The optic nerve sheath hemorrhage is a non-specific finding in cases of suspected child abuse

• Triad and ONSH are non-specific and not pathognomonic for abusive head trauma.
• Both have a traumatic and non-traumatic etiologies.
• The spectrum of natural causes of the triad is vast, but limited for ONSH.
• The forensic significance of ONSH is its limited differential diagnosis.
• Removal of eyes is biased towards suspicious head trauma cases.

In young infants, the triad consisting of acute encephalopathy, retinal hemorrhages, and a subdural hematoma is a nonspecific finding. It has traumatic and non-traumatic etiologies. The triad may be found among a vast spectrum of natural diseases. Optic nerve sheath hemorrhage in infants is typically detected at autopsy. It is a nonspecific finding that can be found in traumatic and non-traumatic etiologies. Neither the triad nor the ONSH are pathognomonic for an abusive head injury. Opposite to the triad, the spectrum of non-traumatic etiologies of ONSH is limited. In infants ONSH rarely occurs in spontaneous subarachnoidal hemorrhage or in infectious conditions. Our results show that the clinical significance of the optic nerve sheath hemorrhage in the forensic work-up of fatal cases of alleged abusive head injury is its limited differential diagnosis. Only after careful differential diagnosis ONSH may contribute to the diagnosis of AHT. However, the main limitation of our study is the sampling bias, as the eyes are usually removed when abusive head trauma is suspected.