University of Pennsylvania

ScholarlyCommons
Departmental Papers (BE) Department of Bioengineering

3-1987

The Shaken Baby Syndrome: A Clinical,

Pathological, and Biomechanical Study
Ann-Christine Duhaime

Thomas A. Gennarelli

Lawrence E. Thibault
University of Pennsylvania

Derek A. Bruce

Susan S. Margulies
University of Pennsylvania, [email protected]

See next page for additional authors

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Recommended Citation
Duhaime, A., Gennarelli, T. A., Thibault, L. E., Bruce, D. A., Margulies, S. S., & Wiser, R. (1987). The Shaken Baby Syndrome: A
Clinical, Pathological, and Biomechanical Study. Journal of Neurosurgery, 66 (3), 409-415. http://dx.doi.org/10.3171/
jns.1987.66.3.0409

This paper is posted at ScholarlyCommons. http://repository.upenn.edu/be_papers/210

For more information, please contact [email protected].
The Shaken Baby Syndrome: A Clinical, Pathological, and Biomechanical
Study
Abstract
Because a history of shaking is often lacking in the so-called “shaken baby syndrome,” diagnosis is usually
based on a constellation of clinical and radiographic findings. Forty-eight cases of infants and young children
with this diagnosis seen between 1978 and 1985 at the Children's Hospital of Philadelphia were reviewed. All
patients had a presenting history thought to be suspicious for child abuse, and either retinal hemorrhages with
subdural or subarachnoid hemorrhages or a computerized tomography scan showing subdural or
subarachnoid hemorrhages with interhemispheric blood. The physical examination and presence of associated
trauma were analyzed; autopsy findings for the 13 fatalities were reviewed. All fatal cases had signs of blunt
impact to the head, although in more than half of them these findings were noted only at autopsy. All deaths
were associated with uncontrollably increased intracranial pressure.

Models of 1-month-old infants with various neck and skull parameters were instrumented with
accelerometers and shaken and impacted against padded or unpadded surfaces. Angular accelerations for
shakes were smaller than those for impacts by a factor of 50. All shakes fell below injury thresholds established
for subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural
hematoma, and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed
as shaking injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to
cause the shaken baby syndrome.

Keywords
shaken baby syndrome, head injury, child abuse

Disciplines
Biomedical Engineering and Bioengineering | Engineering | Social Work

Author(s)
Ann-Christine Duhaime, Thomas A. Gennarelli, Lawrence E. Thibault, Derek A. Bruce, Susan S. Margulies,
and Randall Wiser

This journal article is available at ScholarlyCommons: http://repository.upenn.edu/be_papers/210

 J Neurosurg 66:409-415, 1987

The shaken baby syndrome

A clinical, pathological, and biomechanical study

ANN-CHRISTINE DUHAIME, M.D., THOMAS A. GENNARELLI, M.D.,

LAWRENCE E. THIBAULT, Sc.D., DEREK A. BRUCE, M . D . ,
SUSAN S. MARGULIES, M.S.E., AND RANDALL WISER, M.S.E.
Division of Neurosurgery and Department of Bioengineering, University of Pennsylvania, Philadelphia,
Pennsylvania

v- Because a history of shaking is often lacking in the so-called "shaken baby syndrome," diagnosis is usually
based on a constellation of clinical and radiographic findings. Forty-eight cases of infants and young children
with this diagnosis seen between 1978 and 1985 at the Children's Hospital of Philadelphia were reviewed. All
patients had a presenting history thought to be suspicious for child abuse, and either retinal hemorrhages with
subdural or subarachnoid hemorrhages or a computerized tomography scan showing subdural or subarachnoid
hemorrhages with interhemispheric blood. The physical examination and presence of associated trauma were
analyzed; autopsy findings for the 13 fatalities were reviewed. All fatal cases had signs of blunt impact to the
head, although in more than half of them these findings were noted only at autopsy. All deaths were associated
with uncontrollably increased intracranial pressure.
Models of 1-month-old infants with various neck and skull parameters were instrumented with accelerom-
eters and shaken and impacted against padded or unpadded surfaces. Angular accelerations for shakes were
smaller than those for impacts by a factor of 50. All shakes fell below injury thresholds established for
subhuman primates scaled for the same brain mass, while impacts spanned concussion, subdural hematoma,
and diffuse axonal injury ranges. It was concluded that severe head injuries commonly diagnosed as shaking
injuries require impact to occur and that shaking alone in an otherwise normal baby is unlikely to cause the
shaken baby syndrome.

KEY WORDS 9 shaken baby syndrome 9 head injury 9 child abuse

T
HE term "whiplash shaken baby syndrome" was particularly in the posterior interhemispheric fissure. ~7
coined by Galley 3 to describe a clinicopatho- Because of the ambiguous circumstances of such in-
logical entity occurring in infants characterized juries, medicolegal questions are particularly trouble-
by retinal hemorrhages, subdural and/or subarachnoid some, and the neurosurgeon is often consulted to give
hemorrhages, and minimal or absent signs of external an opinion as to whether the findings are consistent
trauma. Because a nursemaid admitted that she had with child abuse or accidental injury.
held several such children by the arms or trunk and This paper reviews all cases o f the shaken baby
shaken them, the mechanism of injury was presumed syndrome seen at the Children's Hospital of Philadel-
to be a whiplash-type motion of the head, resulting in phia (CHOP) between January, 1978, and March, 1985.
tearing of the bridging veins. Such an injury was be- To better study the mechanism o f injury, autopsy re-
lieved to be frequently associated with fatalities in in- sults in all fatal cases were reviewed, and the biome-
fantile child abuse and has been postulated as a cause chanics of this injury were studied in a series of infant
of developmental delay in survivors. 4'~5 models. Based on these observations, we believe that
While the term "shaken baby syndrome" has become shaking alone does not produce the shaken baby syn-
wetl entrenched in the literature of child abuse, it is drome.
characteristic of the syndrome that a history of shak- Clinical S t u d i e s
ing in such cases is usually lacking. ~2 Shaking is often
assumed, therefore, on the basis of a constellation of Clinical Material and Methods
clinical findings and on the computerized tomography All reports submitted to the Suspected Child Abuse
(CT) picture of subarachnoid and subdural hematomas, and Neglect team were reviewed. Since house officers

J. Neurosurg. / Volume 66/March, 1987 409

 A. C. Duhaime, et al.
TABLE 1 TABLE 2
Initial clinical criteria for diagnosis of shaken baby syndrome Best history in 48 cases of shaken baby syndrome

Cases No. of Cases

Diagnosis* No. Percent Deaths Etiology
No. Percent
retinal hemorrhage + SAH or SDH 29 60 5 shaking only I 2
retinal hemorrhage + SAH & SDH 10 21 5 fall or accidental blunt trauma 15 31
bilateral chronic SDH 3 6 0 strike or fall plus shaking 10 21
SAH &/or SDH & interhemispheric 6 13 3 strike only 3 6
blood on CT trauma or shaking denied, caretakers 8 17
total 48 100 13 in attendance
history unknown, caretakers not in 10 21
* SAH = subarachnoid hemorrhage; SDH = subdural hemorrhage;
attendance
CT = computerized tomography. cardiopulmonary resuscitation 1 2

and emergency room personnel are well trained in

recognizing the clinical manifestations associated with TABLE 3
this syndrome, it is considered that essentially all cases Trauma associated with shaken baby syndrome in 48 cases
seen at C H O P are reported to this group.
Suspicion of shaking was based on history, clinical Cases
Associated Trauma
findings, and CT data. All subjects met the following No. Percent
criteria: presence o f retinal hemorrhages with subdural no evidence of blunt impact to head 18 37.5
and/or subarachnoid hemorrhages, bilateral chronic no extracranial trauma 12 25.0
subdural hematomas, or a CT scan showing subdural additional extracranial trauma 6 12.5
or subarachnoid hemorrhages with interhemispheric acute 3 6.25
blood. In addition, all patients were judged to have his- old trauma only 3 6.25
evidence of blunt impact to head 30 62.5
tories suggestive of child abuse or neglect; well-docu- skull fractures 12 25.0
mented, witnessed accidental trauma was excluded. cranial soft-tissue contusions 18 37.5
Histories were obtained from several interviews with additional extracranial trauma 18 37.5
caretakers by physicians, social workers, and in some acute 15 31.25
old trauma only 3 6.25
cases law enforcement agents. Caretakers were routine-
ly asked specifically about shaking.
Associated trauma data were obtained from physical
examination, skull radiographs, CT scans, and skeletal with a babysitter. There were two cases (4%) with no
surveys. All fatal cases were examined by the Philadel- history to explain the present findings, but both children
phia Medical Examiner, and pathology data were ob- were known to have been abused previously or subse-
tained from that office. quently. One case was associated with cardiopulmonary
resuscitation (2%). In only one case was a history o f
Results shaking alone obtained; this child was reportedly shaken
Fifty-seven patients with suspected shake injury were when she appeared to have difficulty in breathing as-
identified. O f these, detailed clinical information was sociated with a respiratory infection.
available in 48 cases. These patients ranged in age from Associated t r a u m a observed clinically, radiographi-
1 month to 2 years (mean 7.85 months). Thirty-one cally, or at autopsy is listed in Table 3. The presence of
patients were male (65%). There were 13 fatalities scalp contusion, subgaleal or subperiosteal hemorrhage,
(27 %). Initial clinical criteria for diagnosis of the shaken and/or skull fracture was considered evidence of blunt
baby syndrome are listed in Table 1. Thirty-nine pa- impact to the head. Twelve cases (25%) had intracranial
tients (81%) had retinal hemorrhages plus subarachnoid findings associated with the shaken baby syndrome
and/or subdural hemorrhages. The remainder had bi- alone, with no findings of associated blunt trauma to
lateral chronic subdural hematomas (6%) or the above- the head and no extracranial trauma. Six additional
mentioned CT findings without retinal hemorrhages cases (13%) had the syndrome without signs of blunt
(13%). head trauma but did have associated extracranial
The most c o m m o n presenting complaints were leth- trauma. Thirty cases (63 %) had findings of blunt impact
argy, breathing difficulty, irritability, poor feeding, and to the head in addition to the intracranial findings o f
seizures. Best history is listed in Table 2; the most the shaken baby syndrome. O f these, 12 (25%) had
c o m m o n histories were accidental blunt trauma (usu- skull fractures and 18 (38%) had significant cranial soft-
ally a fall) in 15 (31%) and blunt trauma plus shaking tissue contusions. Most of the fractures were in the
in 10 (21%); trauma and shaking were denied in eight occipital or parieto-occipital region.
(17%). In three cases (6%) the child was struck by the Clinical history, physical findings, hospital course,
caretaker. In eight additional cases the history was intracranial pressure (ICP, when measured), and path-
unknown, usually because the child was left alone or ological findings o f the 13 fatalities are listed in Tables

410 J. Neurosurg. / Volume 6 6 / M a r c h , 1987

The shaken baby syndrome
TABLE 4
Clinical and pathological findings in 13 fatal cases of shaken baby syndrome*
Factor Case 1 Case2 Case3 Case4 Case5 Case6 Case7 Case8 Case9 Case 10 Case 11 Case 12 Case 13
age (mos) 24 7 3 22 11 9 8 5 10 13 24 4 19
sex F M M M F F F M F M M M F
history
fall or hit + + + + + + + + + +
shaking + + +
trauma denied
unknown + + +
initial examination
unresponsive + + + + + + + + + + + + +
retinal hemor- + + + + + + + + +
rhages
cranial impact + + + + + +
extracranial + + + + +
trauma
intracranial pressure 1`1` NM 1`]` 1"1" 1"1" NM 1"1" NM 1"]' NM 1"1" 1"]' 1"1"
survival time (days) 2 2 7 2 3 2 2 1 1 1 4 1 1
pathology
cranial contusions + + + + + + + + + + + + +
skull fracture(s) ++ ++ ++ + +
subdural hema- + + + + + + + + + + + + +
toma
subarachnoid + + + + + + + + + + + + +
hemorrhage
hemispheric con- + + + + + +
tusions
white matter tears + + + +
diffuse brain swell- + + + + + + + + + + + + +
ing
* ~']"= increased; NM = not measured; + = factor present; ++ = severe.

4 a n d 5. M e a n age in this g r o u p was 12.23 m o n t h s ; a c c e l e r o m e t e r to m e a s u r e t h e results o f shaking or

54% were male. All o f these children arrived at the i m p a c t m a n i p u l a t i o n s . Since the m e c h a n i c a l properties
hospital in an essentially u n r e s p o n s i v e state, a n d all o f the i n f a n t neck h a v e n o t b e e n studied, t h r e e m o d e l s
died from the effects o f u n c o n t r o l l a b l y increased ICP were b u i l t with different n e c k structures in o r d e r to
associated with m a s s i v e b r a i n swelling. In only one case i n c l u d e t h e range o f l i m i t i n g c o n d i t i o n s t h a t m i g h t exist
was a subdural h e m a t o m a t h o u g h t to be o f significant in t h e live infant. B o t h a fixed c e n t e r o f r o t a t i o n with
size to w a r r a n t surgical i n t e r v e n t i o n , a n d drainage was zero resistance (hinge m o d e l ) a n d m o v i n g centers o f
ineffective in c o n t r o l l i n g e l e v a t e d ICP. r o t a t i o n with low a n d m o d e r a t e resistance ( r u b b e r n e c k
Pathological e x a m i n a t i o n s h o w e d that all o f the chil- m o d e l s ) were tested.
dren w h o died h a d e v i d e n c e o f b l u n t head trauma.
Eight had soft-tissue c o n t u s i o n s a n d five had contusions Experimental Methods
a n d skull fractures. In s e v e n cases, however, i m p a c t T h e h e a d s a n d bodies o f t h e m o d e l s were a d a p t e d
findings were n o t e d o n l y at autopsy, a n d had n o t been f r o m J u s t B o r n dolls. H e a d c i r c u m f e r e n c e was 36 c m ,
a p p a r e n t p r i o r to death. All fatal cases had subdural c o r o n a l w i d t h was l 0 c m , a n t e r o p o s t e r i o r d i a m e t e r was
a n d s u b a r a c h n o i d bleeding. F o c a l cerebral contusions 10.75 c m , a n d height f r o m v e r t e x to base (calculated
a n d lacerations o c c u r r e d in six. M i c r o s c o p i c e x a m i n a - f r o m a line d r a w n f r o m c h i n to c a u d a l o c c i p u t ) was 9.0
tion was p e r f o r m e d in t h r e e cases a n d showed corpus c m ; values were c o m p a r a b l e to h u m a n infants. B r a i n
callosum h e m o r r h a g e s , c o r t i c a l l a m i n a r necrosis, or w e i g h t for an i n f a n t o f this size was a s s u m e d to be 500
white m a t t e r h e m o r r h a g e s . All c h i l d r e n had diffuse a n d gm. ~ T h e ideal weight o f t h e h e a d was e s t i m a t e d by
usually massive b r a i n swelling. b a l a n c e - w e i g h t m e a s u r e m e n t s o f several infants with
an a v e r a g e age o f l m o n t h , a n d was 770 to 870 gm.
Biomechanical Studies
T h e h e a d s o f the m o d e l s were tightly filled w i t h c o t t o n ,
with w a t e r a d d e d until the desired w e i g h t range was
Whole Infant M o d e l s reached. T h e w a t e r was a b s o r b e d b y t h e c o t t o n a n d
T o test the h y p o t h e s i s t h a t infants are particularly d i s t r i b u t e d so that n o sloshing o f t h e c o n t e n t s occurred.
susceptible to i n j u r y f r o m s h a k i n g because o f a rela- T h e h e a d s were r e w e i g h e d after n e c k i n s e r t i o n a n d
tively large h e a d a n d w e a k neck, we c o n s t r u c t e d m o d e l s sealing a n d at the e n d o f all e x p e r i m e n t s .
o f l - m o n t h - o l d i n f a n t s t h a t were i m p l a n t e d with an N e c k length f r o m t h e skull base to the T-1 v e r t e b r a

J. Neurosurg. / Volume 6 6 / M a r c h , 1987 411

 A. C. Duhaime, et al.

TABLE 5 TABLE 6
Summary offindings in 13fatal cases of shaken baby Mean acceleration and time course of shakes and impacts in
syndrome all models

Factor Finding Peak Tangen- Time Angular Angular

Manipu- No. tial Accelera- Velocity Acceleration
age (mos) lation tion (G) (msec) (radians/sec) (radians/sec 2)
mean 12.23
range 3-24 shakes 69 9.29 106.6 60.68 1138.54
sex M/F 7/6 impacts 60 428.18 20.9 548.63 52,475.70
history
fall or hit (three with shaking) 10
unknown 3
initial examination
unresponsive 13 TABLE 7
retinal hemorrhages 9
cranial impact 6 Effects of neck condition and "skull" on mean peak tangential
extracranial trauma 5 acceleration and time course of shakes and impacts
intracranial pressure
measured, unable to control Shakes Impacts
not measured 4 Variant Acceleration Time Acceleration Time
survival time (days) (G) (msec) (G) (msec)
range 1-7
mean 2.2 hinge neck 13.85 92.7 423.42 18.6
pathology flexible rubber neck 5.70 93.3 427.78 21.4
cranial contusions 13 stiff rubber neck 7.02 130.5 433.33 22.8
skull fractures(s) 5 skull 9.86 107.4 436.12 20.2
subdural hematomas (one 13 no skull 8.89 103.5 427.04 21.6
requiring surgery)
subarachnoid hemorrhage 13
unilateral 3
diffuse 3
multifocal 7 TABLE 8
hemispheric contusions 6 Effect of impact surface on mean peak tangential acceleration
diffuse, multiple 3 and time course
focal, coup-contrecoup 3
white matter tears 4 Surface of Acceleration Time
gross 2 Impact (G) (msec)
microscopic 2
diffuse brain swelling ( 11 with 13 padded surface 380.60 24.22
herniation evident) metal bar 489.51 17.13

was m e a s u r e d f r o m lateral neck films o f several n o r m a l did n o t s u p p o r t t h e weight o f the head in the u p r i g h t
infants with a n average age o f 1 m o n t h a n d r a n g e d position b u t d i d n o t k i n k w h e n t h e head was a l l o w e d
f r o m 3.5 to 4.5 cm; all m o d e l s were t h e r e f o r e given to fall u n s u p p o r t e d . M o d e l 3 h a d a 2.9-cm r u b b e r n e c k
n e c k lengths o f 4.0 cm. N e c k s were e m b e d d e d in Cas- with a 1.2-cm l u m e n . T h i s n e c k was able to s u p p o r t the
tolite resin* superiorly, w h i c h was also u s e d to seal the head in the vertical p o s i t i o n b u t allowed full passive
head. T h e i n t e r i o r p a r t o f the n e c k was s e c u r e d in den- m o v e m e n t o f t h e head. In all models, head m o t i o n was
tal s t o n e . t T h e stuffed b o d y was t h e n r e p l a c e d a r o u n d limited in the a n t e r o p o s t e r i o r d i r e c t i o n b y the o c c i p u t
t h e d e n t a l s t o n e " t h o r a x , " with l e a d weights a d d e d as striking the u p p e r b a c k a n d t h e c h i n striking the chest.
necessary to the t h o r a x to reach a t o t a l b o d y weight To test for t h e effect o f the d e f o r m a b i l i t y o f the
o f 3 to 4 kg. A r m s a n d legs were n o t weighted, so the m o d e l heads o n i m p a c t , all m o d e l s were tested with
slightly low t o t a l weight for age reflects a n a t t e m p t to ap- a n d w i t h o u t a n e x t e r n a l " p s e u d o s k u l l " m a d e f r o m ther-
p r o x i m a t e t r u n k : h e a d weight ratios. moplastic.~ T h i s " s k u l l " was 1/8 in. thick a n d was
M o d e l 1 h a d a hinge neck m a d e f r o m a 360 ~ steel m o l d e d to the occipital, parietal, t e m p o r a l , a n d poste-
hinge, 3.6 c m in width, p l a c e d in the h o r i z o n t a l p l a n e rior frontal areas, w i t h the facial area u n c o v e r e d . T h e
to allow c o m p l e t e a n t e r o p o s t e r i o r a n g u l a t i o n o f the "skulls" w e i g h e d 170 to 200 gm.
head. T h e c e n t e r o f r o t a t i o n was 3.3 c m b e l o w the D a t a were r e c o r d e d f r o m a p i e z o e l e c t r i c ' a c c e l e r o m -
e s t i m a t e d level o f the skull base ( a p p r o x i m a t i n g at the eterw e m b e d d e d in a s m a l l piece o f t h e r m o p l a s t i c a n d
C-6 v e r t e b r a l level). M o d e l 2 h a d a 1.9-cm d i a m e t e r a t t a c h e d to t h e v e r t e x in a c o r o n a l plane t h r o u g h t h e
h o l l o w r u b b e r n e c k with a 0 . 8 - c m l u m e n . T h i s neck
:~ Polyform thermoplastic manufactured by Rolyan Medi-
* Resin manufactured by Buehler Ltd., Evanston, Illinois. cal Products, Menomonee Falls, Wisconsin.
t Dental stone, Glastone Type IV, manufactured by Ran- w manufactured by Endevco Corp., San
som and Randolph Co., Toledo, Ohio Juan Capistrano, California.

412 J. Neurosurg. / Volume 6 6 / M a r c h , 1987

The shaken baby syndrome

00.000

E
80,000

~" 70.000
I 500 msec I a ~ a

00,000
0

~ 50,000

DAI
40,000

A
SDH
20 msec ~ 30,000
t I
Z
FIG. 1. Representative tangential acceleration traces for ~= IMPACT
infant models undergoing shake (upper) and impact (lower) 20,000 O= SHAKE
manipulations. While manipulations of the infant models
were performed as described, with a series of shakes followed lO.000
CONCUSSION
by an impact, the magnitude of the impact accelerations was
so much greater than that associated with the shakes that
different scales are used to display the respective acceleration 100 200 300 400 500 600 700 800 900 1,000
traces. ANGULAR V E L O C I T Y (tad/see)

FIG. 2. Angular acceleration versus angular velocity for

center of the neck. Each model was subjected to repet- shakes and impacts, with injury thresholds from primate
itive violent shaking, allowing the head to travel its full experiments scaled to 500-gin brain weight. DAI = diffuse
axonal injury; SDH = subdural hematoma.
excursion several times, by adult male and female ex-
perimenters. The models were held by the thorax facing
the experimenter and were shaken in the anteropos- for shakes was 106.6 msec and for impacts was 20.9
terior plane, since this is the motion most commonly msec. This difference is significan t at the p = 0.001
described in the shaken b a b y syndrome. At the end of level.
each series of shakes the occiput was impacted against Effects o f Neck Condition. Mean tangential accel-
either a metal bar or a padded surface. Each model was erations and time courses for shakes and impacts for
tested at least 20 times. Acceleration traces were ampli- each neck condition are presented in Table 7. There is
fied and recorded. II no significant difference between the hinge neck, the
Angular accelerations were calculated from the meas- flexible rubber neck, and the stiff rubber neck in the
ured peak tangential accelerations by using C-6 as the mean acceleration resulting from impacts (423.4, 427.8,
center of rotation in all cases. Angular velocity was and 433.3 G, respectively) or in the mean time course
calculated as the time integral o f the acceleration curve. (18.6, 21.4, and 22.8 msec, respectively). With shakes,
Translational forces were assumed to be minimal. the m o r e flexible hinge neck is associated with higher
Results accelerations (mean 13.85 G) than the two rubber neck
models (mean 5.7 and 7.0 G) (p < 0.001). There is an
The data were collected from 69 shaking episodes inverse relationship between neck stiffness and time
("shakes") and 60 "impacts." Typical tangential accel- duration of a shake: the stiff rubber neck was associated
eration traces for shake and impact manipulations are with a longer time course than the m o r e flexible rubber
shown in Fig. 1. The criterion for significant difference neck (130.5 msec and 93.3 msec, respectively) (p <
was p < 0.01 in all cases. 0.001 ).
Shakes Versus Impacts. Angular acceleration and Effects of "Skull. " The presence of a hard thermo-
angular velocity for each shake and impact are shown plastic "skull" did not change the magnitude or time
in Fig. 2. Mean peak tangential acceleration for 69 course o f accelerations associated with shaking of the
shaking episodes was 9.29 G; m e a n peak tangential models. The acceleration magnitude and time course
acceleration for 60 impacts was 428.18 G (Table 6). were also unchanged when the models were impacted.
The accelerations due to impact are significantly greater These data are shown in Table 7.
than those obtained by shaking (p < 0.0001); on the
average, impact accelerations exceed shake accelera- Effects o f Impact Surface. I m p a c t against a padded
tions by a factor of nearly 50 times. Mean time interval surface was associated with significantly smaller accel-
eration (mean 380.6 G) and longer time course (mean
24.22 msec) than that against a metal bar (mean 489.5
II Shock amplifier, Model 2740 A, and pulse memory unit,
Model 2743, manufactured by Endevco Corp., San Juan G and 17.13 msec) (p < 0.001). Data are shown in
Capistrano, California. Table 8.

J. Neurosurg. / Volume 66/March, 1987 413

 A. C. Duhaime, e t al.

Discussion the values for impacts span concussion, subdural, and

Clinical head injury can be classified into two major diffuse axonal injury ranges (Fig. 2). This was true for
categories according to the distribution o f pathological all neck conditions with and without skulls. A padded
damage, whether focal or diffuse. '~ Such a distinction surface decreases the magnitude of acceleration and
is important for treatment and prognosis, as well as for lengthens the time course to some extent, but these
establishing the biomechanical conditions necessary to impacts also fall in the injury range.
produce a given injury type. It has been established These results are consistent with the observation that
both experimentally and clinically that most focal in- the fatal cases o f the shaken baby syndrome in this
juries are associated with impact loading, resulting in series were all associated with evidence of blunt impact
contact phenomena, while diffuse injuries are associ- to the head. This preponderance of blunt t r a u m a has
ated with impulsive loading conditions resulting from also been found in at least one other series of nonacci-
acceleration-deceleration phenomena. 6 Damage to the dental head t r a u m a in childhood in which the mecha-
brain occurs as a result of these biomechanical forces nism of injury was investigated. 9 It is of interest that in
and from the secondary effects o f ischemia due to more than half o f our fatal cases, no evidence of
altered autoregulation or brain swelling. external t r a u m a was noted on the initial physical ex-
The shaken baby syndrome has been postulated to amination, which helped to contribute to the diagnosis
result from the effects of nonimpact acceleration-decel- of "shaken b a b y syndrome." Skull fractures and scalp
eration forces. It has been suggested that the back and contusions were found at autopsy, however, most often
forth m o v e m e n t of the head alone is sufficient to cause in the occipital or parieto-occipital region. In addition,
tearing o f bridging veins, resultant subdural hemato- several babies had parenchymal lesions in a distribution
mas, and death. 8,13The relatively large size of an infant's consistent with diffuse axonal injury, t~
head, weakness of the neck musculature, softness of While some reports on the shaken baby syndrome
the skull, relatively large subarachnoid space, and high mention brain swelling, in most reports the subdural
water content o f the brain have been postulated to collections themselves have been postulated as the cause
contribute to the susceptibility of shaking injuries in of death. In this series, all fatalities were consequent
infants. 4,14 to uncontrollable brain swelling, and it is clear that
While shaking alone has been considered sufficient drainage of the small collections present would have
to cause a fatal injury, the usual lack of history of the been useless in controlling the ICP. The problem of
true mechanism of injury in these cases has hampered acute brain swelling is particularly c o m m o n in the pe-
accurate clinicopathological correlations. It is of inter- diatric population, and its cause is poorly understood. 2
est, however, that in a recent series of fatal cases of Whether high accelerations in the anteroposterior direc-
infantile head injuries from suspected child abuse, 5 tion have some particular association to this complica-
white matter tears were found similar to those described tion remains to be investigated.
by Lindenberg and Freytag ~ in blunt t r a u m a in infancy. It is our conclusion that the shaken baby syndrome,
In addition, lesions in the distribution typical of diffuse at least in its m o s t severe acute form, is not usually
axonal injury, like those found in adult head injury and caused by shaking alone. Although shaking may, in
in s u b h u m a n primates subjected to high acceleration- fact, be a part o f the process, it is more likely that such
deceleration injury, 7 were described in some cases. In infants suffer blunt impact. The most c o m m o n scenario
fact, at least one of Caffey's original cases 3 included may be a child who is shaken, then thrown into or
"lacerations of the cerebral p a r e n c h y m a . " Shaking against a crib or other surface, striking the back o f the
alone was the presumed mechanism o f these injuries. head and thus undergoing a large, brief deceleration.
As experience has accumulated in experimental an- This child then has both types of injury - - impact with
gular acceleration injury it has b e c o m e clear that, be- its resulting focal damage, and severe acceleration-de-
sides the magnitude of the acceleration, another impor- celeration effects associated with impact causing shear-
tant biomechanical factor influencing injury type is the ing forces on the vessels and parenchyma. Unless a
time interval over which the acceleration occurs. Thus, child has predisposing factors such as subdural hygro-
large angular accelerations occurring over shorter time mas, brain atrophy, or collagen-vascular disease, fatal
periods tend to result in subdural h e m a t o m a , while cases of the shaken baby syndrome are not likely to
longer intervals are associated with diffuse axonal in- occur from the shaking that occurs during play, feeding,
jury. 6 A tolerance scale relating these two factors to or in a swing, or even from the more vigorous shaking
resultant injury has been developed for the s u b h u m a n given by a caretaker as a means of discipline.
primate by Thibault and Gennarelli. ~6 Values above
certain critical limits result in a particular type of injury
such as concussion, subdural h e m a t o m a , or diffuse Acknowledgments
axonal injury. When such a curve is scaled for the brain The authors are grateful to Lucy Rorkc, M.D., Giustino
mass of an infant the size of our models, it can be seen Tomei, M.D., Karen Hess, M.S.E., Toni Siedl, M.S.W., and
that the angular acceleration and velocity associated Thomas Langfitt, M.D., for advice and assistance with this
with shaking occurs well below the injury range, while project.

414 J. Neurosurg. / Volume 66/March, 1987

The shaken baby syndrome
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