APPEALS
      EX PARTE RICHARD VASQUEZ                   4/20/2015
                                            ABEL ACOSTA, CLERK




                   ***

          IN THE DISTRICT COURT
              148TH DISTRICT
          NUECES COUNTY, TEXAS

               Returnable to

   THE TEXAS COURT OF CRIMINAL APPEALS
              AUSTIN, TEXAS

                   ***


 STATE’S MOTION TO DISMISS AS ABUSIVE
  SUBSEQUENT 11.071 APPLICATION FOR
        WRIT OF HABEAS CORPUS
AND TO DENY MOTION TO STAY EXECUTION


                Douglas K. Norman
                State Bar No. 15078900
                Assistant District Attorney
                105th Judicial District of Texas
                901 Leopard, Room 206
                Corpus Christi, Texas 78401
                (361) 888-0410
                (361) 888-0399 (fax)
                douglas.norman@co.nueces.tx.us

                Attorney for the State

                     1
                                WR-59,201-03

EX PARTE                                    §   IN THE DISTRICT COURT
                                            §
                                            §   148TH JUDICIAL DISTRICT
                                            §
RICHARD VASQUEZ                             §   NUECES COUNTY, TEXAS


      COMES NOW the State of Texas, by and through its Assistant District

Attorney for the 105th Judicial District of Texas, and pursuant to Texas Code

of Criminal Procedure arts. 11.071 and 11.073, files this motion to dismiss

as abusive the present subsequent application for writ of habeas corpus and

to deny the motion to stay execution.

             EXPLANATION FOR UNTIMELY PLEADING

      The State is cognizant of this Court’s “Miscellaneous Rule 11-003"

pertaining to procedures in death penalty cases involving requests for stay of

execution and related filings, and if it applies to responsive pleadings such as

this motion to dismiss Applicant’s subsequent application for writ of habeas

corpus, the State offers this explanation for filing its motion less than seven

days before the date of Applicant’s execution:

      Applicant’s execution is scheduled for Thursday, April 23, 2015.

Applicant did not file his motion for stay of execution and his subsequent

application for post-conviction writ of habeas corpus until late in the

                                        2
afternoon of Wednesday, April 15, 2015, the last day permitted for such

filings     pursuant    to   this   Court’s   “Miscellaneous    Rule    11-003.”

Consequently, it was impossible for the State to read and file a response to

the 92-page application and exhibits attached thereto prior to the expiration

of the deadline for a timely filing in this case. The State has worked

diligently to prepare such response and is filing this, its motion to dismiss

Applicant’s subsequent application for writ of habeas corpus as quickly as it

can.

          The State prays that this Court deem such circumstances as good

cause for the untimely filing of this motion, if in fact this motion is

considered a “pleading requesting affirmative relief in an impending

execution case” under Miscellaneous Rule 11-003, and if in fact that rule

applies to responsive pleadings such as this motion to dismiss.

                             STATEMENT OF FACTS

          The State relies on this Court’s own knowledge of the facts of the case

as set forth in its opinion on the direct appeal. In addition, the State would

point this court to the following testimony that it believes to be particularly

relevant to the present claims being made.

          Deputy Constable Eric Giannamore, the first person to arrive at the

scene, asked Vasquez what had happened. Vasquez replied that Miranda was

                                         3
brushing her teeth in a hall bathroom and fell off a wooden stool, hitting her

head. Giannamore testified, however, that there was no wooden stool in the

area. (R.R. XXXIV - 19-21, 74-77; XLI - State's Exh. 37).

      Emergency medical technician Eugenio Rangel asked what had

happened and Vasquez replied that Miranda had fallen off a stool in the

bathroom while brushing her teeth. While Vasquez kind of pointed when he

said this, Rangel never saw a stool in the area. (R.R. XXXV - 76-78, 83, 85,

101, 108). As the paramedics cut Miranda's clothes off and turned her in

order to place her on a back board, noticeable bruising of various stages was

apparent down her back, as well as on her legs and arms. Miranda also had a

bump on the back of her head and bruising around her eyes. There was no

sign of toothpaste in Miranda's mouth. (R.R. XXXIV - 21-22; XXXV - 78-

82, 85-87, 93-98, 101-102, 108-112; XLI - State's Exh. 37-39).

      Dr. Michael Burke, a pediatric neurosurgeon, testified that Miranda

had multiple bruises on her body. (R.R. XXXV - 95; XXXVI - 69-89; XLII -

State's Exh. 60-63; C.R. I - 38-39, 51-53, 56-61, 69-71, 156-158). Burke

said that her subdural hematoma was caused by trauma to the head and that

Miranda's brain injuries were the equivalent to those she would have

sustained had she been ejected from a car traveling 65 m.p.h. Miranda's

injuries were consistent with being struck multiple times in the head. Burke

                                      4
said his final diagnosis was severe brain injury from child abuse. He

described this as a massive injury and summarized Miranda's condition by

saying, "This child got the living daylights beat out of her to the point that

she quit breathing and there was nothing that could be done at that point."

(R.R. XXXVI - 78-79, 87, 91-94). Dr. Burke used his car accident and

Shaken Baby Syndrome comments only as analogies to attempt to explain

the force of the direct impact injuries in the present case and the lack of

external signs, and he never testified or implied that Miranda had been in a

car accident or that she had Shaken Baby Syndrome. (R.R. XXXVI - 92-

93).

       Leann Box, a sexual assault nurse examiner (SANE) at the hospital,

testified that Miranda had extensive bruising in various stages of healing all

over her body--head, face, chest, pelvic region, genitalia area, ankle, thigh,

shoulder, back, and arms--and described each of those bruises. (R.R. XXXV

- 175-185, 208-211; XLI - State's Exh. 46-48; C.R. I - 23, 27, 75-83, 175).

There were multiple abrasions and tears on her labia majora, fossa, labia

minora, fourchette, perineum, and anal area. Many were oozing tears, which

meant they were fresh enough that they had not begun to scab, which

generally started to occur within a few hours of injury. One such injury

would have probably bled a great deal. Because very little blood was present

                                      5
in the area when the examination took place, Box assumed it had been

cleaned up. (R.R. XXXV - 185-197, 205-208, 211-215; XLII - State's Exh.

49-57; C.R. I - 18-21, 42, 50, 54-55, 72). The bruising on Miranda's hips

was very consistent with injuries that could be caused by being held from

behind while being sexually assaulted. The injuries to Miranda's genital-anal

area were not consistent with a straddle injury. Rather, they were extremely

consistent with someone or something passing over the area below the anus,

tearing the top of the skin, skidding over the anus, and ripping apart the skin

at the perineum. In over 200 sexual assault examinations, this was the first

time Box had seen a complete full thickness tear at the perineum. (R.R.

XXXV - 177, 197-200).

      In his formal statement to the police, Vasquez said that he had

repeatedly asked Miranda why she always acted scared of him. She kept

saying she was not scared of him until Vasquez "got pissed off" and pushed

her. When she still replied that she was not scared of him, Vasquez told her

to stop lying and hit her in the head. She did not fall down because he was

holding her with his other hand. He hit her several more times. She just

looked at him and looked stunned. He told her to go out and play and she

went downstairs and out of the house. About 30 minutes later, Vasquez

called out to Miranda through the window and told her to come inside and

                                      6
brush her teeth or she would not get to go to his sister's house. When she

walked in, Miranda's head was down. She went to Vasquez's mother's room

and got the stool she used when she brushed her teeth. As she started to carry

it to the other bathroom, she fell down. Vasquez told her to get up and go

brush her teeth. Miranda staggered into the bathroom and began to brush her

teeth. Then Vasquez heard what sounded like the stool tipping over. He

called Miranda but she did not answer. He went in the bathroom and saw her

lying on her back on the floor. He hit Miranda because he had a lot of anger

because he couldn't straighten his life out. He could have hit her more than

three times. He just lost it. He was sorry for what he did to her. (R.R.

XXXIV - 56-59; XLI - Sx8).

      Dr. Lloyd White, the Nueces County medical examiner who

performed an autopsy on Miranda's body, noted bruising all over her body

and head of various ages. (R.R. XXXVI - 23-33, 40, 49-50; XLII - State's

Exh. 58-59). The damage to Miranda's genital region was typical of blunt

trauma--pressure exerted to the area that caused scrapes of the skin and

membranes and caused tears of those membranes. They could have been the

result of being poked with an object. A penis could cause bruising,

laceration, and fairly severe injuries in small children. (R.R. XXXVI - 39-

40, 53-54, 58). White said the cause of Miranda's death was blunt force

                                      7
injuries of the head and brain with cocaine intoxication as a contributing

factor. He ruled the manner of death to be homicide. White could not say

how many blows Miranda received but there were at least 20-30 areas of

contusion on her body, including evidence of perhaps dozens of impacts to

all areas of her head--back, under the chin, front, either side, and top. The

bruising around Miranda's eyes, ear, surrounding face, and scalp, which was

edematous, was due to recent impact. He could also not say how hard she

was struck except that it was hard enough to produce fatal injury. He said it

was very unlikely that Miranda would die from falling off the stool. White

was of the opinion that the bruises to Miranda's back and chest were not the

result of resuscitation efforts. The bruises to Miranda's hips were consistent

with her being restrained and sexually assaulted from behind. (R.R. XXXVI

- 38-43, 55-57; XLI - State's Exh. 45; C.R. I - 31-36). Dr. White explained

that most fatal falls require at least 10 to 15 feet in height, but conceded that

“[f]alls from so-called ground level or falls from a very low level producing

fatal injuries are very, very rare; although they do occur.” (R.R. XXXVI -

41-42).

      Dr. James Lukefahr, a pediatrician who devotes a large part of his

practice to child abuse, testified that he had reviewed the medical records

and photographs in the case, and was of the opinion that Miranda's injuries

                                       8
were the result of a sexual assault. He discussed the various injuries to the

genital-anal area, noting in particular the large penetrating injury into the

perineal body. That injury was quite deep as evidenced by deeper tissues

which were visible in the photographs and the fact that a doctor had had to

repair it with sutures that were completely buried well beneath the surface of

the skin. Lukefahr said that the injuries were not consistent with a straddle

injury. The bruises on Miranda's hips were very unlikely to be accidental

because they were localized in an area that would generally be well

cushioned by clothing. Lukefahr opined that they were sustained during the

sexual assault and were probably the result of being restrained during the

time the really violent act of penetration was occurring in Miranda's anal

area. The injuries were also unusually symmetrical. They were more

consistent with Miranda being conscious and struggling when they occurred

than being sustained when she was unconscious. There was a suggestion that

Miranda's anus had been penetrated but Lukefahr could not say for sure. The

fact that semen was not found did not change Lukefahr's opinion that a

sexual assault had occurred. He felt that most of the injuries were most

consistent with having been caused by contact with an object which was in

motion, so that the skin basically was rubbed off in those areas. The really

deep wound in the perineal body, on the other hand, was a penetrating injury,

                                      9
caused by an object penetrating into the substance of the perineal body. It

would have taken a very substantial amount of penetrating force to have

caused that injury because that area of the body has a lot of resilience and

padding. There was no way to know whether that injury was caused by a

man's penis or some other foreign object.

      Vasquez testified in his own defense that he was mad and hit Miranda

in the head. While he acknowledged hitting her in the head, Vasquez denied

hitting her in her face. She was not doing anything wrong that required

discipline. He claimed to not know how many times he hit her. Although in

his written statement, Vasquez said he held Miranda by the head when he hit

her, he testified that he did not do so. (R.R. XXXVII - 92-94, 116-117, 121-

122, 135). When Miranda appeared, she looked dazed and could not keep

her head up. Vasquez knew something was wrong with her. He told her to

get her stool from his parents' room and go brush her teeth. As she returned

with the stool, she fell down. She still could not keep her head up. (R.R.

XXXVII - 94-96, 112-113, 136). Vasquez later went into the bathroom and

found her with her head down and toothpaste on her face, and still later went

back to the bathroom and found her with her head in the sink. He thought

she hit her head with the faucet although he could not recall what type of

faucet it was. (R.R. XXXVII - 96-97, 119-121). Vasquez repeatedly tried to

                                     10
make Miranda stand by herself but she kept falling down. He then shook her

and asked her what was going on. As he did that, he took her into his parents'

bedroom and either threw or laid her on their bed. (R.R. XXXVII - 97-99,

117, 140). Vasquez said he did not try to kill Miranda and he did not know

what his intent was when he hit her. He did not remember whether he had hit

her until she became unconscious. (R.R. XXXVII - 110, 134-135, 140-141,

147).    Vasquez admitted that he was the only adult in the house that

morning. (R.R. XXXVII - 113, 125-126).

           STATE’S RESPONSE TO THE PRESENT CLAIMS

        The crux of all of Vasquez’s claims in this subsequent writ is that new

scientific evidence supposedly shows that the victim’s fall from a small stool

might reasonably have caused her fatal injury, contradicting trial testimony

from Dr. Burke and Dr. White implying that this was not a plausible theory.

Specifically, in the “Introduction” to his application, Vasquez asserts that

“[i]n light of modern scientific knowledge, it is now clear that the child had

actually died after falling from a stool, and that the science underlying the

State experts’ conclusions [that Vasquez beat her to death] was

fundamentally flawed.” (Subsequent Application p. 6) In discussing his

primary claim, Vasquez further explains his claim that “science has now

clarified that short falls, such as the one taken by Miranda from the stool,


                                       11
can and in fact do cause the type of catastrophic head injury observed upon

Miranda’s arrival in the emergency room.” (Subsequent Application p. 16)

Vasquez’s other claims of new evidence regarding Shaken Infant Syndrome,

biomechanics, and Second Impact Syndrome are either dependent upon the

validity of the fall theory or are clearly unsupported and insufficient to

justify relief.

       Certainly it might be possible to imagine a case where the defendant

claimed at trial that the victim fell from a sufficient height to have caused a

fatal injury, where that theory was discredited by expert testimony

considered valid at the time, and where new scientific evidence would

suggest that the theory in question was a valid explanation for the fatal

injury based on data comparing substantially similar fatal and non-fatal falls.

Such a case might justify relief under Article 11.073. This is not that case,

for many reasons.

       This was not a case of a single head injury that could equally have

been explained by either an intentional blow or an accidental fall. It was

multiple blows to the head, as admitted by Vasquez himself, causing severe

and extensive injury to the brain. This was not a case of an otherwise loving

parent who had no proclivity to hurt the child in question. Vasquez was

clearly an abusive parental figure by anyone’s measure, who the evidence

                                      12
suggests not only hit the victim but also lethally injected her with cocaine

and sexually assaulted her. This was not a case of an accidental fall from

two-to-ten feet in the air. It was a stepping stool depicted in SX # 16 and

which the State has measured to be approximately 10&1/2 inches high. (See

Appendices A & B). This is not a case where the fall in question had been

seen by some disinterested witness or otherwise verified. Vasquez was the

only adult home at the time, the emergency responders did not even see the

stool in question, and no toothpaste was found in the victim’s mouth, in spite

of the fact that she had supposedly been brushing her teeth when she fell and

lost consciousness.

                           Supporting Affidavits.

      Vasquez has attempted to support his “new science” allegations with

attached affidavits from two pathologists, Dr. Thomas Young and Dr.

Waney Squier. These affidavits fall far short.

                            Dr. Young’s Affidavit.

      Dr. Young, in his affidavit, pointed to two journal articles that

supposedly “falsified the notion that short falls do not cause death in

children.” (Exhibit A, Young Affidavit p. 3) However the two medical

articles cited by Dr. Young do not even involve fatal brain injuries from falls

that could reasonably be compared with the present short fall from a

                                      13
10&1/2-inch stool by four-year-old Miranda.

        Fatal Pediatric Head Injuries Caused by Short-Distance Falls (See

Appendix C) – The only children four years and older who died from falls

fell from at least three feet or from an undetermined height at least two feet

but possibly as much as six to eight feet, these being falls from a swing. The

falls in the study were from playground equipment and not from falling off

something like a stool in the home. It stands to reason that the dynamics and

motions involved in falling from a swing or other movable playground

equipment are different from those involving in falling from a stationary

stool, as well as the nature of the surface or structure onto which the child

fell.

        Delayed Sudden Death in an Infant Following an Accidental Fall

(See Appendix D) – The case study involved only one death of a nine-

month-old, who fell from a bed some 30 inches high, onto a concrete floor.

The authors of the case study admit that “lethality of short falls … are still

controversial. One widely held belief is that short falls are almost never

fatal.” The authors further submit, “We do not argue the widely noted

observation that simple falls from low heights rarely result in significant

primary brain injury.” (p. 373)

        Moreover, both of these articles are based strictly on data from cases

                                      14
where the falls in question did cause death, and do not contain data or

comparisons with cases of non-fatal falls. Accordingly, there is no attempt

in either article to address the frequency with which short falls of this nature

are fatal or to refute the proposition that in the vast majority of cases short

falls are not fatal, as is consistent with Dr. Burke’s and Dr. White’s

testimony at trial.

      Although Dr. Young also disagreed with certain statements made by

Dr. Burke at trial concerning Shaken Baby Syndrome and comparison with

injuries suffered in a high speed car accident, and with Dr. White and Dr.

James Lukefahr’s opinions concerning sexual assault , he offered nothing to

support a “new science” claim on these grounds.            (Exhibit A, Young

Affidavit pp. 3-4)

                            Dr. Squier’s Affidavit.

      Dr. Squier, in her affidavit, asserted that “Miranda’s primary cause of

death was blunt force injuries to the head consistent with a fall from a stool,”

and that “[t]he strikes to Miranda’s head by Mr. Vasquez, on their own, were

probably insufficient to cause fatal injuries.”       However, she bases this

conclusion on an unverified assumption that Vasquez, the only adult present

at the time, was telling the truth about the sequence of events at the time of

the injury. (Exhibit B, Squire Affidavit p. 2)

                                      15
       Dr. Squier also disagreed with Dr. Burke’s Shaken Baby Syndrome

and high speed accident analogies, but not based on any “new science.” On

the contrary, Dr. Squier attempts to support her assertions based on a study

published in 1987, well before Vasquez’s trial. (Exhibit B, Squire Affidavit

p. 3, n.2)

       The only assertions that Dr. Squier makes that are arguably supported

by new science involve her Second-Impact Syndrome claim that Miranda

died as a result of the combined impact of being initially hit by Vasquez and

then falling from the stool. (Exhibit B, Squire Affidavit p. 4) However, as

discussed below, under Texas’ law concerning concurrent causation, this

would not have relieved Vasquez of responsibility for the death.

                           Concurrent Causation.

       With regard to causation, the Penal Code provides that “[a] person is

criminally responsible if the result would not have occurred but for his

conduct, operating either alone or concurrently with another cause, unless

the concurrent cause was clearly sufficient to produce the result and the

conduct of the actor clearly insufficient.” Tex. Pen. Code Ann. § 6.04 (a).

The Court of Criminal Appeals has interpreted this to mean that, “[i]f the

additional cause, other than the defendant's conduct, is clearly sufficient, by

itself, to produce the result and the defendant's conduct, by itself, is clearly

                                      16
insufficient, then the defendant cannot be convicted.” Robbins v. State, 717

S.W.2d 348, 351 (Tex. Crim. App. 1986); see also Turner v. State, 435

S.W.3d 280, 283 (Tex. App.—Waco 2014, pet. ref’d).

      In the present case, there is no showing that Vasquez’s repeated blows

to Miranda’s head were clearly insufficient to cause her death, and it remains

highly unlikely that her fall from a short stool would have been sufficient, by

itself, to cause the death. Accordingly, even under the supposedly newly-

developing science of Second-Impact Syndrome, Vasquez cannot escape

responsibility for her murder.

      In addition, Vasquez’s initial blows arguably themselves caused

Miranda to be in such a dazed state that she fell from the stool in question,

making the second impact as well a direct result of his own conduct.

                           The Prejudice Prong.

      In order to prevail under 11.073, the Court not only has to find that

there is new, admissible, previously unavailable scientific evidence, but also

that “had the scientific evidence been presented at trial, on the

preponderance of the evidence, the person would not have been convicted.”

(Emphasis added).

      In the present case, even if some or all of the “new science”

arguments are found to have some validity, it is highly unlikely that this new

                                      17
science would have changed the outcome, as the evidence of guilt was

overwhelming.

                                  PRAYER

      WHEREFORE, the State prays that the Court will dismiss as abusive

the present subsequent application for writ of habeas corpus and deny the

motion to stay execution.

                                 Respectfully submitted,

                                 /s/ Douglas K. Norman
                                 ___________________
                                 Douglas K. Norman
                                 State Bar No. 15078900
                                 Assistant District Attorney
                                 105th Judicial District of Texas
                                 901 Leopard, Room 206
                                 Corpus Christi, Texas 78401
                                 (361) 888-0410
                                 (361) 888-0399 (fax)

                     CERTIFICATE OF SERVICE

      This is to certify that a copy of this document was e-served on April

18,   2015,   on   Applicant’s     attorneys,    Mr.   Andrew       M.   Edison,

Andrew.edison@emhllp.com,           and         Mr.     James        Chambers,

james.chambers@emhllp.com.

                                 /s/ Douglas K. Norman
                                 ___________________
                                 Douglas K. Norman


                                      18
APPENDIX A
APPENDIX B
                                AFFIDAVIT

THE STATE OF T E X A S
C O U N T Y OF N U E C E S

     B E F O R E M E , the undersigned authority, on this day personally
appeared John Mitchell, who after being by me duly swom upon oath says:

        M y name is John Mitchell and I am a Deputy District Clerk for
Nueces County and the Records Management Supervisor for the office. I
am over 18 years of age, I have never been convicted of a crime, and I am
tliliy competent to make this affidavit. I have personal knowledge of the
facts stated herein, and they are all true and correct.

      On A p r i l 17, 2015,1 reviewed the attached photographs of a stool that
had been admitted into evidence as SX#9 in the murder trial o f Richard
Vasquez, Cause N o . 98-CR-0730-E, in the 14^^^ District Court of Nueces
County, Texas, and that I am presently holding as custodian ofthe evidence.

      The attached photographs, with tape measure next to them, accurately
show the height of the stool, which was measured to be approximately 10
&1/2 inches t a l l

      Further affiant saith naught.




Subscribed and sworn to before me by the said John Mitchell this 17th day o f
A p r i l , 2015, to certify which witness my name and seal of office.
2
APPENDIX C
r
I

I            The
           American Journal of
           Forensic Medicine
           and Pathology
      Volume 22 Number I            March 2001

      1         Fatal Pediatric Head Injuries Caused by Short-Distance Falls
                John Plunkett

      13        Case Report of Sudden Death After a Blow to the Baell' of the Neck
                Gregory G. Davis and Jay M. Glass

      19        Sudden Cardiac Death and Right Ventricular Dysplasia
                E. N. Michalodirnitrakis, D. D.-A. Tsiftsis, A. M. Tsatsakis, and I. Stiakakis

     23         Simultaneous Sudden Infant Death Syndrome: A Proposed Definition and Worldwide Review of Cases
                Steven A. Koehler, Shaun Ladham, Abdulrezzak Shakir, and Cyril H. Wecht

     33         Simultaneous Sudden Infant Death Syndrome: A Case Report
                Shaun Ladham, Steven A. Koehler, Abdulrezzak Shakir, and Cyril H. Wecht




                                                                     (Continued)




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   The American Journal of Forensic Medicine and Pathology   22(1):1-12, 2001.    ©2001 Lippincott Williams & Wilk.ins, Inc., Philadelphia




  Fatal Pediatric Head.Injuries Caused by Short-Distance Falls

  John Plunkett,        M.D.




 Physicians disagree on several issues regarding head in-                  Many physicians believe that a simple fall can-
 jury in infants and children, including the potential                   not cause serious injury or death (1-9), that a
 lethality of a short-distance fall, a lucid interval in an ul-          lucid interval does not exist in an ultimately fatal
 timately fatal head injury, and the specificity of retinal
 hemorrhage for inflicted trauma. There is scant objective               pediatric head injury (7-13), and that retinal hem-
 evidence to resolve these questions, and more informa-                 orrhage is highly suggestive if not diagnostic for
 tion is needed. The objective of this study was to deter-              inflicted trauma (7,12,14-21). However, several
 mine whether there are witnessed or investigated fatal                 have questioned these conclusions or urged cau-
 short-distance falls that were concluded to be accidental.             tion when interpreting head injury in a child
 The author reviewed the January l, 1988 through June
 30, 1999 United States Consumer Product Safety Com-                    (15,22-28). This controversy exists because most
 mission database for head injury associated with the use               infant injuries occur in the home (29,30), and if
 of playground equipment. The author obtained and re-                   there is history of a fall, it is usually not witnessed
 viewed the primary source data (hospital and emergency                 or is seen only by the caretaker. Objective data are
 medical services' records, law enforcement reports, and                needed to resolve this dispute. It would be helpful
coroner or medical examiner records) for all fatalities in-
 volving a fall.                                                        if there were a database of fatal falls that were
   The results revealed 18 fall-related head injury fatali-             witnessed or wherein medical and law enforce-
ties in the database. The youngest child was 12 months                 ment investigation unequivocally concluded that
old, the oldest 13 years. The falls were from 0.6 to 3 me-             the death was an accident.
ters (2-10 feet). A noncaretaker witnessed 12 of the 18,                   The United States Consumer Product Safety
and 12 had a lucid interval. Four of the six children in
whom funduscopic examination '"'as documented in the                   Commission (CPSC) National Injury Information
n1edical record had bilateral retinal hemorrhage. The au-              Clearinghouse uses four computerized data sources
thor concludes that an infant or ciiild may suffer a fatal             (31). The National Electronic Injury Surveillance
bead injury from a fall of less than 3 meters (10 feet).               System (NEISS) file collects current injury data as-
The injury may be associated with a lucid interval and                 sociated with 15,000 categories of consumer prod-
bilateral retinal hemorrhage.
Key Words: Child abuse-Head injury-Lucid interval-                     ucts from 101 U.S. hospital emergency depart-
Retinal hemorrhage-Subdural hematoma.                                  ments, including 9 pediatric hospitals. The file is a
                                                                       probability sample and is used to estimate the num~
                                                                       ber and types of consumer product-related injuries
                                                                       each year (32). The Death Certificate (DC) file is a
                                                                       demographic summary created by information pro-
                                                                       vided to the CPSC by selected U.S. State Health
                                                                       Departments. Tbe Injury/Potential Injury Incident
                                                                      (IR) file contains sun1Illaries, indexed by consun1er
                                                                      product, of reports to the CPSC from consumers,
                                                                      medical examiners and coroners' (Medical Exam-
                                                                      iner and Coroner Alert Project [MECAP]), and
                                                                      newspaper accounts of product-related incidents
                                                                      discovered by local or regional CPSC staff (33).
                                                                      The In-Depth Investigations (AI) file contains sum-
                                                                      maries of investigations performed by CPSC staff
  1\1anuscript received April 10, 2000; revised September 15,         based on reports received from the NEISS, DC, or
2000; accepted September 24, 2000.                                    IR files (34). The AI files provide details about
  From the DepartmentS of Pathology and Medical Education,
Regina Medical Center, 1175 Nininger Road, Hastings MN                the incident from victim and witness interviews,
55033, U.S.A.; Email: plunkettj@reginarnedical.com.                   accident reconstruction, and review of law enforce-

                                                                  I
   2                                                   J. PLUNKETT


   ment, health care facility, and coroner or medical         be the highest point of the arc. Twelve of the 18
   examiner records (if a death occurred).                    falls were witnessed by a noncaretaker or were
                                                              videotaped; 12 of the children had a lucid interval
                                                              (5 minutes-48 hours); and 4 of the 6 in whom fun-
                            METHODS
                                                              duscopic examination was performed had bilateral
      I reviewed the CPSC, DC, IR, and AI files for all       retinal hemorrhage (Table 1).
   head and neck injuries involving playground equip-
   ment recorded by the CPSC from January 1, 1988
   through June 30, 1999. There are 323 entries in the                               CASES
  playground equipment IR file, 262 in the AI file, 47
                                                              Case 1
  in the DC file, and more than 75,000 in the NEISS
                                                                 This 12-month-old was seated on a porch swing
  file. All deaths in the NEISS file generated an IR or
                                                              between her mother and father when the chain on
  AI file. If the file indicated that a death had oc-
                                                              her mother's side broke and all three fell sideways
  curred from a fall, I obtained and reviewed each
                                                              and backwards 1.5 to 1.8 meters (5-6 feet) onto
  original source record from law enforcement, hos-
                                                              decorative rocks in front of the porch. The mother
  pitals, emergency medical services (EMS), and
                                                              fell first, then the child, then her father. It is not
  coroner or medical examiner offices except for one
                                                              known if her father landed on top of her or if she
  autopsy report. However, I discussed the autopsy
                                                              struck only the ground. She was unconscious im-
  findings with the pathologist in this case.
                                                              mediately. EMS was called; she was taken to a
                                                             local hospital; and was ictal and had decerebrate
                            RESULTS                          posturing in the emergency room. She was intu-
                                                             bated, hyperventilated, and treated with mannitol.
     There are 114 deaths in the Clearinghouse data-
                                                             A computed tomography (CT) scan indicated a
  base, 18 of which were due to head injury from a
                                                             subgaleal hematoma at the vertex of the skull, a
  fall. The following deaths were excluded from this
                                                             comrninuted fracture of the vault, parafalcine sub-
  study: those that iuvolved equipment that broke or
                                                             dural hemorrhage, and right parietal subarachnoid
  collapsed, striking a person on the head or neck
                                                             hemorrhage. There was also acute cerebral edema
  (41); those in which a person became entangled in
                                                             with effacement of the right frontal horn and com-
  the equipment and suffocated or was strangled (45),
                                                             pression of the basal cisterns. She had a cardiopul-
  those that involved equipment or incidents other
                                                             monary arrest while the CT scan was being done
  than playground (6 [including a 13.7-meter fall
                                                             and could not be resuscitated.
 from a homemade Ferris wheel and a 3-meter fall
 from a cyclone fence adjacent to a playground]);
 and falls in which the death was caused exclusively          Case2
 by neck (carotid vessel, airway, or cervical spinal            A 14-month-old was on a backyard "see-saw"
 cord) injury (4 ).                                           and was being held in place by his grandmother.
    The falls were from horizontal ladders (4),              The grandmother said that she was distracted for a
 swings (7), stationary platforms (3), a ladder at-          moment and he fell backward, striking the grass-
 tached to a slide, a "see-saw'', a slide, and a retain-     covered ground 0.6 meters (22.5 inches) below the
 ing wall. Thirteen occurred on a school or public           plastic seat. He was conscious but crying, and she
playground, and five occurred at home. The data-             carried him into the house. Within 10 to 15 minutes
base is uot limited to infants and children, but a           he became lethargic and limp, vomited, and was
 13-year-old was the oldest fatality (range: 12              taken to the local hospital by EMS personnel. He
months-13 years; mean, 5.2 years; median, 4.5                was unconscious but purposefully moving all ex-
years). The distance of the fall, defined as the dis-        tremities when evaluated, and results of fundus-
tance of the closest body part from the ground at           copic examination were normal. A CT scan indi-
the beginning of the fall, could be determined from         cated an occipital subgaleal hematoma, left-sided
CPSC or law enforcement reconstruction and actual           cerebral edema with complete obliteration of the
measurement in 10 cases and was 0.6 to 3.0 meters           left frontal horn, and small punctate hemorrhages
(mean, 1.3 ± 0.77; median, 0.9). The distance               in the left frontal lobe. There was no fracture or
could not be accurately determined in the seven fa-         subdural hematoma. He was treated with mannitol;
talities involving swings and one of the falls from a       his level of consciousness rapidly improved; and he
horizontal ladder, and may have been from as little         was extubated. However, approximately 7 hours              I
as 0.6 meters to as much as 2.4 meters. The maxi-           after admission he began to have difficulty breath-
mum height for a fall from a swing was assumed to           ing, both pupils suddenly dilated, and he was rein-

A1n J Forensic Med Pathol, VoL 22. No. 1, March 2001                                                                   I
                                                                                                                       j
                                                                                            TABLE 1.      Summary of cases
                                                                                                                Lucid       Retinal           Subdural
       No.       CPSC No.            Age      Sex          Fall from      Distance M/F       Witnesse;d        interval   hemorrhage         hemorrhage         Autopsy         Cause of death             FP

             DC 9108013330         12 mos      F           Swing         1.5--1.8/5.0-6.0       No        No              N/R               Yes +IHF            No        Complex calvarial fracture       No
                                                                                                                                                                           with edema and
                                                                                                                                                                           contusions
       2     Al 890208HBC3088      14 mos     M            See~saw       0.6/2.0                No        10-15           No                No                  No        Malignant cerebral edema         No
                                                                                                            minutes                                                        with herniation
        3    IR F910368A            17 mos     F           Swing         1.5-1.8/5.0-6.0        No        No              N/R               Yes +IHF            Yes       Acute subdural hematorna         Yes
                                                                                                                                                                            wit~.secondary cerebral
                                                                                                                                                                            edema
        4    Al 921001 HCC2263      20 mos     F           Platform      1.1/3.5                 No       5-10            Bilateral         Yes +IHF            Limited   Occipital fracture with          Yes
                                                                                                            minutes          multilayered                                   subdural/subarachnoid                 ~
                                                                                                                                                                            hemorrhage progreSsing                S2
                                                                                                                                                                            to cerebral edema and                 r
        5'   DC 9312060661          23 mos     F           Platform      0.70/2.3                Yes      10 minutes      Bilateral, NOS    Yes                  Yes
                                                                                                                                                                            herniation
                                                                                                                                                                          Acute subdural hematoma          Yes    ~
                                                                                                                                                                                                                  ;,,:
        6    DC 9451016513          26 mos     M           Swing         0.9-1 c8/3.0-6.0        Yes      No              Bilateral         Yes +IHF             Yes      Subdural hematoma··Yflth         Yes    ti
                                                                                                                             multi!ayered                                   associated cerebral
                                                                                                                                                                            edema                                 ~
                                                                                                                                                                                                                  <..,
        7'   Al 891215HcC2094        3 yrs     M           Platform      0.9/3.0                 Yes      10 minutes      N/R               Yes                  No       Acute cerebral edema with
                                                                                                                                                                                                                  "
        8    Al 910515HCC2182        3 yrs     F           Ladder        0.6/2.0                 yes       15 minutes     N/R               Yes                  Yes
                                                                                                                                                                            herniation
                                                                                                                                                                          Complex calvarial fracture,
                                                                                                                                                                                                           No
                                                                                                                                                                                                           Yes    ~
                                                   '                                                                                          (autopsy only)                 contusions, cerebral                 t;J
                                                                                                                                                                                                                  ~
                                                                                                                                                                             edema with herniation
         9   DC 9253024577            4 yrs    M           Slide         2.1/7.0                 Yes       3 hours        N/R               No                   Yes       Epidural hematoma               Yes
        10   Al920710HIVE4014         5 yrs    M           Horizontal
                                                              ladder
                                                                         2.1/7.0                 No        No             N/R               Yes                  No        Acute subdural hematoma
                                                                                                                                                                             with acute cerebral
                                                                                                                                                                                                           Yes    ~
                                                                                                                                                                             edema                                ~
        11    Al 960517HCC5175        6 yrs    M           Swing         0.6-2.4/2.0-8.0         No        10 minutes     No                Yes +IHF             No        Acute subdural hematoma         Yes    a
                                                                                                                                                                                                                  ;,,,
        12    Al 970324HCC3040        6 yrs    M           Horizontal    3.0/10.0                Yes       45 minutes     N/R               No                   No        Malignant cerebral edema        Yes
                                                             ladder                                                                                                         with herniation
                                                                                                                                                                                                                   ';-I

,,.     13    Al 881229HCC3070        6 yrs        F        Horizontal
                                                              ladder
                                                                          0.9/3.0                Yes       1 +hour         N/R               Yes +IHF            Yes       Subdural and subarachnoid
                                                                                                                                                                             hemorrhage, cerebral
                                                                                                                                                                                                            Yes    ti
                                                                                                                                                                                                                   [;i

                                                                                                                                                                                                                   ~
'-.                                                                                                                                                                          infarct, and edema
:ii     14    Al 930930HIVE5025       7 yrs     M           Horizontal    1.2-2.4/4.0-8.0        Yes       48 hours        N/R               No                  Yes       Cerebral infarct secondary       Yes
,
",.
<
                                                              ladder                                                                                                         to carotid/vertebral artery
                                                                                                                                                                             thrombosis
                                                                                                                                                                                                                  f;l
.
~       15

        16
              Al 970409HCC1096

              Al 890621 HCC3195
                                      8 yrs

                                     10 yrs     M
                                                   F        Retaining
                                                             .wall
                                                            Swing
                                                                          0.9/3.0

                                                                          0.9-1.5/3.0-5.0
                                                                                                 Yes

                                                                                                 Yes
                                                                                                           12+ hours

                                                                                                           10 minutes
                                                                                                                           N/R

                                                                                                                           Bilateral
                                                                                                                                             Yes
                                                                                                                                               (autopsy only)
                                                                                                                                             Yes
                                                                                                                                                                 Yes

                                                                                                                                                                 Yes
                                                                                                                                                                           Acute subdura! hematoma

                                                                                                                                                                           Acute subdural hematoma
                                                                                                                                                                                                           Yes

                                                                                                                                                                                                            No
                                                                                                                                                                                                                  ;,;,
                                                                                                                                                                                                                   ~
"'""
0
~
                                                                                                                              mum layered                                    contiguous with an AV
                                                                                                                                                                             malformatiorl
/ii
~       17    Al 920428HCC1671       12 yrs        F        Swing         0.9-1.8/3.0-6.0         Yes      No              N/R               No                   Yes      Occipital fracture With          Yes
,..,
N                                                                                                                                                                            extensive contra-coup
                                                                                                                                                                             contusions

,..~
        18    Al 891016HCC1511       13 yrs            F    Swing         0.6-1.8/2.0-6.0         Yes      No              N/R               Yes +IHF             Yes      Occipital fracture, subdural     Yes
                                                                                                                                                                             hemorrhage 1 cerebral
                                                                                                                                                                             edema
 §:
 ,.
 Cl        ~he original CT scan for case #7 and the soft tissue CT windows for case #5 could not be located and were unavailable for review.
 N         CPSC, Consumer Products Safety Commission; Al, accident investigation; IR, incident report; DC, death certificate; M, male; F, female; Distance, the distance of the closest body part
 §      from the ground at the start of the fall (see text); M/F, meters/feet; Witnessed, witnessed by a noncaretaker or videotaped; N/R, not recorded; IHF, including interhemispheric or fa!x; FP,
        forensic pathologist-directed death investigation system.                                                                                                                                                     "'
   4                                                   J. PLUNKETT


   tubated. A second CT scan demonstrated progres-              Cases
   sion of the left hemispheric edema despite medical             A 23-month-old was playing on a plastic gym set
   management, and he was removed from life sup-               in the garage at her home with her older brother.
   port 22 hours after admission.                              She had climbed the attached ladder to the top rail
                                                               above the platform and was straddling the rail, with
                                                               her feet 0.70 meters (28 inches) above the floor.
   Case3                                                       She lost her balance and fell headfirst onto a I-cm
      This 17-month-old had been placed in a baby
                                                               (%-inch) thick piece of plush carpet remnant cover-
   carrier-type swing. attached to an overhead tree
                                                               ing the concrete floor. She struck the carpet first
   limb at a daycare provider's home. A restraining
                                                               with her outstretched hands, then with the right
   bar held in place by a snap was across her waist.
                                                              front side of her forehead, followed by her right
  She was being pushed by the daycare provider to
                                                               shoulder. Her grandmother had been watching the
  an estimated height of 1.5 to 1.8 meters (5-6 feet)
                                                              children play and videotaped the fall. She cried
  when the snap came loose. The child fell from the
                                                              after the fall but was alert and talking. Her grand-
  swing on its downstroke, striking her back and
                                                              mother walked/carried her into the kitchen, where
  head on the grassy surface. She was immediately
                                                              her mother gave her a baby analgesic with some
  unconscious and apneic but then started to breathe
                                                              water, which she drank. However, approximately 5
  spontaneously. EMS took her to a pediatric hospi-
                                                              minutes later she vomited and became stuporous.
  tal. A CT scan indicated a large left-sided sub-
                                                              EMS personnel airlifted her to a tertiary-care uni-
  dural hematoma with extension to the interhemi-
                                                              versity hospital. A CT scan indicated a large right-
  spheric fissure anteriorly and throughout the length
                                                              sided subdural hematoma with effacement of the
 of the falx. The hematoma was surgically evacu-
                                                              right lateral ventricle and minimal subfalcine herni-
 ated, but she developed malignant cerebral edema
                                                              ation. (The soft tissue windows for the scan could
 and died the following day. A postmortem exami-
                                                              not be located and were unavailable for review.)
 nation indicated symmetrical contusions on the
                                                              The hematoma was immediately evacuated. She re-
 buttock and midline posterior thorax, consistent
                                                             mained comatose postoperatively, developed cere-
 with impact against a fiat surface; a small residual
                                                             bral edema with herniation, and was removed from
 left-sided subdural hematoma; cerebral edema
                                                             life support 36 hours after the fall. Bilateral retinal
 with anoxic encephalopathy; and uncal and cere-
                                                             hemorrhage, not further described, was docu-
 bellar tonsillar herniation. There were no cortical
                                                             mented in a funduscopic examination performed 24
 contusions.
                                                             hours after admission. A postmortem examination
                                                             confirmed the right frontal scalp impact injury.
  Case4                                                      There was a small residual right subdural hema-
    A 20-month-old was with other family members             toma, a right parietal lobe contusion (secondary to
 for a reunion at a public park. She was on the plat-        the surgical intervention), and cerebral edema with
 form portion of a jungle gym when she fell from             cerebellar tonsillar herniation.
 the side and struck her head on one of the support
 posts. The platform was 1.7 meters (67 inches)              Case6
 above the ground and I.I meters (42 inches) above             A 26-month-old was on a playground swing
 the top of the support post that she struck. Only her       being pushed by a 13-year-old cousin when he fell
 father saw the actual fall, although there were a           backward 0.9 to 1.8 meters (3--6 feet), striking his
 number of other people in the immediate area. She           head on hard-packed soil. The 13-year-old and sev-
 was initially conscious and talking, but within•5 to       eral other children saw the fall. He was immedi-
 10 minutes became comatose. She was taken to a             ately unconscious and was taken to a local emer-
 nearby hospital, then transferred to a tertiary-care       gency room, then transferred to a pediatric hospital.
facility. A CT scan indicated a right occipital skull       A CT scan indicated acute  ' cerebral edema and a
fracture with approximately 4-mm of depression              small subdural hematoma adjacent to the anterior
and subarachnoid and subdural hemorrhage along              interhemispheric falx. A funduscopic examination
the tentorium ·and posterior falx. Funduscopic ex-          performed 4 hours after admission indicated exten-
amination indicated extensive bilateral retinal and         sive bilat~ral retiqal hemorrhage, vitreous hemor-
preretinal hemorrhage. She died 2 days later be-            rhage in the left eye, and papilledema. He had a
cause of uncontrollable increased intracranial pres-        subsequent cardiopulmonary arrest and could not
sure. A limited postmortem examination indicated            be resuscitated. A postmortem examination con-
an impact subgaleal hematoma overlying the frac-            firmed the retinal hemorrhage and indicated a right
ture in the mid occiput.                                    parietal scalp impact injury but no calvarial frac-

Am J Forensic Med Pathol, Vol. 22, No. I, March 2001
                           FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS                                                     5


  ture, a "film" of bilateral subdural hemorrhage,           Case9
  cerebral edema with herniation, and· focal hemor-            A 4-year-old fell approximately 2.1 meters (7
  rhage in the right posterior midbrain and pons.           feet) from a playground slide at a state park, land'
                                .                           ing on the dirt ground on his buttock, then falling to
   Case7                                                    his left side, striking his head. T:ljere was no loss of
     This 3-year-old with a history of TAR (thrombo-        consciousness, but his family took him to a local
   cytopenia-absent radius) syndrome was playing            emergency facility, where an'. evaluation was nor-
  with other children on playground equipment at his        mal. However, be began vomiting and complained
  school when he stepped through an opening in a           of left neck and bead pain approximately 3 hours
  platform. He fell 0.9 meters (3 feet) to the hard-        later. He was taken to a second hospital, where a
  packed ground, striking his face. A teacher wit-         CT scan indicated a large left parietal epidural
  nessed the incident. He was initially conscious and      hematoma with a midline shift. He was transferred
  able to walk. However, approximately 10 minutes          to a pediatric hospital and the hematoma was evac-
  later he had projectile vomiting and became co-          uated, but he developed malignant cerebral edema
  matose, was taken to a local hospital, and subse-        with right occipital and left parietal infarcts and
 quently transferred to a pediatric hospital. A CT         was removed from the respirator 10 days later. A
 scan indicated a small subdural hematoma and dif-         postmortem examination indicated a small residual
 fuse cerebral edema with uncal herniation, accord-        epidural hematoma, marked cerebral edema, bilat-
 ing to the admission history and physical examina-        eral cerebellar tonsillar and uncal herniation, and
 tion. (The original CT report and scan could not be       hypoxic encephalopathy. There was no identifiable
 located and were unavailable for review.) His             skull fracture.
 platelet count was 24,000/mm3 , and he was treated
 empirically with platelet transfusions, although he        Case 10
 had no evidence for an expanding extra-axial mass.           A 5-year-old was apparently walking across the
 Resuscitation was discontinued in the emergency           horizontal ladder of a "monkey bar," part of an in-
 room.                                                     terconnecting system of homemade playground
                                                           equipment in his front yard, when his mother
  Case8                                                    looked out one of the windows and saw him laying
    This 3-year-old was at a city park with an adult       face down on the ground and not moving. The hor-
  neighbor and four other children, ages 6 to 10. She      izontal ladder was 2.1 meters (7 feet) above com-
  was standing on the third step of a slide ladder 0.6     pacted dirt. EMS were called, be was taken to a
 meters (22 inches) above the ground when she fell        local hospital, and then transferred to a pediatric
 forward onto compact dirt, striking her head. The        hospital. A CT scan indicated a right posterior tem-
 other children but not the adult saw the fall. She       poral linear fracture with a small underlying
 was crying but did not appear to be seriously in-        epidural hematoma, a 5-mm thick acute subdural
 jured, and the neighbor picked her up and brought        hematoma along the right temporal and parietal
 her to her parents' home. Approximately 15 min-          lobes, and marked right-sided edema with a 10-mm
 utes later she began to vomit, and her mother called     midline shift. He was hyperventilated and treated
 EMS. She was taken to a local emergency room,            with mannitol, but the hematoma continued to en-
 then transferred to a pediatric hospital. She was ini-   large and was surgically evacuated. However, he
 tially lethargic but responded to hyperventilation       developed uncontrollable cerebral edema and was
 and mannitol; she began to open her eyes with            removed from life support 10 days after the fall.
stimulation and to spontaneously move all extre;ni-
ties and was extubated. However, she developed             Case 11
malignant cerebral edema on the second hospital              A 6-year-old was on a playground swing at a pri-
day and was reintubated and hyperventilated but           vate lodge with his 14-year-old sister. His sister
died the following day. A postmortem examination          heard a "thump,'' turned around, and saw him on
indicated a subgaleal hematoma at the vertex of the       the grass-covered packed earth beneath the swing.
skull associated with a complex fracture involving        The actual fall was not witnessed. The seat of the
the left frontal bone and bihiteral temporal bones.       swing was 0.6 meters (2 feet) above the ground,
There were small epidural and subduraJ bematomas          and the fall distance could have been from as high
(not identifiable on the CT scan), bilateral "contra-     as 2.4 meters (8 feet). He was initially conscious
coup" contusions of the inferior surfaces of the          and talking but within 10 minutes became co-
frontal and temporal lobes, and marked cerebral           matose and was taken to a local emergency room,
eden1a with uncal herniation.                             then transferred to a tertiary-care hospital. A CT

                                                                     Am J Forensic Nled Parhol, Vol. 22, No. 1, March 2001
   6                                                   J. PLUNKETT


    scan indicated a large left frontoparietal subdural        ture, subdural and subarachnoid hemorrhage, and a
   hematoma with extension into the anterior inter-            right cerebral hemisphere infarct. The infarct in-
   hemispheric fissure and a significant midline shift         cluded the posterior cerebral territory and was
   with obliteration of the left lateral ventricle. There     thought most consistent with thrombosis or dissec-
   were no retinal hemorrhages. He was treated ag·             tion of a right carotid artery that bad a persistent
   gressively with dexamethasone and hyperventila-            fetal origin of the posterior c'erebral artery. She
   tion, but there was no surgical intervention. He died      remained con1atose and was removed from the
   the following day.                                         respirator 6 days after admission. A postmortem
                                                              examination indicated superficial abrasions and
   Case 12                                                    contusions over the scapula, a prominent right pari-
     This 6-year-old was at school and was sitting on         etotemporal subgaleal bematoma, and a right pari-
   the top crossbar of a "monkey bar" approximately 3       , eta! skull fracture. She bad a 50-ml subdural
  meters (10 feet) above compacted clay soil when an          bematoma and cerebral edema with global hypoxic
  unrelated noncaretaker adult saw him fall from the          or iscbemic injury ("respirator brain"), but the
  crossbar to the ground. He landed flat on his back          carotid vessels were normal.
  and initially appeared to have the wind knocked out
  of him but was conscious and alert. He was taken to         Case 14
  the school nurse who applied an ice pack to a con-             A 7-year-old was on the playground during
  tusion on the back of bis bead. He rested for ap-           school hours playing on the horizontal ladder of a
 proximately 30 minutes in the nurse's office and             "monkey bar" when he slipped and fell 1.2 to 2.4
  was being escorted back to class when be suddenly           meters (4-8 feet). According to one witness, be
 collapsed. EMS was called, and be was transported            struck his forehead on the bars of the vertical lad-
 to a pediatric hospital. He was comatose on admis-          der; according to another eyewitness he struck the
 sion, the fundi could not be visualized, and a bead         rubber pad covering of the asphalt ground. There
 CT scan was interpreted as normal. However, a CT            are conflicting stories as to whether he had an ini-
 scan performed the following morning approxi-               tial loss of consciousness. However, he walked
 mately 20 hours after the fall indicated diffuse cere-      back to the school, and EMS was called because of
 bral edema with effacement of the basilar cisterns          the history of the fall. He was taken to a local hos-
 and fourth ventricle. There was no identifiable sub-        pital, where evaluation indicated a Glasgow coma
 dural hemorrhage or cal varial fracture. He devel-          score of 15 and a normal CT scan except for an oc-
 oped transtentorial herniation and died 48 hours            cipital subgaleal bematoma. He was kept overnight
 after the fall.                                             for observation because of the possible loss of con-
                                                             sciousness but was released the following day. He
  Case 13                                                    was doing homework at home 2 days after the fall
    This 6-year-old was playing on a school play-            when his grandmother noticed that he was stum-
  ground with a 5th grade student/friend. She was            bling and had slurred speech, and she took him
 hand-over-hand traversing the crossbar of a "mon-          back to the hospital. A second CT scan indicated a
 key bar" 2.4 meters (7 feet 10 inches) above the           left carotid artery occlusion and left temporal and
 ground with her feet approximately 1 meter (40             parietal lobe infarcts. The infarcts and subsequent
 inches) above the surface. She attempted to slide          edema progressed; he had brainstem herniation;
 down the pole when she reached the end of the              and be was removed from life support 3 days later
 crossbar but lost her grip and slid quickly to the         (5 days after the initial fall). A postmortem exanli-
 ground, striking the compacted dirt first with her         nation indicated ischemic infarcts of the left pari-
 feet, then her buttock and back, and finally 'her          etal, temporal, and occipital lobes, acute cerebral
 head. The friend inforn1ed the school principal of         edema with herniation, and thrombosis of the left
the incident, but the child seemed fine and there           vertebral artery. Occlusioli. of the carotid artery,
was no intervention. She went to a relative's home          suspected premortem, could not be confirmed.
for after-school care approximately 30 minutes
after the fall, watched TV for a while, then com-           Case 15
plained of a l\eadache and laid down for a nap.               This 8-year-old was at a public playground near
When her parents arrived at the home later that             her home· with se;,,eral friends her age. She was
evening, 6 hours after the incident, they discovered        hanging by her hands from the horizontal ladder of
that she was incoherent and "drooling." EMS trans-          a "monkey bar" with her feet approximately 1.1
ported her to a tertiary-care medical center. A CT          meters (3.5 feet) above the ground when she at-
scan indicated a right parieto-occipital skull frac-        tempted to swing from the bars to a nearby 0.9-

Am J Forensic Med Pathol, Vol. 22, No. J, March 2001
                           FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS                                                     7


  meter (34-inch) retaining wall. She landed on the         lost her balance and fell 0.9 tol.8 )lleters (3-6 feet)
   top of the wall but then lost her balance and fell to    to the asphalt surface, striking her posterior thorax
  the ground, either to a hard-packed surface (one          and occipital scalp. She was inunediately uncon-
  witness) or to a 5.1-cm (2-inGh) thick.resilient rub-     scious and was taken to a tertiary-care hospital
  ber mat (a second witness), striking her back and         emergency room, where she was, pronounced dead.
  head. She initially cried and complained of a             A postmortem examination ii;idic'ated an occipital
  headache but continued playing, then later went           impact injury associated with an extensive com-
  home. Her mother said that she seemed normal and          minuted occipital fracture extending into both mid-
  went to bed at her usual time. However, when her          dle cranial fossa and "contra-coup" contusions of
  mother tried to awaken her at approximately 8:30          both inferior frontal and temporal lobes.
  the following morning (12 hours after the fall) she
  complained of a headache and went back to sleep.           Case 18
 She awoke at 11 a.m. and complained of a severe               This 13-year-old was at a public playground with
 headache then became unresponsive and had a                 a friend. She was standing on the seat of a swing
 seizure. EMS took her to a nearby hospital, but she         with her friend seated between her legs when she
 died in the emergency room. A postmortem exami-             lost her grip and fell backwards 0.6 to 1.8 meters
 nation indicated a right temporoparietal subdural           (2-6 feet), striking either a concrete retaining wall
 hematoma, extending to the base of the brain in the         adjacent to the playground or a resilient 5.1-cm (2
 middle and posterior fossae, with flattening of the         inch) thick rubber mat covering the ground. She
 gyri and narrowing of the sulci. (The presence or          was immediately unconscious and was given emer-
 absence of herniation is not described in the au-          gency first aid by a physician who was nearby
 topsy report.) There was no calvarial fracture, and        when the fall occurred. She was taken to a nearby
 there was no identifiable injury in the scalp or           hospital and was purposefully moving all extremi-
 galea.                                                     ties and had reactive pupils when initially evalu-
                                                            ated. A CT scan indicated interhemispheric sub-
 Case 16                                                    dural hemorrhage and generalized cerebral edema,
    A 10-year-old was swinging on a swing at his            which progressed rapidly to brain death. A post-
 school's playground during recess when the seat de-        mortem examination indicated a linear nonde-
 tached from the chain and he fell 0.9 to 1.5 meters        pressed midline occipital skull fracture, subdural
 (3-5 feet) to the asphalt surface, striking the back of    hemorrhage extending to the occiput, contusion of
 his head. The other students but not the three adult       the left cerebellar hemisphere, bifrontal "contra-
 playground supervisors saw him fall. He remained           coup" contusions, and cerebral edema.
 conscious although groggy and was carried to the
 school nurse's office, where an ice pack was placed
                                                                                 DISCUSSION
 on an occipital contusion. He suddenly lost con-
 sciousness approximately 10 minutes later. and             General
EMS took him to a local hospital. He had decere-              Traumatic brain injury (TBI) is caused by a force
brate posturing when initially evaluated. Fundus-           resulting in either strain (deformation/unit length)
copic examination indicated extensive bilateral con-        or stress (force/original cross-sectional area) of the
fluent and stellate, posterior and peripheral               scalp, skull, and brain (35-37). The extent of injury
preretinal and subhyaloid hemorrhage. A CT scan             depends not only on the level and duration of force
showed a large acute right frontoparietal subdural          but also on the specific mechanical and geometric
hematoma with transtentorial herniation. i Trhe             properties of the cranial system under loading
hematoma was surgically removed, but he devel-              (38-40). Different parts of the skull and brain have
oped malignant cerebral edema and died 6 days later.       distinct biophysical characteristics, and calculating
A postmortem examination indicated a right parietal        deformation and stress is complex. However, an ap-
subarachnoid AV malformation, contiguous with a            plied force causes the skull and brain to move, and
small amount of residual subdural hemorrhage, and          acceleration, the time required to reach peak accel-
cerebral edema with anoxic encephalopathy and her-         eration, and the duration of acceleration may be
niation. There was no calvarial fracture.                  measured at specific locations (36,41). These kine-
                                                           1natic parameters do not cause the . actual brain
Case 17                                                    damage but are useful for analyzing TBI because
   A 12-year-old was at a public playground with a         they are easy to quantify. Research in TBI using
sister and another friend and was standing on the          physical models and animal experiments has shown
seat of a swing when the swing began to twist. She         that a force resulting in angular acceleration pro-

                                                                      Am J Forensic Med Pathol, Vol. 22, No. I, March 2001
   8                                                   J PLUNKETT


    duces primarily diffuse brain damage, whereas a            ing surface is usually less than 5 milliseconds
    force causing exclusively translational acceleration       (39,59-61). Experimentally, impact duration longer
   produces only focal brain damage (36). A fall from          than 5 milliseconds will not cause a subdural
   a countertop or table is often considered to be ex-         hematoma unless the level of angular acceleration
   clusively translational and therefore assumed inca-         is above 1.75 X 105 rad/s 2 (61). A body in motion
   pable of producing serious injury (3, 7-9). However,        with an angular acceleration of 1.75 X 105 rad/s 2
   sudden impact deceleration must have an angular             has a tangential acceleration of 17 ,500 rn/s 2 at 0.1
   vector unless the force is applied only through the         meters (the distance from the midneck axis of rota-
   center of mass (COM), and deformation of the               tion to the midbrain COM in the Duhaime model).
   skull during impact must be accompanied by a vol-          A human cannot produce this level of acceleration
  ume change (cavitation) in the subdural "space"             by impulse ("shake") loading (62).
   tangential to the applied force (41). The angular '           An injury resulting in a subdural hematoma in an
   and deforn1ation factors produce tensile strains on        infant may be caused by an accidental fall
  the surface veins and mechanical distortions of the         (43,44,64). A recent report documented the findings
  brain during impact and may cause a subdural                in seven children seen in a pediatric hospital emer-
  hematoma without deep white matter injury or even           gency room after an accidental fall of 0.6 to 1.5
  unconsciousness (42-44).                                    meters who had subdural hemon-hage, no Joss of
      Many authors state that a fall from less than 3         consciousness, and no symptoms (44). The charac-
  meters (10 feet) is rarely if ever fatal, especially if     teristics of the hemon-hage, especially extension
  the distance is Jess than 1.5 m~ters (5 feet)              into the posterior interhemispheric fissure, have
  (1-6,8,9). The few studies concluding that a short-        been used to suggest if not confirm that the injury
  distance fall may be fatal (22-24,26,27) have been         was nonaccidental (9,62,65-68). The hemon-hage
 criticized because the fall was not witnessed or was        extended into the posterior interhemispheric fissure
 seen only by the caretaker. However, isolated re-           in 5 of the 10 children in this study (in whom the
 ports of observed fatal falls and biomechanical             blood was identifiable on CT or magnetic reso-
 analysis using experimental animals, adult human            nance scans and the scans were available for re-
 volunteers, and models indicate the potential for se-       view) and along the anterior falx or anterior inter-
 rious head injury or death from as little as a 0.6-         hemispheric fissure in an additional 2 of the 10.
 meter (2-foot) fall (48-52). There are limited
 experimental studies on infants (cadaver skull frac-         Lucid Interval
 ture) (53,54) and none on living subadult nonhu-                Disruption of the diencephalic and midbrain por-
 man primates, but the adult data have been extrap-           tions of the reticular activating system (RAS)
 olated to youngsters and used to develop the                 causes unconsciousness (36,69,70). "Shearing" or
Hybrid II/III and Child Restraint-Air Bag Interac-            "diffuse axonal" injury (DAI) is thought to be the
tion (CRAB!) models (55) and to propose standards            primary biophysical mechanism for immediate
for playground equipment (56,63). We simply do               traumatic unconsciousness (36,71). Axonal injury
not know either kinematic or nonkinematic limits             has been confirmed at autopsy in persons who had
in the pediatric population (57,58).                         a brief loss of consciousness after a head injury and
     Each of the falls in this study exceeded estab-         who later died from other causes, such as coronary
lished adult kinematic thresholds for traumatic              artery disease (72). However, if unconsciousness is
brain injury (41,48-52). Casual analysis of the falls        momentary or brief ("concussion") subsequent ~e­
suggests that most were primarily translational.             terioration must be due to a mechanism other than
However, deformation and internal angular acceler-           DAI. Apnea and catecholamine release have been
ation of the skull and brain caused by the itnpact           suggested as significant factors in the outcome fol-
produce the injury. What happens during the im-             lowing head injury (73,74). In addition, the cen-
pact, not during the fall, determines the outcome.          tripetal theory of traumatic unconsciousness states
                                                            that primary disruption of the RAS will not occur
Snbdural Hemorrhage                                         in isolation and that structural brainstem damage
   A "high strain" impact (short pulse duration and         from inertial (impulse) or impact (contact) loading
high rate for deceleration onset) typical for a fall is     must be accompanied by evidence for cortical and
more likely to cause subdural hemon-hage than a             subcortical damage (36). This theory has been vali-
"low strain" in1pact (long pulse duration and low           dated by magnetic resonance imaging and CT scans
rate for deceleration onset) that is typical of a           in adults and children (75,76). Only one of the chil-
motor vehicle accident (42,61). The duration of de-         dren in this study (case 6) had evidence for any
celeration for a head-impact fall against a nonyield-       component of DAI. This child had focal hemor-

Am J Forensic Med Pathol, Vol. 22, No. 1, March 2001
                                FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS                                                    9


        rhage in the posterior midbrain and pons, thought        amination and has been recommended as part of
        by the pathologist to be primary, although there         the evaluation of any pediatric patient with head
        was no skull fracture, only "a film" of subdural         trauma (89). None of the children in this study had
        hemorrhage, no tears in thr:~corpus, _<;:allosum, and    a formal retinal evaluation, and only six had fun-
        no lacerations of the cerebral white matter (grossly     duscopic examination .documented in the medical
        or microscopically).                                     record. Four of the six had bilateral retinal hemor-
          The usual cause for delayed deterioration in in-       rhage.                        '
       fants and children is cerebral edema, whereas in
        adults it is an expanding extra-axial hematoma          Pre-existing Conditions
       (77). If the mechanism for delayed deterioration           One of these children (case 16) had a subarach-
       (except for an expanding extra-axial mass) is ve-        noid AV malformation that contributed to develop-
       nospasm, cerebral edema may be the only morpho-          ment of the subdural hematoma, causing his death.
       logic marker. The "talk and die or deteriorate           One (case 7) had-TAR syndrome (90), but his death
       (TADD)" syndrome is well characterized in adults         was thought to be caused by malignant cerebral
       (78). Two reports in the pediatric literature discuss    edema not an expanding extra-axial mass.
      TADD, documenting 4 fatalities among 105 chil-
      dren who had a lucid interval after head injury and        Cerebrovascnlar Thrombosis
      subsequently deteriorated (77,79). Many physicians            Thrombosis or dissection of carotid or vertebral
      believe that a lucid interval in an ultimately fatal       arteries as a cause of delayed deterioration after
      pediatric head injury is extremely unlikely or does        head or neck injuries is documented in both adults
      not occur unless there is an epidural hematoma             and children (91,92). Case 14 is the first report of a
      (7,8,11). Twelve children in this study had a lucid        death due to traumatic cerebrovascular thrombosis
      interval. A noncaretaker witnessed 9 of these 12          in an infant or child. Internal carotid artery throm-
z
0     falls. One child had an epidural hematoma.                bosis was suggested radiographically in an addi-
-0
                                                                tional death (case 13) but could not be confirmed at
g                                                               autopsy. However, this child died 6 days after ad-
>      Retinal Hemorrhage
                                                                mission to the hospital, and fibrinolysis may have
"
m        The majority of published studies conclude that
      retinal hemorrhage, especially if bilateral and pos-      removed any evidence for thrombosis at the time
      terior or associated with retinoschisis, is highly        the autopsy was performed.
      suggestive of, if not diagnostic for, nonaccidental
                                                                Limitations
      injury (9,14-21). Rarely, retinal hemorrhage has
      been associated with an accidental head injury, but        1. Six of the 18 falls were not witnessed or were
      in these cases the bleeding was unilateral (80). It is          seen only by the adult caretaker, and it is pos-
      also stated that traumatic retinal hemorrhage may               sible that another person caused the nonob-
      be the direct mechanical effect of violent shaking             served injuries.
      (15). However, retinal hemorrhage may be caused            2. The exact height of the fall could be deter-
      experimentally either by ligating the central retinal          mined in only 10 cases. The others (7 swing
      vein or its tributaries or by suddenly increasing in-          and 1 stationary platform) could have been
      tracranial pressure (81,82); retinoschisis is the re-          from as little as 0.6 meters (2 feet) to as much
      sult of breakthrough bleeding and venous stasis not            as 2.4 meters (8 feet).
      "violent shaking" (15,83). Any sudden increase in          3. A minimum impact velocity sufficient to
     intracranial pressure may cause retinal hemorrhage              cause fatal brain injury cannot be inferred
      (84-87). Deformation of the skull coincident t& an             from this study. Likewise, the probability that
     impact nonselectively increases intracranial pres-              an individual fall will have a fatal outcome
     sure. Venospasm secondary to traumatic brain in-               cannot be stated because the database depends
     jury selectively increases venous pressure. Either             on voluntary reporting and contractual agree-
     mechanism may cause retinal hemorrhage irrespec-               ments with selected U.S. state agencies. The
     tive of whether the trauma was accidental or in-               NEISS summaries for the study years esti-
     flicted. Further, retinal and optic nerve sheath hem-          mated that there were more than 250 deaths
     orrhages associated with a ruptured vascular                   due to head and neck injuries associated with
     malformation are due to an increase in venous pres-            playground equipment, but there are only 114
     sure not extension of blood along extravascular                in the files. Further, this study does not in-
     spaces (81-83,88). Dilated eye examination with an             clude other nonplayground equipment-related
     indirect ophthalmoscope is thought to be more sen-             fatal falls, witnessed or not witnessed, in the
     sitive for detecting retinal bleeding than routine ex-         CPSC database (32).

                                                                          Am J Forensic Med Pathol, Vol. 22, No. J, March 2001
   10                                                  J. PLUNKETT


                         CONCLUSIONS                             is not uniform (45). This analysis requires awareness
                                                                 of the shape of the deceleration curve, knowledge of        or
            .   fall is a complex event. There must be a
     1. E very       .                       . 'd        .       the mechanical properties and geometry of the cra-          loc
          biOme"chanical analysis for any inc1 ent 1n
                                                                 nial system, and comprehension of the stress and            cc
          which the severity of the injnry appears .to be.       strain characteristics for the specific part of the skull   (n
          lncOnsistent with the history. The question 1s
                                                                 and brain that strikes the ground. A purely transla-        (rr
          not "Can an infant or child be seriously in-
                                                                 tional fall requires that the body is rigid and that the    ge
         jured or killed from a short-distance fall?''. but
                                                                external forces acting on the body pass only through
         rather "If a child falls (x) meters and strikes
                                                                the COM, i.e., there is no rotational component. A ! -       L
                                 a
         his other head on nonyielding surface, what
                                                                meter-tall 3-year-old hanging by her knees from a
         will happeu ?"
                                                                horizontal ladder with the vertex of her skull 0.5 me-
     2. Retinal hemorrhage may occur whenever in-
                                                                ters above hard-packed earth approximates this
         tracranial pressure exceeds venous pressure or
                                                                model. If she looses her grip and falls, striking the        gL
         whenever there is venous obstruction. The
                                                                occipital scalp, her impact velocity is 3.1 m/second.        tic
         characteristic of the bleeding cannot be used
                                                                An exclusively angular fall also requires that the
         to determine the ultimate cause.
                                                                body is rigid. In addition, the rotation must be about
    3. Axonal damage is unlikely to be the mecha-
                                                                a fixed axis or a given point internal or external to
        nism for lethal injnry in a low-velocity impact
                                                                the body, and the applied moment and the inertial
        such as from a fall.                                                                                                     2
                                                               moment must be at the identical point or axis. If this
    4. Cerebrovascular thrombosis or dissection
                                                                same child has a 0.5-meter COM and has a "match-
        must be considered in any injury with appar-
                                                               stick" fall while standing on the ground, again strik-             3
        ent delayed deterioration, and especially in
                                                               ing her occiput, her angular velocity is 5.42 rad/sec-
        one with a cerebral infarct or an unusual dis-
                                                               ond and tangential velocity 5.42 m/second at impact.
        tribution for cerebral edema.
                                                               The impact velocity is higher than predicted for an               4
    5. A fall from less than 3 meters (10 feet) in an in-
                                                               exclusively translational or external-axis angular fall
        fant or child may cause fatal head injury and                                                                            s
                                                               when the applied moment and the inertial moment
       may not cause irrunediate syinptoms. The in-
                                                               are at a different fixed point (slip and fall) or when
       jnry may be associated with bilateral retinal
                                                               the initial velocity is not zero (walking or running,
       hemorrhage, and an associated subdural
                                                               then trip and fall), and the vectors are additive. How-
       hematoma may extend into the interhemi-
                                                               ever, the head, neck, limbs, and torso do not move
       spberic fissure. A history by the caretaker that
                                                               uniformly during a fall because relative motion oc-
       the child may have fallen cannot be dismissed.
                                                               curs with different velocities and accelerations for
   Acknowledgements: The author thanks the law en-             each component. Calculation of the impact velocity
 forcement, emergency medical services, and medical           for an actual fall requires solutions of differential
 professionals who willingly helped him obtain the origi-     equations for each simultaneous translational and
 nal source records and investigations; Ida Harper-Brown      rotational motion (45). Fnrther, inertial or impulse
 (Technical Information Specialist) and Jean Kennedy
 (Senior Compliance Officer) from the U.S. CPSC, whose        loading (whiplash) may cause head acceleration
 enthusiastic assistance made this study possible; Ayub K.    more than twice that of the midbody input force and
 Ommaya. M.D., and Werner Goldsmith. Ph.D.• for criti-        may be important in a fall where the initial impact is         ](
cally reviewing the manuscript; Jan E. Leestrna, M.D.,        to the feet, buttock, back, or shoulder, and the final
and Faris A. Bandak, Ph.D., for helpful conunents; Mark       impact is to the head (46,47).
E. Myers, M.D., and Michael B. Plunkett, M.D., for re-
view of the medical imaging studies; Jeanne Reuter and            The translational motion of a rigid body at con-
Kathy Goranowski, for patience, humor, and completing         stant gravitational acceleration (9.8 m/s 2 ) is calcu-
the manuscript; and all the families who shared ~e sto-       lated from:                                                    1:
ries of their sons and daughters and for whom this work
                                                                                        2
is dedicated.                                                           F =ma          v = 2as       v =at

                                                                 where F = the sum of all forces acting on the body          l

                         APPENDIX                             (newton), m = mass (kg), a = acceleration (rnls 2 ),           [.
                                                              v =velocity (mis), s =distance (m), and t =time (s).
   Newtonian mechanics involving constant acceler-               The angular motion.of a rigid body about a fixed            1
ation may be used to determine the impact velocity            axis at a given point of the body under constant
in a gravitational fall. However, c6nstant accelera-          gravitational acceleration (9.8 m/s 2 ) is calculated
tion formulas cannot be used to calculate the rela-           from:
tions among velocity, acceleration, and distance
traveled during an impact because the deceleration                     M =Ia
Am J Forensic Med Pathol, Vol. 22, No. 1, March 2001
                                               FATAL HEAD INJURIES WITH SHORT-DISTANCE FALLS                                                            11

     !SS           where M = the applied moment about the COM                                 sociated systemic findings in suspected child abuse; a
                                                                                              necropsy study. Arch Opthalmol 1990;108:1094-101.
        of      or about the fixed point where the axis of rotation is                  18. Williams DF, Swengel RM, Scbarre DW. Posterior seg-
        ~a­     located, I = the inertial moment about this same                              ment manifestations of ocular trauma. Retina 1990;10
     nd         COM or fixed point, a = angular acceleration                                  (suppl):535-44.
                                                                                        19. Rosenberg NM, Singer J, Bolte R, et al. Retinal hemor-
     111        (rad/s2 ), w = angular velocity. (radfs·), r = radius                         rhage. Pediatr Emerg Care 1994;10i303-5.
     la-        (m), v' = tangential velocity (mis), and a' = tan-                     20. Swenson J, Levitt C. Shaken baby Syndrome: diagnosis
     he         gential acceleration (rn/s 2 ).                                               and prevention. Minn Med 1997;80:41-4.
                                                                                       21. Altman RL, Kutscher ML, Brand DA. The "shaken-baby
     gh           The angular velocity w for a rigid body of length                           syndrome." N Engl J Med 1998;339:1329-30.
      l-        L rotating about a fi>~d point is calculated from:                     22. Hall JR, Reyes HM, Horvat M, et al. The mortality of
         a                                                                                    childhood falls. J Trauma 1989;29:1273--5.
                          lfI0 w2 = maL/2           I 0 = (1/3) rnL 2                  23. Rieber GD. Fatal falls in childhood: how far must children
    e-                                                                                       fall to sustain fatal head injury: report of cases and review
    Lis            where I 0 = the initial inertial moment, w = an-                          of the literature. Am J Forensic Med Pathol 1993;14:
    ie          gular velocity (rad/s), m = mass (kg), a = gravita-                          201-7.
                                                                                      24. Root I. Head injuries from short distance falls. Am J Foren-
    d.          tional acceleration (9.8 rn/s 2 ), and L = length.                           sic Med Pathol 1992;13:85-7.
    1e                                                                                25. Nashelsky MB, Dix JD. The time interval between lethal
     ut                                                                                      infant shaldng and onset of symptoms: a review of the
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Am J Forensic Med Pathol, Vol. 22, No. J, March 2001
APPENDIX D
                                                              CASE REPORT




             Delayed Sudden Death in an Infant Following an
                            Accidental Fall
                           A Case Report With Review of the Literature
                                   Scott Denton, MD, and Darinka Mileusnic, MD, PhD


                                                                          treated with nebulizer, was witnessed by his grandmother to
Abstract: Several controversies exist regarding ultimately lethal
head injuries in small children. Death from short falls, timing of        fall backwards off the edge of a queen-sized bed, 30 inches
head injury, lucid intervals, presence of diffuse axonal inJUt)' (DAI),   off the floor. The child was sitting on the edge of the bed as
and subdural hernatoma (SDH) as marker of DAI are the n1ost recent        the grandmother dressed her 2-year-uld daughter. The child
controversial topics of debate in this evolving field of study. In this   fell back vvards and rotated fron1 the sitting position, striking
area of debate, \Ve present a case of delayed death from a witnessed      the 1nidback of his head on a vinyl-covered concrete floor at
fall backwards off a bed in a 9-month-old black male child who            8:00 AM. He i1n111ediately began crying, and the grandmother
struck his head on a concrete floor and was independently witnessed       placed ice on a knot on the back of his head. He stopped
as "healthy" postfall for 72 hours until he was discovered dead in        crying and was consolable within a few minutes. The child
bed. Grandn1other, babysitter, and mother all independently corrob-
                                                                          was taken to the babysitter's residence, where the babysitter
orated under police investigation that the child "acted and behaved
normally" after the fall until death. Autopsy showed a linear non-
                                                                          was told of the fall and to watch for any behavioral changes.
displaced parietal skull fracture, diastasis of adjacent occipital su-    The tnother \Vas at work the tnorning when the fall occurred.
ture, subgaleal hemorrhage 'Nith evidence of aging, small posterior       When the mother picked the child up at the babysitter's in the
clotting SDH, marked cerebral eden1a, and a sinall tear of the            afternoon. he appeared 'Nell. The babysitter reported no
midsuperior body of the corpus calloswn consistent with focal             problems and that he acted, ate, and behaved as usual. For the
axonal injury (F Al). No DAI was seen, and there \Vere no retinal         next 2 days, the grandmother, mother, and babysitter did not
hemorrhages. All other causes of death were excluded upon thor-           notice any abnormalities in either behavior or appearance of
ough police and medical examiner investigation. Although this             the child.
seems to be a rare phenomenon, a delayed,, seemingly symptom-free
                                                                                 Approximately 72 hours after the fall off the bed, the
interval can occur between a clinically apparent mild head injury
                                                                          child was found at the foot of the mother's bed, where he
and accidental death in a young child.
                                                                          usually slept, prone, cold, and unresponsive. Paramedics were
(Am J Forensic Med Pathol 2003;24: 371-376)                               called, and in spite of resuscitative.: efforts, he was pro-
                                                                          nounced dead upon arrival at the hospital. He \·vas last seen
                                                                          alive 8 hours prior when he was fed by his mother and given
                         CASE REPORT
                                                                          his usual albuterol breathing treahnent. No abnormalities on
 I\ 9-rnonth-old black male child weighing 22 pounds (10                  the child were seen in the emergency department. There was
/'"'\kg) and measuring 28 inches (71 crn), 80th percentile and            no evidence of overlying or asphyxia.
50 1h percentile for age, respectively, with a history of asth1na                Medical and family history revealed that the child was
                                                                          born full-term weighing 7 pounds 4 ounces. He was diag-
                                                                          nosed with asthma after complaints of \Vheezing episodes and
Manuscript received March 19, 2003; accepted May 29, 2003.                was prescribed an a!buterol nebulizer twice daily. The child's
From the Cook County Office of the Medical Examiner, and Deparlmt'nt of   father, who does not reside in the hon1e, bas asthma. The
   Pathok1gy, Rush College of Medicine, Chicago, Illinois (J.S.D.), and
                                                                          n1other and grandn1other reside together in a public housing
   Knox County Office of the Medical Examiner. and Department of
   Pathology, Graduate School of Medicine, Univt:rsity of Tt:nnessee,     develop1nen1. Depart1nent of Child and Family Services
   Knoxville, Tennessee (D.M.).                                           records revealed no prior incidents concerning the deceased,
Reprints: Darinka Mih.msnic, MD, PhD, Regional Forensic Center, Univer-   but the mother had I report of being a victitn of prior abuse.
   sity of Tennessee Memorial Hospital, 1924 Alcoa Highway, Knoxville,
                                                                          The grand1nother has a remote history of cocaine abuse. Her
   1N 37920. E-mail: dmileusn@mc.utmck.edu
Copyright© 2003 by Lippincott Williams & Wilkins
                                                                          2-year-old daughter is well and lives with her.
0195-7910/03/2404-037 l                                                          Autopsy revealed a well-developed and well-nourished
DOI: I 0.1097/0 ! .paf.0000097851.18478.16                                black 111alc child appearing the stated age and without exter-

The American journal of Forensic Medicine and Pathology • Volume 24, Number 4, December 2003                                          371
Denton and Mileusnic         The American journal of Forensic Medicine and Pathology • Volume 24, Number 4, December 2003




nal abnormality. There was no swelling or contusion of the
back of the head. Complete postmortem radiographs revealed
a linear, nondisplaced, posterior right parietal skull fracture.
Internal exa1nination confirmed the skull fracture, as well as
a patch or right posterior subgaleal hemorrhage that was
centrally red with yellow margins. The underlying right
posterior linear skull fracture was 3.0 inches (9.0 cm) long
and extended to the right parieto-occipital suture, causing
mild diastasis of the suture, 2.5 inches (7.5 cm) Jong (Fig. 1).
There was a thin adherent clotted SDH underlying the frac-
tme, 2.0 X 2.0 X 0.1 cm. The brain weighed 1035 g
(expected average weight for age, 750 g) and showed severe
edema with flattening of the gyri, loss of sulci, and notching
of both unci and cerebellar tonsils (Fig. 2). After formalin
fixation, serial sectioning of the brain revealed diffusely
dusky white matter and a focal tear of the midsuperior corpus




                                                                   FIGURE 2. Severely edematous brain demonstrating flattening
                                                                   of the gyri and narrowing of the sulci.



                                                                   callosum, 1 1nrn, with surrounding hemorrhage, 2 n1m. There
                                                                   were no other gross neuropathologic findings. The remaining
                                                                   internal organs were unremarkable, without other new or old
                                                                   fractures, petechiae, or gross asthma changes. Comprehen-
                                                                   sive toxicologic screening using gas chromatography and
                                                                   nlass spectrometry was negative. Microscopically, the corpus
                                                                   callosum tear showed hemo1Thage with intact red blood cells,
                                                                   PAI, and 1nicroglial activation without inflammation (Fig. 3).
                                                                   Extensive sections of the brain showed only edema without
                                                                   evidence of DAL Sections of the subgaleal hemorrhage
                                                                   showed hen1orrhage of coalescing red blood cells with neu-
                                                                   trophilic inflammation. Decalcified sections of the parietal
                                                                   fracture showed an acute fracture with early periosteal reac-
                                                                   tion at the fracture margin. Lung sections showed mild focal
FIGURE 1. View of the linear skull fracture Involving the pos-     peribronchial lymphocytic aggregates consistent with bron-
terior right parietal bone1 after removal of the overlying sub-    chitis without asthma changes. There were neither eosino-
galeal hemorrhage.                                                 phils nor 1nucus plugs. Sections of remaining organs were

372                                                                                          © 2003 Lippincott Williams & Wilkins
   The American journal of Forensic Medicine and Pathology     111   Volume 24, Number 4, December 2003             Delayed Sudden Death




                                                                          in the majority of lethal events, are still controversial. One
                                                                          \videly held belief is that short falls are almost never fatal.
                                                                          Second, if a child is going to die follo\ving head trauma,
                                                                          either accidental or abusive, he or she is severely impaired
                                                                          and inost likely i1nmediately unconscious, without a lucid
                                                                          interval. Finally, in severe injuries where children are im1ne-
                                                                          diately comatose and die shortly after the incident from either
                                                                          shaking and/or direct impact, it is believed that DAI is the
                                                                          111echanism. Certain reviews have gone so far to identify
                                                                          subdural hemorrhage, frequently present in certain forms of
                                                                          early childhood abusive head traun1a, as a "marker" of unde-
                                                                          tectable DAL 1 1f this were true, then reports describing
                                                                          radiologically presen1 old and/or new subdural hemorrhages,
                                                                          with or without focal shear hemorrhages in the white matter,
   FIGURE 3. Coronal section of the corpus callosum showing               in living children would be a rarity rather than a com1non
   wedge-shaped laceration (right upper corner) surrounded by a           place. 2
   rim of hemorrhage, FAI and activated microglia (1 OOX, hema-                  In this present case, we discuss the death of a 9-month-
   toxylin-eosin).                                                        old child who died 3 days after a witnessed backward fall
                                                                          from a bed on a concrete floor. Main pathologic findings
                                                                          consisted of a linear nondisplaced skull fracture, minimal
                                                                          clotting subdural hemorrhage, severe brain swelling with
   without pathologic changes. The eyes were examined by an
                                                                          tonsillary herniation, and a small tear in the body of the
   ophthalmic pathologist consultant and were normal. A foren-
                                                                          corpus callosu1n, which appeared histologically as FAL Anal-
   sic radiologist consultant also reviewed postmortem radio-
                                                                          ysis of the fall revealed a rotational component of the body
   graphs and repo1ted no additional findings.
                                                                          and head movement, 1.vhich could account for the described
                                                                          injuries. The location and appearance of the prin1at)' injury
   Follow-up Investigation                                                was consistent viith flipping backward and striking the back
          Prior to the autopsy, Chicago police detectives \Vere
                                                                          of the head. There was no diffuse axonal da1nage or retinal
   notified of the skull fracture and attended the examination.
                                                                          hemorrhage. Thorough workup, including scene investigation
   After autopsy, police re1nanded the grandmother and mother
                                                                          and independent police questioning of all individuals in-
   to the police station, where they were interviewed separately
                                                                          volved in the care of the infant, prior to, during, and after the
   about the injuries. Upon extensive questioning about any
                                                                          accident, were unanin1ous. There were no inconsistencies,
   possibility of inflicted trauma and abuse that the baby could have
                                                                          and the stories have never varied from the beginning to the
   sustained, they both spontaneously gave the similar story of the       conclusion of the investigation. There were no other instances
   fall 3 days prior. The babysitter was questioned and confinned
                                                                          of trau1na to the head observed by the caretakers. Based on
   the accounts and timing of the reported events. Police detectives
                                                                          several independent accounts, the infant's behavior following
   and evidence technicians accompanied the mother and grand-
                                                                          the head trauma up to his sudden death was ordinary and did
   mother back to their residence and verified the scene and
                                                                          not require medical attention, qualifying as a lucid or symp-
   reenactment of the fall. A week later, the prosector patholo-
                                                                          tom-free interval.
   gist (JSD) and a specialist child death scene investigator of
                                                                                 Deciding whether head injury in a very young child is
   the Medical Exa1niner's Office went to the residence and
                                                                          accidental or nonaccidental has always been proble1natic for
   again inspected the residence, interviewed the grandmother
                                                                          clinicians and forensic pathologists alike. 3 ·4 We realize that a
   and 1notber. and reenactcJ. the fi.lll. As with the police detec-
                                                                          number of child abuse experts would have a problem with the
   tives, all felt the grandmother and mother to be truthful and
                                                                          accidental detenninlltion of the manner of death in the present
   grieving appropriately for the circumstances. After consider-
                                                                          case. We do not argue the widely noted observation that
   ation of the autopsy, toxicologic, histologic, consultative, and
                                                                          simple falls from low heights rarely result in significant
   investigative findings, the death was certified as craniocere-
                                                                          prin1ary brain injury. 5 However, every fall is different, as well
   bral injuries due to a fall fron1 the bed backwards onto a
                                                                          as the individual reaction to the pri tnary insult. Son1e experts
   concrete floor. The manner was determined accidental.
                                                                          in head trauma consider the term minor head injury an
                                                                          oxymoron. 6 We believe that a series of secondary injuries,
                           DISCUSSION                                     known to occur after a primary insult, resulted in the extreme
          Ce1tain issues in pediatric head trauma, such as lethal-        swelling of the brain and death of the child. What is widely
   ity of short falls, timing of head injury, and presence of DAI         understated and so1ncti1nes forgotten about is secondary brain

   © 2003 Lippincott Williams & Wilkins                                                                                               373


Copyright       Lippincott
Denton and Mileusnic          The American journal of Forensic Medicine and Pathology • Volume 24, Number 4, December 2003




 injury, which occasionally may be the principal force deter-       ists involved in the care of abused children accept as true that
mining the outco1ne after a see1ningly trivial head injury. 7- 12   all children who eventually die, regardless of the type of the
Another frequently forgotten factor is the influence of age and     head injury, must be severely disabled, usually comatose
sex on the presentation and the outco1ne of head injury. The        from the ve1y moment the injury occurred. 23 From personal
grouping together of different pathologies such as subdural         experience and based on the literature review, this tenet is not
hemorrhages, cerebral contusions, FAI, and DAI, as well as          necessarily true. 24 '25 Although there are clearly scenarios in
lumping together of infants, toddlers, and preschool children,      which this principle could be applicable, there is undoubtedly
needs to be addressed. It has been shown that infants and           a subpopulation of infants and especially toddlers with a
young toddlers lose consciousness less frequently, and a             completely different constellation of injuries and a dissitnilar
 smaller proportion of their head injuries lead to immediate        presentation. Occasionally, these children have nonspecific
 coma in comparison to other children with the same grades of        symptoms for several hours to a day prior to the onset of
traumatic energy. 13 Pohl et a1 9 demonstrated that evolution of    either coma or seizure followed by coma. Common observa-
posttraumatic brain da1nage after head trauma in developing         tions include reduced physical activity, lethargy, drowsiness,
rodents is a highly dynamic process exhibiting age-dependent        irritability, temperature irregularities, poor feeding, and gas-
excitotoxic and distant apoptotic cell death.                       trointestinal symptoms. 232627 Careful analysis of the history
       Reviewing the literature on childhood head trauma, one       and the events leading to the critical symptoms indicate that
can clearly see that a gradual sideway drift or evolution of        there was a certain progression of symptomatology.
findings and conclusions of the original reports, research, and            Occult intracranial injury in infants younger than 12
data had taken place. One of them, also frequently encoun-          months of age is not uncommon. 28 Clinical symptoms and
tered in cou1t, is that ve1y young children, especially infants,    signs are insensitive indicators of intracranial inju1y in in-
are auton1atically assu1ned to be the victi1ns of "shaken baby      fants.29 Radiologic observations can so1netimes be of litnited
syndrome." 14 - 16 However, fro1n the literature and from per-      value as well. 30 Also, slow deterioration following mild head
sonal experience, findings of direct impact to the head pre-        injuries in children have been reported. 31 Furthermore) l of
vail. The problem is not only se1nantic in nature but has 1najor    the most frequently cited articles on restricting the time of
and far-reaching consequences since the character, location,        injury in fatal inflicted head injuries draws its pediatric
and clinical presentation of the injuries arc different from the    population mainly from motor vehicle accidents, with the
rare purely shaken babies. 17 ·18                                   average age of the study group patients being 8.5 years, with
       Another encountered fallacy is that the children who         a SD of 4.0 yearsn
die of head trau1na, especially abusive head trau1na, sustain              Although many studies have offered guidelines for
DAL Going back to some of the original research, it is clear        determining the age of cerebral injuries, various factors limit
that the authors explicitly stated that the 2 worst types of head   the reliability of these 1nethods; for example, reduced cere-
injury are SDH and DAI. These 2 have different mechanisms           bral blood flow n1ay impede the ceilular response. Not infre-
of causation: SDH occurs much more commonly in nonve-               quently, injured children survive in the hospital for additional
hicular injuries, such as falls and abusive head trauma, while      2 to 3 days or even longer, sometimes undergoing craniot-
DAI is caused almost exclusively by vehicular mecha-                omy, rendering timing of the injuries based on the autopsy
nisms.19-22 Although both injuries frequently share a com-          findings, including histologic examination of the cerebral
mon mechanical cause such as angular acceleration, they             injuries, extre1nely difficult. 8-23 -33- 35
differ in degree. SDH usually occurs with a rotational injury              DAI is most likely a rarity in nonaccidental head
of short duration and a high rate of acceleration. Conversely,      trauma, and the term is misleading. 17 • 18 ' 36 Coma may be more
motor vehicle accidents tend to cause longer-duration, lower-       of a reflection of the severity of axonal damage in particular
acceleration-rate injuries leading to DAI rather than SDH. 8·21     regions of the brain, most notably the brainstem, rather than
SDHs occur in a greater number in children with inflicted           the total su1n of axonal injury distributed throughout the
versus noninflicted traumatic brain inju1y, whereas shear           brain. Furthermore, the plane of head rotational acceleration
injuries are commonly visualized in the noninflicted inju1y         plays an important role in determining both the distribution of
group. 22 Therefore, current supposition that the presence of       axonal damage and the production of coma. 36 The localized
SDH is a marker of DAI is likely inaccurate.                        axonal damage demonstrated in corticospinal tracts in the
       A frequently asked question is whether delayed 1nental       lower brainstem and rostral cervical cord, presumably caused
status deterioration can occur following head injury in chil-       by stretch to the neuroaxis produced by cervical hyperexten-
dren. This is critically important in unwitnessed circu1n-          sion, may be more significant This finding also provides an
stances such as child abuse. A widely held dogma is that if a       explanation for the frequent occurrence of apnea at presen-
child becomes unresponsive while in the care of an individual       tation. Tn many of the cases reported by Geddes et al, 18 the
who is reporting the onset of unconsciousness, that same            axonal damage at the craniocervical junction was survivable;
individual must be the perpetrator. Currently, some special-        what was life-threatening was the subsequent hypoxic injury

374                                                                                            © 2003 Lippincott Williams & Wilkins
The American journal of Forensic Medicine and Pathology • Volume 24, Number 41 December 2003                                       Delayed Sudden Death




 and brain swelling. In addition, true contusional tears, which                  9. Pohl D, Bittigau P, Ishimaru MJ, et al. N-methyl-D-aspartate antagonists
are peculiar to the brains of young infants, represent localized                     and apoptotic cell death by head trauma in developing rat brain. Proc
                                                                                     Natl Acad Sci. USA. 1999;96:2508-2513.
"shearing" between gray and white inatter after an impact and                   10. Gilles EE, Nelson MD. Cerebral complications of nonaccidental head
should not automatically imply DAL 17                                                injury in childhood. Pediatr Nertrol. 1998;19:119-128.
       Cerebral hypoperfusion, followed by hypoxia/ische1nia                    11. Bergsneider M, Hovda D, Lee SM, et al. Dissociation of cerebral
                                                                                     glucose metabolism and level of consciousness during the period of
and diffuse brain swelling, characteristic in injured children                       inetabolic depression following human traumatic brain injury. J Neuro-
younger than 24 months of age, are key pathophysiological                            trauma. 2000;17:389-401.
findings associated with poor outcome following severe trau-                    12. Ruppel RA. Clark RS, Bayir H, et al. Critical mechanisms of secondary
                                                                                     damage afl:er inflicted head injury in infants and children. Neurosurg
matic brain injury. s,37- 39 Primary brain damage occurs at                          Clin North Am. 2002;13:169-182.
impact and appears irrunediately or shortly after injury. Sec-                  13. Barney J, Froidevaux A-C, Favier J. Paediatric head trauma: influence of
ondary brain injury may be more important, particularly in                           age and sex, II: biomechanical and anatomo-clinica! correlations. Child
                                                                                    Nerv Syst. 1994;10:517-523.
delayed fatalities, and occurs distant to the ilnpact. Secondary                14. Caffey J. On the theory and practice of shaking infants: its potential
events may not becon1e apparent until several hours after                            residual effocts of permanent brain damage and mental retardation. Am J
injury. The largest controlled neuropathological study of                           Dis Child. 1972;124:161-169.
                                                                                15. Caffey J. The whiplash shaken infant syndrome: manual shaking by the
nonaccidental infant head injury showed that axonal damage                           extremities with whiplash-induced intracranial and lntraocular bleed-
occurred in the brain of both head-injured subjects and in                           ings, linked with residual permanent brain damage and mental retarda-
controls in the same distribution. This is not DAI but rather                        tion. Pediatrics. I 97454:396-403.
                                                                                16. Levin AV. Retinal haemorrhages and child abuse. Rec Adv Paediatr.
diffuse vascular or hypoxic-ischc1nic injury due to brain                            2000; 18: 151-219.
swelling and raised intracranial pressure. The study demon-                     17. Geddes JF, Hackshaw AK, Vowles GH, et al. Neuropathology of
strated that the diffuse brain damage responsible for loss of                        inflicted head injury in children, I: patterns of brain damage. Brain.
                                                                                     2001; 124: 1290-1298.
consciousness is a hypoxic secondary reaction and argues                        18. Geddes JF, Vowles OH, Hackshaw AK, et al. Neuropathology of
against DAI. One of the inain conclusions of the study was                           inflicted head injury in children, II: microscopic brain injury in infants.
that focal, localized axonal injury and secondary vascular-                         Brain. 2001;124:1299-1306.
                                                                                19. Gennarelli TA, Thibault LE. Biomechanics of acute subdural hematoma.
hypoxic changes characterize the mechanism of brain                                 J Trauma. 1982;22:680-686.
death. 18                                                                      20. Gennarelli TA, Thibault LE, Adams JH, et al. Diffuse axonal injury and
       In conclusion, we present a case of a seetningly minor                       traumatic coma in the primate. An11 Neurol. 1982;12:564-574.
                                                                               21. Gennarelli TA. Head i11jury in man and experimental animals: clinical
brain injury in an infant with a symptom-free interval, which                       aspects. Acta Neurochir. 1983;32(suppl):l-13.
resulted in delayed, sudden death. The importance of the                       22. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging. physical,
mechanism of injury, location of injury, age of the child,                          and developmental findings after inflicted and noninflicted traumatic
                                                                                    brain injury in young children. Pediatrics. 199Kl02:300-307.
and secondary brain injury with special reference to non-                      23. Duhaime A-C, Christian CW, Balian Rorke L, Zimmerman RA.
accidental head trauma of childhood, as well as need for                            Nonaccidental head injury in infants-the "shaken-baby syndrome."
further research, are discussed. Although this is a rare                            N Engl J Med. 1998;338: 1822-1829.
                                                                               24. Nashelsky MB, Dix JD. The time interval between lethal infant shaking
presentation of a traumatic brain injury, based on recent                           and onset of symptoms: a review of the shaken baby syndrome literature.
advances in traumatic neuropathology, it is conceivable, as                         Am J Forensic Med Pathol. 1995;16:154-157.
in this case, that a delayed asymptomatic deterioration to                     25. Huntington RW UL Symptoms following head injury. Am J Forensic
                                                                                    Med Pathol. 2002;23:105.
death can occur.                                                               26. Ward JD. Pediatric issues in head trauma. New Horiz. l 995;3:539-545.
                                                                               27. Haviland J, Ross Russell Rl. Outcome after severe non-accidental head
                                                                                    injury. Arch Di:f Child. 1997;77:504-507.
                             REFERENCES                                        28. Greenes DS, Schutzman SA. Occult intracranial injury in infants. Ann
 1. Case ME, Graham MA, Corey Handy T, et al. Position paper on fatal               Emerg Med. 1998:32:680-686.
    abusive head injuries in infants and young children. Am J Forensic Med     29. Greenes DS, Schutzman SA. Clinical indicators of intracranial injury in
    Pathol. 2001;22: 112-122.                                                       head-injured infants. Pediatrics. 1999;104:861-867.
 2. Demaerel P, Casteels l, Wilms G. Cranial imaging in child abuse. Eur       30. Dias MS, Backstrom J, Falk M, Veetai L. Serial radiography in the
    Radial. 2002;12:849-857.                                                        infant shaken impact syndrome. Pediatr Neurvsurg. 1998;29:77-85.
 3. Maxeiner H. Lethal subdural bleedings of babies: accident or abuse?        31. Snoek JW, Minderhoud JM, Wilmink IT. Delayed deterioration follow-
    Med Law. 2001;20:463-482.                                                       ing mild head injury in children. Brain. 1984;107:15-36.
 4. Fung ELW, Sung RYT, Severn Nelson EA, Poon WS. Unexplained                 32. Willman KY, Bank: DE, Senac M, Chadwick DL. Restricting the time of
    subdural hematoma in young children: is it always child abuse? Pediatr          injury in fatal inflicted head injuries. Child Abuse Neg/. 1997;2 l :929-
    Internat. 2002;44:37-42.                                                        940.
 5. Duhaime AC, Alario AJ, Lewander WJ, et al. Head injury in very young       33. McD. Anderson R, Opeskin K. Timing of early changes in brain trauma.
    children: n1echanisms, injury types, and ophthalmologic findings in 100         Am J Forensic Med Pathol. 1998;19:1-9.
    hospitalized patients younger than 2 years of age. Pediatrics. 1992;90:    34. Wilkinson AE, Bridges LR, Sivaloganathan S. Correlation of survival
    179-185.                                                                        time with size of axonal swellings in diffuse axonal injury. Acta
 6. Schutzman SA, Greenes DS. Pediatric minor head trawna. Ann Emerg                Neuropathol. 1999;98: 197-202.
    Med. 2001;37:65-74.                                                        35. Oehmichcn M, Thcuerkaufl, Meissner C. Is traumatic axonal injury (AI)
 7. Bruce DA. Head injuries in the pediatric population. Curr Prob! Pediatr.        associated with an early microglial activation? Application of a double-
    1990;20;61-107.                                                                 laboling technique for simultaneous detection ofmicroglial and Al. Acta
 8. Pearl GS. Traumatic neuropathology. Clin Lab Med. 1998:18:39-64.                Neuropathol. 1999;97:491-494.


© 2003 Lippincott Williams & Wilkins                                                                                                                     375
Denton and Mileusnic             The American journal of Forensic Medicine and Pathology • Volume 24 1 Number 4, December 2003




36. Smith DH, Nonaka M, Miller R, et al. Immediate coma following           38. Ewing~Cobbs L, Prasad M, Kramer L, Landry S. Inflicted traumatic
    inertial brain injury dependent on axonal damage in the brainstem.          brain injury: relationship of developmental outcome to severity of injury.
    J Neurosurg. 2000;93:315-322.                                               Pediatr Neurosurg. l 999;31 :251-258.
37. Adelson PD, Clyde B, Kochanek PM, et al. Cerebrovascular response in    39. Tabori U, Kornecki A, Sofor S, et al. Repeat computed tomographic scan
    infants and young children following seveno traumatic brain injury: a       within 24-48 hours of admission in children with moderate and severe
    preliminary report. Pediatr Neurosurg. 1997:26:200-207.                     head trauma. Crit Care Med. 2000~28:840-844.




376                                                                                                         © 2003 Lippincott Williams & Wilkins
                                                   LETTERS TO THE EDITOR




    Diagnosis of Traumatic                             /3-APP is a single me1nbrane-                          REFERENCES
                                               spanning protein, which is present in           1. Tun1er PR, O'Connor K, Tate WP, et al. Roles
     Diffuse Axonal Injury                     membranous structures of the cell such             ofamyloid pr~cursor protein and its fragments
                                                                                                  in reguloi1ing neurnl activity, plasticity and
                                               as the endoplasmic reticulum, Golgi                memory. Frog Neurn!Jiol. 2003;10:1-32.
    To the Editor:                             compartment, and the cell 1nembrane,            2. Smith C, Graham DI, Geddes JF, et al. The
          In the December 2003 issue of the    encoded by the APP gene localized to               interpretation of Beta-APP immunoreactivity:
                                                                                                  a respons~ to C. Neiss et al., Acta Neuroparhof
   American Journal of Forensic i\!fedicine    chroinosome 21. and is ubiquitously ex-            (2002) 104:79. Acla Neuropathol. 2003;106:
   and Pathology, there was a case report      pressed in 1nany cell and tissue types,            97-98.
   written by Drs. Scott Denton and            including endotheha, glia, and neurons          3. Smith DH, Meaney OF, Shull WH. Diffuse
   Darinka Mileusnic titled "Delayed Sud-                                                         axonal injury in head trauma. J Head Trauma
                                               of the brain. /3-APP is a resotrrce-rich           Rehabi!. 2003;18:307-316.
    den Death in an Infant Following an        molecule that is involved in diverse nor-       4. Medana JM, Esiri MM. Axonal damage: a lrny
   Accidental Fall: A Case Report With         mal cell functions, being the center of            predictor of outcome in human CNS diseases.
   Review of the Literature." This article                                                        Brain. 2003;126:515-530.
                                               many converging metabolic and regula-
                                                                                               5. Blumbergs PC, Scott G, Manavis J, et al.
   presented a case of delayed. death in a     tory patlnvays, including cell adhesion,           Topography of axona! lnJUry as defined by
   9-month-old infant a'i a result of severe   intercellular signaling, membrane-to-nu-           amyloid precursor protein and the s~L:!or scor-
   craniocerebral injuries, which were sus-                                                       ing method in mild and severe closed head
                                               cleus signaling, cholesterol metabolism,
   tained from an accidental fall in the                                                          injury. J Neurotrauma. 1995;!2:565-572.
                                               gene transcription, axonal transport, and       6. McKenzie KJ, McLellan DR, Gentleman SM,
   domestic environment. The authors had
                                               neurotrophic and ncttroproliferative ac-           et al. ls J3-APP a marker \.ifaxonal dan1age in
   affirmed that there was no evidentiary                                                         short-surviving head injury'! Acta Neuro-
                                               tivity.1
   finding of diffuse axonal injury (DAI).                                                        patho!. !996;92:608-613.
                                                       In the neuron, /3-APP is synthe-        7. Adams JH, Doyle D, Ford I, et al. Diffuse
   The scientific validity of this assertion
                                               sized in the perikaryon and transported            axonal injury in head injury: definition, diag-
   remains in doubt since the authors nei-                                                        nosis and grading. Ilistopatholo'b'V· l 989; 15:
                                               anterogradely and retrogra<le!y in the
   ther mentioned nor perfonned any tissue                                                        49-59.
                                               axon by fast/rapid axonal transport ( 100       8. Ellison D, Love S, Chimelli L, et al.
   /3-amyloid precursor protein (/3-APP)
   immunohistochemical analyses, given         to 400 mm/day). In normal, structurally            Neuropathology: A Reference Text of CNS
                                               intact axons, /3RAPP does not accumu-              Pathology. Philadt:lphia, PA: Harcourt Pub-
   our current level of knowledge in the                                                          lishers Limitcti: 2000.
   diagnosis of severe traumatic brain in-     late to a level that allows its detection in    9. Lec!erc4 PD, McKenzie JE. Graham DI, et al.
   jury, including DAL 1- 6 Since the 1980s,   tissue sections. However, once struc-              Axonal injury is accentuated in the caudal
                                               tural a.xonal injury and damage occur              corpus callosum of head-injured patients.
   tissue innnunohistochemistry for /3-APP                                                        J Neurotrauma. 2001;!8:1-9.
   has emerged as the most sensitive meth-     and the fast axonal transport is irnpaired,    JO. Geddes JF, Whitwell HL, Graham DI.
   odology and gold standard for the detec-    J3-APP accun1ulates in the proximal and            Traumatic axona! injury: practical issues for
   tion, confirmation, and diagnosis of dif-   distal axonal seg1nent to a level that             diagnosis Ill medicolegal cases. Neuropathof
                                                                                                  Appl Neurobiol. 2000;26: [05-116.
   fuse and focal axonal injuty. With the      allows its dctectiun by tissue immuno-
   absence of any /3-APP in1n1unohisto-        histochen1istry within l.75 to 3 hours
   chemical confirmation of DAI, what the      following injury. /3-APP has been re-               Response to letter
   authors had referred to as a "laceration"   ported to retnain detectable by tissue
   of the splenium of the corpus ca1Iosun1     immunohistochemistry for up to 99 days               From Dr. Omalu
   may actually represent Adan1 's grade Tl    following axonal injury. 1•6
   DAJ 7 •8 since DAI is accentuated in the            For this specified case report by
                                                                                                     We thank Dr. Omalu for his com-
   splenium of the corpus callosum.9 In        Scott Denton and Darinka Mileusnic,
                                                                                              ments regarding our recent case report. 1
   Adam's grade I DAI, there is no gross       /3-APP tissue in1rnunohistochemistry
   evidence of axonal injury; however,                                                        Dr. Omalu certainly seems knowledge-
                                               that is performed according to the rec-
   there is diffuse /3-APP inununopositi v-                                                   able in his review of f3 amyloid precur-
                                               ommended medicolegal protocoJ 10 n1ay
   ity for axonal injury. In Adam's grade ll                                                  sor protein (/3-APP) and is apparently a
                                               reveal grades l or II DAL This finding
   DAI, there are gross lesions (parenchy-                                                    strong advocate for {3-APP itnmunohis-
                                               tnay additionally and 1nore interestingly
   mal heinorrhages) of the corpus callo-                                                     tochemistry in cases of head injw-y. Dr.
                                               reaffinn that children who sustain low
   sun1, in addition to /3-APP tissue immu-                                                   Omalu stated that there was no scientific
                                               grades of DAI may 1nanifest a delayed,
   nopositivity. In Adam's grade lII DAI,                                                     validity that diffuse axonal iajmy (DAI)
                                               symptomatic, or fatal presentation.
   there are gross lesions (parenchymal                                                       \Nas not there in our case. Dr. Omalu
   hemorrhages) of the corpus callosum                          Bennet I. Omalu, MD           also asserted that the tear in the corpus
   and dorsolateral 1nidbrain/pons, in addi-         Division of Forensic Neuropathology      callosum \Vas an advanced stage of DAL
   tion to diffuse /3-APP tissue immuno-              Allegheny County Coroner's Office       We would have expected to see micro-
   positivity .7•8                                               Pittsburgh, Pennsylvania     scopic evidence of DAI on the numer-

   270                         The American journal of Forensic Medicine and Pathology • Volume 25, Number 3, September 2004



CopyriQht      Lippincott \!Vililarns & Wilkins. Unauttlorized n-;production of this articif) is prohibited
    ous hen1atoxylin and eosin sections,         do note that we have received advertise-             Sincerely,
    given the tilne interval from the wit-       n1ents fro1n Dr. 01nalu and his Forensic
    nessed fall to the child's death. The tear   NeLffopathology Consultation Service                                    Scott Denton, MD
    of the corpus eallosum was frotn the         for performing {3-APP testing. As of                         Deputy Medical Examiner
                                                                                                  Cook County Medical Examiners Office
    impact fro1n the fall as the corpus callo-   note, in his advertisen1ent Dr. On1alu
                                                                                                        Assistant Professor of Pathology
    sun1 struck the falx cerebri. We would       states that in ht>ad injury deaths it "has
                                                                                                        Rush University Medical Center
    argue the assertion that 13-APP is ac-       been established and highly ITcom-                                          Chicago, IL
    cepted as the most sensitive methodol-       mended that /3-APP immunostaining be
    ogy and gold standard for detection of       perfonned in multiple topographically                   Darinka Miluesnic, MD, PhD
    DAI and the 1nedicolegal protocol refer-     targeted regions of the brain" and that               Assistant Chief Medical Examiner
    enced in Dr. 01nalu's letter above is not    applications include "tin1ing of injury          Knox County Me<lica[ Exan1iners Office
    accepted as such in our practices. We do     sustenance and determination of tin1e of         University ofTenne~see Mec.lical Center
    not perform routine /3-APP testing in        death." We are unaware of this timing of                           Knox ville, Tennessee
    our offices.                                 injury and death data that would surely
          We respect Dr. 01nalu's advocacy       solve the major critical proble1ns in pe-                     REFERENCES
    for {3-APP testing, although we do not       diatric head injury deaths. We sincerely     1. Denton S. Mileusnic D. Delayed sudden death
                                                                                                 in an infant following an ac:cidental fall: a case
    feel {3-APP would have changed our           \vish Dr. Omlllu well in advancing his          repl1rt with review of the litwature. Am J Fo-
    conclusions or shown hidden DAI. We          /3-APP research and enterprise.                 rensic J.fed Pathol. 2003;24.371-376.




   The American journal of Forensic Medicine and Pathology • Volume 25 1 Number 31 September 2004                                           271


CopyriQht © Lippincott Williams & Wilkins. Unauthoriz0d rnproduclion of this article is prohibite<L
