Retinal hemorrhages due to intracranial hypertension, is it possible to differentiate them from those associated with abuse?

Retinal hemorrhages (RHs) are suggestive of abusive head trauma (AHT). Even so, controversy persists about other possible causes, a fact that hinders the diagnosis of abuse. To determine the prevalence and patterns of RHs associated with increased intracranial pressure (ICP) in young children. Prospective, single center study of children aged 29 days-3 years undergoing a lumbar puncture with opening pressure (OP) measured during routine clinical care in the emergency department, over a 4-year period. Children with known causes of RHs were excluded. All the children underwent a detailed ophthalmological examination within 72 h of admission. For children with RHs, an in-depth investigation was carried out to rule out AHT. Thirty-four patients were included: 20(58.8 %) were boys, median age 11.7 months (range 1-33 months). Overall, 29(85.3 %) had clinical findings of increased ICP. The duration of symptoms was ≤4 days in all patients except one, in whom it was 1.5 months. The median OP was 27cmH2O (range 20-60cmH2O). One of the children was found to have RHs, with evaluation resulting in a diagnosis of AHT. No RHs were found in any of the others studied. Using the Wilson method, we can be confident to an upper limit of 95 % that the probability of RHs occurring secondary to increased ICP alone is at most 0.1. RHs were not detected in patients with isolated nontraumatic increased ICP, measured via OP and diagnosed in the ED. Therefore, if RHs are detected, investigation into the possibility of AHT is warranted. •What is known? There is controversy whether an isolated increase of intracranial pressure produces retinal hemorrhages in healthy infants•What this study adds? Acute increased intracranial pressure is rarely associated with retinal hemorrhages being mandatory to rule out maltreatment.