急性硬膜下血腫を来した被虐待児症候群の3例

Three cases of acute subdural hematoma in abused children

I．はじめに

　1946年アメリカの小児放射線医Caffeyが，小児の長管骨の異常な多発性骨折と硬膜下出血の合併する6例を発表し^2），1962年にKempeがchild abuseによる特殊な外傷をbattered child syndrome（被虐待児症候群）として報告して以来^9），本邦においても数多くの報告がなされている^{1,5,8,10-12）}．この被虐待児症候群においては，皮膚症状，骨折・脱臼，硬膜下出血，精神運動発達の遅滞，腹腔内損傷などの多彩な症状を呈するが，この中でも頭部外傷が予後に与える影響はきわめて大きい．今回われわれは急性硬膜下血腫を形成した被虐待児症候群の3症例を経験したので，その臨床経過を提示し，早期診断と患児・両親に対する早期治療の重要性につき報告する．

We encountered 3 cases of battered children with acute subdural hematoma. In this report, we discuss the difficulties in treating this condition surgically, and we emphasize the importance of early diagnosis and treat-ment of abused children and their parents.

Case 1: A girl, aged 2 months, was brought in by her mother, because the child had become drowsy. The mother stated that the child had been battered by her father. Physical examination revealed tense anterior fontanelle, bruises on her face, consciousness disturb-ance and retinal bleeding. Marked anemia was revealed on laboratory studies. A computed tomographic (CT) scan demonstrated an interhemispheric subdural hema-toma in the parietooccipital region. She was treated conservatively for 2 months. Follow-up CT revealed a bilateral chronic subdural hematoma. Burr hole irriga-tion and drainage on both sides brought about complete disappearance of these lesions.

Case 2: A girl, aged 1 year and 9 months, was brought in by her parents. According to her mother's allegation, the child fell down from the top of an indoor slide and became comatose. Physical examination re-vealed severe malnutrition, loss of consciousness, di-lated pupils and negative light reflex. Numerous areas of subcutaneous bleeding and skin erosions were seen on her back and abdomen. Marked anemia was re-vealed on laboratory studies. CT scan demonstrated a left acute subdural hematoma and massive brain swel-ing. Despite an emergency craniotomy, the child died 5 days later.

Case 3: A 4-year-old boy was admitted in a com-atose state. According to his mother's allegation, he was thrown to the floor from a 1.5m height and struck against a wall by his father. Physical examination re-vealed severe malnutrition, consciousness loss, dilated pupils and negative light reflex. Many scratches and bruises were seen over his whole body, especially on his back. Marked anemia was revealed on laboratory studies. A CT scan demonstrated a left acute subdural hematoma and massive brain swelling. Three days la-ter, he died despite emergency craniotomy.

The incidence of battered children is increasing in Japan, and these cases sometimes involve severe head injuries, such as subdural hematoma. In these cases, successful surgical treatment is difficult after admission to the neurosurgical institute. This may result from late admission as well as marked anemia and malnutrition. Therefore, we conclude that early diagnosis of child abuse and treatment of the abused child and psycholo-gical treatment for their parents are very important.