Dokkyo Journal of Medical Sciences
36（2）：99 〜 102，200999

Case ReportThree Cases of Shaken Baby Syndrome without
a History of Shaking1）

2）

3）

4）

George Imataka , Shigeko Kuwashima , Kouji Wake , Keizo Chiba ,Hideo Yamanouchi 1）, Osamu Arisaka1）

Department of 1） Pediatrics, 2）Radiology, 3）Critical care ＆ medicine and 4）Ophthalmology,
Dokkyo Medical University School of Medicine

SUMMARY
Three cases of Shaken Baby Syndrome（SBS）without a history of abusive shaking have been reported.
The reason why SBS without intentional shaking as follows；case 1was throwing, case 2 was dropping, case
3 was unknown. For all 3 reported cases, attending physicians suspected the SBS from the presence of subdural hematoma and fundus hemorrhage. All 3 cases occurred at home, and the parents had no knowledgeof SBS. After a detailed interview, the diagnosis of SBS without a history of intentional shaking was made.
Although the mechanism in detail was unclear in 3 cases, these SBS may happen by the difference between
acceleration and the deceleration during the throwing and dropping movement；similar to intentional shaking that causes of common SBS.
For subdural hematoma and fundus hemorrhage of unknown cause, it is important to conduct an interview with the possibility of unintentional SBS in mind, without the occurrence of abusive shaking. In addition, attention should be paid to both pediatrician and parents about the risk of SBS in the care of infant in
the everyday life.
Key Words： shaken baby syndrome, magnetic resonance imaging, abusenosis of SBS should be made carefully 5）, whether in-INTRODUCTION

tentional abuse is present or not. We herein report 3

Shaken baby syndrome was first reported byCaffey1, 2）

cases of SBS without a history of intentional shaking.

in 1974 regarding intracranial hemorrhage

CASE REPORT

and fundal hemorrhage that developed after shaking
the head of an infant. Since its symptoms comprise theCase 1：

characteristics of a head injury due to abuse, it is clas-

The patient was 5-month-old boy. The chief com-sified as a battered child syndrome

3, 4）. SBS is diag-

plaints included spasm and respiratory problems. Ac-

nosed when the head is strongly shaken in early infan-

cording to an interview, his father repeated the action

cy, concurrently causing a subdural hematoma andof throwing the child up to approximately 50 cm over-fundal hemorrhage. Uncommonly, however, SBS hap-head several times, intending to soothe him to sleep.

pens without intentional shaking. Therefore, the diag-

There was no fact of a head shaking. Fifteen minutes
later, the boy was transported to the hospital due to a

Received March 24, 2009；accepted May 21, 2009
Reprint requests to：George Imataka MD
Dokkyo Medical University School ofMedicine, Mibu, Tochigi 321 − 0293 Japan.

spasm status and was put under artificial respiration
management. Both eyegrounds showed preretinal fundal hemorrhage（Fig. 1A）. A head CT（Figs, 1B, 1C）
showed a subdural hematoma along the cerebral falx.

100George ImatakaFig. 1DJMS

A：A fundal hemorrhage was observed on admission using a magnifier lens. B, C：In thebrain CT performed on admission, a region of high absorbance was observed along thecerebral falx, resulting in the diagnosis of subdural bleeding. D, E：In both theT1-weighted image（D）and T2-weighted image（E）of the brain MRI performed on Day
17 of hospitalization, crescentic regions exhibiting high signals were observed beneath thedura mater on both sides.

The diagnosis of SBS was made based on the presenceof the upper limbs. Three months after the onset, theof fundal hemorrhage and subdural hematoma. On thesubdural hematoma remained on MRI（Figs. 2D, 2E）.

forth day, the examination of the spinal fluid showed

Four months after the onset, the patient was on a re-xanthochromia. An MRI on the seventeenth day

habilitation program for spasticity of the limbs.

showed subacute subdural hematoma（Figs. 1D, 1E）.
Artificial respiration was required for 12 days. Six

Case 3：

years after the onset, the patient’s IQ was 75 and he is

The patient was a 2-month-old boy. The chief com-in a handicapped school for the intellectual disability.

plaints included respiratory problems, ocular deviation,

Intense amblyopia was detected, and epilepsy was con-and partial spasm of the limbs. No evidence of shaking

trolled by anticonvulsants.

was obtained in the interview of the parent. Fundal
hemorrhage was detected in both eyes. Brain CT re-Case 2：

vealed a subdural hematoma along the cerebral falx

Case 2 is that of a 2-month-old boy. His fatherand extensive cerebral edema in the area of left occipi-

dropped the child from a height of approximately 1 mtal region（Figs. 3B, 3C）. As partial spasm progressed,

onto a mattress and there was no evidence of headthe child was admitted to the ICU, where head coolingshaking. After ten minutes, respiration became irregu-and steroid pulse therapy was implemented. Twolar, and the boy was taken to the hospital via emer-

months after the onset, a brain MRI showed subdural

gency transport. On admission, an examination of thehematoma and cerebral atrophy in the right frontotem-

fundus revealed extensive preretinal hemorrhage ac-poral area. The opposite side showed severe cystic en-companying soft exudates. A skull X-ray showed nocephalomalacia（Figs. 3D, 3E）. At 3 months after thefracture and brain CT（Figs. 2B. 2C）demonstrated

onset, oral feeding became possible, however, the dis-

subdural hemorrhage along the cerebral falx and cere-

turbance of the visual field and visual impairment re-bral edema. On the second day after admission, mida-mained unchanged. The patient was put on a rehabili-

zolam was administered via continuous intravenous in-tation program for spastic quadriplegia.

fusion in order to control prolonged partial convulsions

36（2）（2009）

Three Cases of Shaken Baby Syndrome without a History of Shaking

Fig. 2

A：In the fundus examination performed on fourth day from admission, diffuse preretinal
bleeding with soft exudates was observed. B, C：Brain CT showed images of subdural
hemorrhage along the cerebral falx and cerebral edema. D, E：In the T1-weighted image（D）and T2-weighted image（E）of the brain MRI performed at 3 months after onset, thesubdural hematoma remained in the right anterior temporal area.

Fig. 3

A：In the fundus examination performed on seventh day from admission, diffuse
preretinal bleeding was observed. B, C：Brain CT on admission, revealed a subdural
hematoma along the cerebral falx and extensive cerebral edema on the area of left
occipital region. D, E：At 2 months after the onset, a head MRI T1-weighted image（D）
and T2-weighted image（E）showed images of subdural hematoma and cerebral atrophyin the right front temporal area. The left side showed a finding of severe multiple cystic
encephalomalacia.

DISCUSSION
The diagnosis of SBS is not difficult when awareness101of the shaking of an infant has occured, intractable
hemorrhage on CT or MRI, and fundus hemorrhage.
Physicians who are aware of SBS would not miss this102

George Imataka

when hearing evidence of shaking from parents during
an interview4〜10）DJMSScience and Technology （MEXT） KAKENHI No.

. However, it has been reported that

18790733 Graint-in-Aid for Young Scientists（B）andevidence of obvious shaking is not apparent in somethe Dokkyo Medical University, Investigator-Intiated5）

cases of SBS . In this report, there was no evidence ofResearch Grant（No. 2010-01-6）.

intentional shaking by the parents in any of the 3 cas-REFERENCES

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Acknowledgement.

This study was partially sup-ported by the Ministry of Education, Culture, Sports,

431, 1971.