Prognostic indicators for vision and mortality in shaken baby syndrome

Objective: To study ocular and nonocular signs of patients diagnosed as hav ing "shaken baby syndrome" and determine prognostic indicators for vision a nd mortality. Methods: Medical records of child abuse cases involving bilateral retinal h emorrhages were reviewed. Particular attention was paid to visual function and pupillary light reaction at the time of admission as well as the locati on of retinal hemorrhages, neuroimaging findings, ventilatory requirement, and associated skeletal injuries. These findings were correlated with visua l prognosis and mortality. Results: Thirty consecutive cases met the criteria for review. At the initi al visit, mean age of the children was 9.3 months (range, 1-39 months) and 12 children (40%) had at least fix-and-follow vision. Preretinal and intrar etinal hemorrhages (93% [n=28]and 100% [n=30]) were more common than vitreo us hemorrhage (10% [n = 3]). Subdural hematomas were detected in 21 patient s (70%). Twenty children (67%) had seizures and 16 (53%) required ventilato ry support; bruises and long bone fractures were seen in 14 (47%) and 4 (13 %) children, respectively. Eight patients died. All patients with nonreacti ve pupils on presentation died, while all patients with a pupillary light r eaction lived (P<.001). Six (86%) of 7 patients with midline shift died, wh ereas 21 (91%) of 23 with no midline shift lived (P<.001). At follow-up, re tinal hemorrhages had resolved in nearly all children by 4 months, and 16 c hildren (73%) had at least fix-and-follow vision. Ventilatory requirement w as as sociated with poorer vision (P<.01). Conclusions: Nonreactive pupils and midline shift of the brain structures c orrelate highly with mortality. Ventilatory requirement, but not visual acu ity on presentation, predicts visual outcome.