Infantile Ischemic Occipital Scalp Ulcers May Mimic Impact Sites

The clinical or forensic pathologic evaluation of an infant with an apparently inflicted head injury can be challenging, particularly when objective findings are limited to the classic triad ascribed to “Shaken Baby Syndrome” – subdural and retinal hemorrhages and anoxic brain injury. These three findings together, in the absence of an apparent impact site (scalp or skull injury) have a controversial differential diagnosis. However, the discovery of an impact site of virtually any size is sufficient for some forensic pathologists to make the diagnosis of homicidal (impact) blunt head trauma in babies with limited additional evidence of abuse, or with the classic triad, but without careful consideration of its differential diagnosis. Although relatively uncommon in modern intensive care units, occipital scalp ulcers can and do occur, and may mimic the appearance of a blunt impact site. Two separate cases of infant death are presented to illustrate the nature and appearance of occipital pressure ulcers. Abnormalities of the occipital scalp were not detected in either infant upon hospital admission, but scalp lesions were clearly observed at autopsy. Macroscopically, these lesions closely resembled blunt impact sites. They were determined to be pressure ulcers based predominantly on the histologic findings of epidermal thinning and dermal homogenization, combined with the absence of both hemorrhage and stainable free iron. Further supportive factors were the absence of skull fractures, intracranial hemorrhages, and cerebrocortical contusions.