MILD HEAD INJURY IN PEDIATRIC AGE

GROUP,

AN OVERVIEW OF CURRENT

MANAGEMENT STRATEGIES

NABIL HASSAN M.KHALILEmeritus Professor in Neurosurgery  Department

Faculty of Medicine Suez Canal University ,IsmailiaHonorary president of ESNS

Chief of Egyptian accreditation council for assigning neurosurgery university staffs

EgyptTel.+20663234244, Mobile.+20103732045

Email: nabilkh@hotmail.com

INTRODUCTION

In the spectrum of all patients suffering neurotrauma, children with serious brain

and spinal cord injuries represent a relatively a small portion of the population. However when one considers this problem only within the pediatric age group, these injuries, especially traumatic brain injury,

are now common cause of death and disability.

Differences in the characteristics of traumatic brain injuries between children and adults;

• Expected distribution of injury severity.

• Occurrence and characters of skull fractures.

• Incidence and type of traumatic mass lesions.

• Occurrence and characters of brain swelling, post traumatic epilepsy.

• Associated systemic complications.

•The different expected outcomes.

• Injury-related pathophysiological responses of the very immature brain are different from the more mature one.

MILD OR MINOR HEAD INJURY

DEFINITON,

brain injured patients are generally categorized clinically as having sustained mild, moderate or severe brain injury, based mostly on the Glasgow Coma Scale (GCS):

Mild 13-15

Moderate 9-12

Severe 3-8

EPIDEMIOLOGY

•Mild closed head injury is one of the most common causes for seeking urgent medical attention, representing over 10% of all emergency room visits for pediatric patients.

•So it is important to detect the subpopulation that harbor a potentially life threatening or disabling brain injury.

•Boys are twice as likely as girls to suffer from head injury.

Aetiology and mechanism of head injury in pediatrics

1- Aetiology: In older children the causes are;

•RTA

•Accidental falls

•Child abuse

In neonates;

•Birth injuries

•Accidental falls

•RTA

•Child abuse

Mechanism of head injury;

Mechanical inputs can be 1-static loading 2-dynamic loading

Most head injuries are due to:

1-Contact injuries:

Local contact e.g fissure # , depressed #

Remote contact e.g # base

2-Acceleration injuries:

Transitional

Rotational Angular (most frequent)

Special Attributes of the Pediatric Nervous System

•The pliable thin immature skull of pediatrics.

•The smaller subarachnoid space in infancy.

•The soft texture of the immature brain.(contrecoup injury incidence).

•The size of the head in relation to the size of the body.(rate of growth of brain to the skull).

•The chemical composition of the brain.

•The developing brain.(development and cognition).

•The cerebral blood flow differences.

•The blood brain barrier of the immature brain.

•Functional differences in neuroplasticity.

CHILD ABUSE

Many cases of unexplained developmental delay and retardation are the result of abuse related injuries in infancy.

Child Abuse Syndromes:

1-The Battered-Child Syndrome.

2-The Shaking Impact Syndrome.

CLINICAL EVALUATION

• Assessment of the airway, breathing, circulation, and evaluation of other body systems.

• History of mechanism and severity of trauma.

• Duration of loss of consciousness, post-traumatic amnesia, vomiting and seizures.

• Examination of the head for scalp injuries, evidence of skull base fractures.

• Assessment of the conscious level according to the GCS for pediatrics.

GCS FOR INFANTS AND OLDER CHILDREN

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33TToo ccoommmmaannddssTToo ssoouunnddss 22TToo ppaaiinnTToo ppaaiinn 11NNoonneeNNoonnee

EEyyee ooppeenniinngg

55oorriieenntteeddAApppp.. FFoorr aaggee 44DDiissoorriieenntteedd CCrriieess bbuutt

ccoonnsscciioouuss 33IInnaapppprroopprriiaattee PPeerrssiisstteennttllyy

iirrrriittaabbllee 22IInnccoommpprreehheennssiibbll

ee RReessttlleessss,, lleetthhaarrggyy

11NNoonneeNNoonnee

BBeesstt vveerrbbaallrreessppoonnssee

66OObbeeyy ccoommmmaannddssSSppoonnttaanneeoouuss 55SSaammee LLooccaalliizzeess ppaaiinn 44 SSaammeeWWiitthhddrraawwss 33 SSaammeeFFlleexxiioonn 22 SSaammeeEExxtteennssiioonn 11 SSaammeeNNoonnee

BBeesstt mmoottoorrrreessppoonnssee

1155 TToottaall

CLINICAL PRESENTATION

• Concussion.

• Post-traumatic vomiting.

• Post-traumatic headache.

• Traumatic seizures and post-traumatic epilepsy.

• Focal neurological signs.

• Deterioration.

• Intracranial hematomas

• Infection.

DIAGNOSTIC EVALUATION

PLAIN RADIOGRAPHY:

Plain X-ray of the skull is essential and mandatory investigation for any patient with head trauma, especially who may be fully conscious (GCS= 15) at the time of examination.

Expected findings;

1-linear skull fracture.

2-Depressed skull fracture.

FINDINGS:linear skull fractures;

•They constitute 3/4 of all fractures, the diagnosis is suspected when significant scalp swelling is present. (figs.)•A special type of linear skull fracture is the diastatic sutural fracture in which the suture is disrupted and becomes widely separated

complications of linear skull fractures:complications of linear skull fractures:

• intracranial hematomas

• growing skull fractures

GROWING SKULL FRACTURE

Also known as a “leptomeningeal cyst”.

In this lesion, a dural tear occurs with a linear fracture and usually a brain injury deep to the site of the fracture is present. Because the gliotic cortex adheres to the edges of the dural lacerations, the dura

does not heal. (fig.)

DEPRESSED SKULL FRACTURE

Occurs when an object of a small surface area impacts the skull with a high kinetic force (fig.)

It may be 1- closed.

2- open.

A variant in pediatrics is the ping pong fracture

BASILAR SKULL FRACTURE

•Occurs in 5% of pediatric head trauma, (fig.)

•Clinically: fracture anterior cranial fossa.

fracture petrous.

•CT here is helpful for diagnosis

•Risk of complications

CSF fistula

meningitis

cranial nerve deficits

COMPUTERIZED TOMOGRAPHY

Patients with mild head injury may harbor a potentially life threatening or disabling brain injury.

Considering this, it seems likely that an acceptable practice parameter must include the very liberal and early use of CT scanning for those patients.

Findings: focal contusions (fig.)

intracranial hematomas (fig.)

pneumocephalus (fig.)

fracture base of the skull (fig.)

diffuse brain edema or swelling (fig.)

MAGNETIC RESONANCE IMAGING

It has limited value in the initial evaluation of mildly head-injured children. It is mainly

valuable in follow up evaluation and prognostication.

TREATMENT OF MILD HEAD INJURIES IN PEDIATRICS

*Aim: to prevent secondary complications.

prediction of long term out-come.

*Careful observation for signs of neurological deterioration when admission occurs.

*Criteria for admission:

Patient with linear or depressed fracture.

Patient with clinical or radiological evidence of basilar skull fracture.

Amnesia. (con.)

*Con.criteria of admission,

Unconsciousness for any length of time.

Marked headache or vomiting or any neurologic deficit.

NEUROBEHAVIORAL OUTCOME

Pre-existing neuropsychiatric disorders such as attention deficit, hyperactive disorder and learning disability.

Long-term neurobehavioral outcome after mild head injury.

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