Diagnostic and Prognostic Value of Retinal and Intracranial Hemorrhages in Abusive Head Trauma: A Retrospective Study

Purpose: To evaluate the prevalence, patterns, and associations of retinal hemorrhages (RH) and intracranial hemorrhages (ICH) in confirmed abusive head trauma (AHT) cases, with attention to instances in which RH is identified without radiographic evidence of ICH. Methods: The authors retrospectively reviewed 137 confirmed AHT cases in children younger than 36 months treated between 2017 and 2023. Data included demographics, imaging results, skeletal surveys, and ophthalmologic examinations. Logistic regression analyses were used to identify predictors of RH and assess associations with ICH and clinical outcomes. Results: ICH was present in 87.6% of cases, most commonly subdural hemorrhage (76.6%). RH was identified in 63.5% of cases, including 3 (3/137, 2.2%) without visible ICH on computed tomography, all of which demonstrated marked cerebral edema that may have obscured underlying hemorrhage. Subdural hemorrhage (odds ratio [OR]: 4.90, 95% CI: 1.83 to 13.16, P = .001) and subarachnoid hemorrhage (OR: 3.73, 95% CI: 1.32 to 10.52, P = .011) were independent predictors of RH, whereas abnormal skeletal survey (OR: 0.33, 95% CI: 0.14 to 0.77, P = .010) and mention of injuries in the chief complaint (OR: 0.31, 95% CI: 0.12 to 0.79, P = .014) were inversely associated. RH was significantly more likely in children older than 4 months (OR: 3.85, 95% CI: 1.50 to 9.87, P = .005) and was associated with increased mortality (26.4% vs 4.0%, P < .001). Conclusions: RH may occur in rare AHT cases without visible ICH, potentially due to masking by cerebral edema, supporting their continued role in clinical evaluation. The inverse association between RH and skeletal trauma suggests differing injury mechanisms, warranting further investigation.