False Assumption #4:
All Subdural Hematomas will be immediately symptomatic, so whoever is holding the baby when he or she arrests, must have caused the subdural.

Truth:
Medical literature and case studies have documented numerous instances of asymptomatic subdurals in fatal childhood head injury cases. Our data indicates that nearly 75% of fatal childhood head injury cases have asymptomatic subdural hematomas. This issue is undisputed in adults.

There is little controversy in the field of head injuries as to whether it is possible for an adult to suffer an impact to the head and appear relatively normal until some time later when the individual collapses and dies. The undefined period of time between impact and loss of consciousness or death, when consciousness seems to be relatively unaffected, is referred to as a "lucid interval." The phenomenon has been described by several different names in different bodies of literature, but it is generally agreed to occur. Doctors specializing in sports medicine have coined the term "Second Impact Syndrome" to describe athletes who incur a blow to the head and suffer little to no alteration in consciousness, until hours or days later when the individual unexpectedly lapses into unconsciousness or death (1). Pediatricians use the term "Talk and deteriorate or Die" or TADD to describe the lucid intervals in individuals with epidural hematomas (2). It is the very reason we keep people under 24-hour observation when they have suffered a major head injury and why parents are told to wake up their children periodically after such an event. Apparently the only controversy that exists is whether the phenomena can occur in babies with subdural hematomas. The state's experts argue that lucid intervals do not occur in children because children are somehow different than adults. This contention is not only unsupported by any evidence or explanation, it is refuted by both logic and the published medical literature in the field (3).

Recent studies have shown that lucid intervals are fairly common with subdural hematomas. In John Plunkett's 2001 study of short falls from playground equipment, 12 of the 18 children had lucid intervals with lengths ranging from 5 minutes to 48 hours. It has also long been recognized that intracranial injuries can go undiagnosed, or may be misdiagnosed, as something benign, only to result in complications later (4,5,6). Several studies have recently disproved the theory that decomposition begins immediately after a SDH is formed (7,8,9).

Even the trial testimony of leading prosecution witnesses support the existence of a lucid interval after a subdural hematoma. Prosecution witness Randall Alexander has testified that subdural hematomas can often be mistaken for gastroenteritis or other minor childhood ailments (10), and that as many as 50% of the SBS cases have evidence of an old subdural hematoma. We know from the cases themselves that many of these children have been seen by doctors or have been cared for by parents who are physicians or nurses, and yet the child's subdural went undetected. It is here again that we must put logic and science up against a well meaning theory. If 50% of these cases have a previously undetected subdural hematoma, then obviously children can and do have lucid intervals after incurring a subdural.

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Citations

1. Kelly, J Sports Related Recurrent Brain Injuries: Second Impact Theory 2000;46 (10) 224-227.

2. Trial Testimony, People v. John Stevens, Pg 118.

3. Ron Usinski Shaken Baby Syndrome: Fundamental Question. British Journal of Neurosurgery 2002; 16(3): 217-219.

4. Jenny, C,. Hymel, K.P., Ritzen, A., Reinert, S.E. and Hay, T.C. Analysis of missed cases of abusive head trauma. JAMA 1999; 281(7):621-626.

5. Greenes, D. Schultzman, S.A. Occult intracranial injury in infants. Annals of Emergency Medicine 1998; 32(6):680-686.

6. Dacey, R.G., Alves, W., Rimel, R., Winn, R., and Jane, J. Neurosurgical complications after apparently minor head injury. Neurosurgery 1986; 65:203-210.

7. Barnes, Patrick D. Ethical Issues in Imaging Nonaccidental Injury: Child Abuse Topics in Magnetic Resonance Imaging 2002 13(2) 85-94.

8. Nahelsky, M. and Dix, J. The time interval between lethal infant shaking and onset of symptoms: A review of the Shaken Baby Syndrome Literature. The American Journal of Forensic Medicine and Pathology 1995 ;16(2):154-157.

9. Snoek, W. Delayed deterioration following mild head injury in children. Brain 1984; (107) 15-36.

10. Alexander Randall, Trial Testimony in People v. Weaver Pg 33 lines 17-18.