1/7/2018 Pediatric trauma - ESNR trauma Sundgren.pdf · pneumocephalus CSF leakage Classification...

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Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp

Pediatric trauma

Prof. Pia C Sundgren MD, PhD

Department of Diagnostic Radiology, Clinical Sciences, Lund University, Sweden


1. Primary brain injuries

occur at the time of the accident and are direct result of the

impact

- extra-axial

- intra-axial

2. Secondary brain injuries

is casued by systemic factors such as:

- increased intracanial pressure - edema

- brain herniation - compression of intracranial

blood vessels

- hypotension - hypoxia

Classification


1. Primary brain injuries - extra-axial

epidural hematoma (EPI)

subdural hematoma (SDH)

subarchnoid hemorrhage (SAH)

intraventricular hematoma (IVH)

Classification


1. Primary brain injuries – intra-axial

diffuse axonal injury (DAI)

cortical contusions

subcortical lesions

intracerebral hematoma (ICH)

brainstem lesions

Classification

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2. Secondary brain injuries

brain edema

obstuction of the CSF

herniation

ischemia

secondary hemorrhage

pneumocephalus

CSF leakage

Classification


encephalomalcia, porencephaly

axonal injury

diabetes insipidus

”growing fracture”

liquorhoe

cranial nerve injuries

hydrocephalus

carotid-cavernous fistulae

Sequelae


sensible for bleeding MPR reconstruction

sensible for fracture possiblity for 3D reconstractions


Skull fractures

result from direct impact to the calvarium

important because of their association with

intracranial injury

the incidence ranges from 2 to 20%

the parietal > occipital > frontal > temporal bones

linear fractures are most common, followed by

depressed and basilar fractures

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Impression / depressed fracture

A classic fracture in children

- ping-pong injury

- soft calverium

- surgery might be needed


Impression / depressed fracture


linear fracture with damage to the underlying dura

close to sutures

diastas >3-4 mm: growing fracture

children < 3 yrs- strapped meningier

- pulsative liquore

Growing fracture


meningier and brain tissue

brain tissue that became gliotic porencephalic cyst

growing

fracture

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90% associated with skull fracture at coup site

cause

90% arterial (middle meningeal artery)

10% venous (sinuses) especially children < 2 years

localization

epidural space

95% unilat.

90-96% supratentorial

complication

re-bleed

growing rapidly

Epidural hematoma (EDH)


• biconvex

• hyperdense

• cross dural folds (falx, tentorium)

• do not cross sutures

• shift of the midline structures

• associated with contusions

or brain edema

Epidural hematoma (EDH)


CT

lucid interval 1-2 days in 50% of the

cases

20% not visible on the first CT!!!

MR

• the signal pattern is related

to age of the bleed

• the displaced dura can be

seen on T2-w images

• effacement of the dural

sinuses - MRA

Imaging - Epidural hematoma


- grow more rapid than in

adults (due to plasticity of

the infants brain)

24h primaEpidural hematoma (EDH)

- epidural hematoma can cross sutures

if associated fracture with diastases

of the suture and rift of the dura

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cause

tearing of the bridging veins

tearing of larger veins

localization

subdural space on the contre-coup side

cross suture lines but is limited by falx and tentorium

issues

symptoms may be delayed in children

(due to large CSF spaces)

re-bleeding common

SDH of different age - ? child abuse

Subdural hematoma (SDH)



cause

combination of edema and increased hypertension

reduced vascular resistance and autoregulation

1/5 of all severe cranial trauma

children > adults

development 24 - 48 hours

high mortality

Diffuse cerebral edema


brain swelling max 24-72h

any insult leading to release neurotransmitters and

neuropeptides

a secondary cascade of vascular leakiness

obstruction arterial inflow - ischemia

Acta Neuropathol (2011) 122:519–542Courtesy Dr M Argyropoulou

Encephalopathy

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Encephalopathy

J Neuroradiol (2007) 34:109–114

Patterns

primary irreversible

contusion point of brain impact

diffuse axonal injury

secondary potentially reversible

diffuse supratentorial brain swelling

infarction of parasagittal watershed areas in cerebrum &

cerebellum

venous ínfarction - parieto-occipital


CT not sensitive at initial stage

MRI very sensitive

3 - 7 days post trauma

maximal edema and cell necrosis

MR imaging

multiple, small focal lesions

5-15 mm oval, ellipsoid, parallel to white matter tracts

T2 = hyperintense

SWI or GRE T2*

Diffuse axonal injury (DAI)


Ashwal et al, Dev Neurosci 2006; 28:309-26


premature (v 36)

after sectio due to

risk for asphyxia

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T1 DWISWI


- all sports and recreation-related concussion in U.S.

1.6-3.8 million/year

- concussion is COMMON in youth sports: 8.9% of

high school athletes

- 47% of all reported sports concussions occur

during high school football

Sports-Related TBI


football: 64

ice hockey: 54

lacrosse: 40

soccer: 19

wrestling: 22

.

soccer: 33

lacrosse: 31

field hockey: 22

basketball: 19

Rates per per 100,000 athletic exposures

Male

Female

Boys Girls


Sharp DJ, Scott G, Leech R. Nat Rev Neurol 2014;10:156-66.

Traumatic Brain Injury

Structure and Function

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De

lta

FA

RWEcp

Corpus Callosum

Courtesy Dr Christoffer Whitelow, Wake Forest, USA


• IFOF and ILF

• Terminals

Tract Terminal Regions

Delta F

A

IFOF ILF

RWEcp

Delta F

A

RWEcp


microbleed

MRI finding Boxing

(N=98)

Non-boxing

(161)

OR 95% CI P-

value

Microhemorrhage

3(3%) 0 - 0.053

Diffuse axonal

injuries

26(27%) 0 - 0.000

Cavum septum

pellucidum (CSP)

58

(59%)

92 (57%) 1.08 0.63-

1.87

0.800

Dilated

perivascular

space (DPVS)

61

(62%)

52 (32) 3.46 1.97-6.05 0.000

Posttraumatic

cysts

2 (2) 0 - 0.142

Association of abnormal finding in MRI brain and thai boxing

Higher statistically significant in young boxer

Higher prevalence, but no statistically significant

Higher statistically significant in young boxer

Prof. Jiraporn Laothamatas, Mahidol University, Bangkok, Thailand

The 1st Bangkok International Pediatrics Update (BIPU 2017)

AIMC.mahidol.ac.th & med.mahidol.ac.th

IQ of Child Boxers vs Normal Control

IQ 90-110 Can complete Diploma or Bachelor degree

IQ 80-90 Can complete High School

p = 0.87

p = 0.89

Exposed Duration (Year)

Beauchamp,et al 2012

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Increased MD over 2 years follow up p<0.00001 (N=113): further gliosis and neuronal damage

Decreased FA over 2 years follow up p<0.00001 (N=113):

further damage of the brain connectivity due to axon and myeline damage




Decreased MD p<0.00001 (N=113) 2-5 years boxing experience group cytotoxic edema and acute demyelinating process

Increased R2* p>0.00001 (N=113) Further increased iron accumulation of old blood product



boxing in pediatrics has definitely caused structural

brain damage in both gross and microstructural brain

functional brain damage such as decreased memory

tasks with only better motor skill

these damages increase in severity with numbers of

years of boxing

result from neuropsychological test has shown

significantly decreased overall IQ with longer years of

boxing. AIMC.mahidol.ac.th & med.mahidol.ac.th

Summary




normal developmental anatomy that may mimic

trauma:

• ossification tip of dens (completes 3-6y)

incomplete ossification of tip of dens mimics increased

distance between C2 and occiput

Pediatric spine - normal variants/findings

http://radiographics.rsna.org/content/23/3/539/F21.large.jpg

http://radiographics.rsna.org/content/23/3/539/F21.large.jpg

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normal developmental anatomy that may mimic

trauma:

• secondary ossification centers

- unfused ring apophyses

(normal physis are smooth with subchondral sclerotic lines)

Lustrin ES, et al. Radiographics 2003; 23: 539-560




Synchondroses (symmetrical, expected location)

Courtesy Prof T Huisman

Jones TM, et al. J Am Acad Orthop Surg 2011;19:600-611


wedged vertebral

bodiesossification congenital non-union


non calcified

apophysis

The distance between

atlas and dens:

child < 4.5 mm

adult 3 mm


Brachial plexus birth palsy : 1 per 1000 live births

Risk factors:

• macrosomia

• prolonged labor

• breech delivery

• previous deliveries with brachial plexus birth palsy

Injuries at birth

Brachial plexus palsy occurs

when traction forces are applied

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upper plexus C5 and C6

lower plexus C7 and C8

± T1

Plexus anatomy

• pure upper trunk: C5 , C6

• upper plexus C5, C6, C7: Erb’s palsy 80%

• lower plexus C7, C8: Klumpke’s palsy

(very rare)• total plexus: 20% (from C5 to T1)


upper brachial plexus injury

infant is unable to:

- abduct the arm from the shoulder

- rotate the arm externally from the shoulder

- supinate the forearm

This results in the classic 'waiter's tip' appearance

Erb´s palsy


imbalance of the intrinsic and extrinsic muscles

- intrinsic muscles must be paralyzed - claw deformity

- long extensor muscles hyperextend the MCP joint

- long flexor muscles flex the PIP and DIP joints

CAVE: injuries of the sympathetic

branch to the stellate ganglion

= Horner’s syndrome

Klumpke´s palsy

lower brachial plexus palsy


- intramedullary edema in the acute phase

- myelomalacia in the chronic phase

- hypointense lesions on GRE T2-w* - hemorrhage

MRI of the spine and additional findings

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in the absence of neurological improvement at

4 to 6 months

microsurgical nerve reconstruction

postoperative improvement in muscular tone:

- pure upper trunk 80%

- Erb’s palsy 75%

- complete palsy 45%

Treatment


injury to the spinal column and spinal cord is the

major cause of disability, affecting predominately

young healthy individuals

spinal cord injuries are rare in infants

and children (1-2% of all pediatric trauma victims)

the type of injuries is slightly different in the

pediatric population compared to adults

Accidental spine and spinal cord injury


Cause < 3 years2 1-20 years1 overall

Motor vehicle 66% 44% 47.7%

Fall 15% 14% 20.8%

Pedestrian 11%

Bicycle 6%

Violence 14.6%

Sports 16% 14.2%

Causes for accidental injuries

1Kokoska E et al. Characteristics of pediatric… J. Ped. Surg. 2001:36;100-105 (408 cases (+))2Polk-Williams A et al. Cervical spine injury…. J. Ped. Surg. 2008:43;1718-1721 (1523 cases (+))


Spinal trauma and spinal cord injury

< 8 years of age 50% in C1-C2 (-C3) region

incidence of dislocations

incidence of cord injuries

> 8 years of age shift towards C5 and below

- C-spine fractures

mortality rates 17% (overall), higher in small

children

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Imaging of children with spine trauma

If low velocity trauma or minor fall:

no pain at motion

no tenderness

no neurological deficits

NO imaging

or plain films

If high velocity trauma or trauma with

tenderness

reduced motion

pain at motion

or suspected head injury (multitrauma)

CT

Neurological symptoms MRI

NEXUS Low-Risk Criteria, CanadianC-spine rule, NICE guidelines 2016Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 Antwerp

increased flexibility of the cervical spine due to:

incomplete ossifications of the vertebral bodies

ligament laxity

incomplete development of the spinous process

increased head-to-torso ratio

week cervical musculature

cervical spine injuries at higher levels

Causes for higher cervical injuries in children


• uncinate processes small <10y

• junction between vertebral body and end plates is cartilaginous ~> risk for injury (Salter-Harris I)

• more horizontal orientation of cervical facets

greater range of physiologic flexion/extension

• shallow occipital condyles

VanderHave et al J Am Acad Orthop Surg 2011;19:319-327

Causes for higher cervical injuries in children


Typical spine injuries in children

• odontoid fracture, subluxation

• cranio-cervical dislocation or disassociation

• Chance fracture (“seatbelt injury” especially in

the thoracic spine)

• SWICORA

always look for ligamentous injury

NOTE: always look for more

(common with multiple injuries)

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Odontoid fracture

rapid deceleration with flexion (MVC

often through synchondrosis of

C2 at the odontoid base



Complex of occipital-atlanto-axial dislocation

occipital condyle is small, almost horizontal

and lacks inherent stability

severe hyperextension w/wo distraction

- rupture transverse lig. of the dens -

• anterior translation (hypereflextion)

• posterior translation (hyperextension)

• longitudinal

incomplete – subluxation

complete – dislocation/disassociation

atlanto-occipital condyle distance > 5mm


Consider the complex when:

- distance odontoid process and the basion >

12 mm

- occipital condyles and atlas > 5mm

- Wackenheim line does not touch the tip of the

odontoid process

- joint widening on CT and joint fluid on MRI

Complex of atlanto-occpital dislocation

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Atlanto-occiptal dislocation


Asymmetrical dislocation

CT underestimates the degree of soft tissue

injury


vertebral bodies change shape on follow up !!

developing skeleton

Asymmetrical dislocation


Craniocervical distraction injury

CT sag CT sag CT cor

CT upon admission

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MRI upon admission

T1 sag T2 corT2 sag




MRI 6 days later

T1 sag T2 corT2 sag


Chance fracture

- failure of the interspinous ligaments at flexion

- anterior axial loading

- often at the thoracolumbar region

- burst fracture of the vertebral body

- widening of spinous processes

in adolescent spine:

- fracture line through the physeal plate

(never through disc)

in adult spine:

- fracture line through the intervertebral disc/

vertebral body

Courtesy Dr J Schneider, Basel


Spinal cord injury without radiographic abnormality

- SCIWORA -

specific to children and extremely rare in adults

incidence: 19-34% of all spinal cord injuries in children

more common in younger children < 8 years of age

can have delayed onset of clinical symptoms and

signs up to 4 days after initial injury

recurrent SCIWORA several days to weeks after

initial event (17%)

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• immature and elastic pediatric spine

• vulnerable to external forces

• allows for significant inter-segmental movement

• transient disc protrusion

compression and stretching of the spinal cord

cord injury

Spinal cord injury without radiographic abnormality

- SCIWORA -


The elasticity of neonatal bony spine is eight

times that of the cord

Biomechanics in children

5

cm

6/7

mm

Leventhal H. J. Pediatr 56:447 1969


SCIWORA


SCIWORA

4 month later

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3 year old in MVA

SCIWORA


T2-wSTIRT1-w


lack of visualization does not imply root avulsion

pseudomeningoceles are NOT pathognomonic of

root avulsions

intact roots have been shown in the presence of

pseudomeningoceles

pseudomeningocele AND absent nerve rootlets

best predictor of root avulsions

Plexus injury

visualization of the nerve rootlets strongly suggests

a preserved root


pre-ganglionic:

nerve root avulsion

post-ganglionic:

conduction deficits

Spectrum of injuries

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Plexus injury- nerve root avulsion

methemoglobin

Day 4

Day 14

pseudomeningocele


- evaluation of ventral and dorsal nerve roots

- detection of intradural nerve defects

CT-myelography

equal or better than standard myelography and

MR imaging, especially at the C5 and C6 levels


- usually filled with contrast media

- appear as lateral outpouching of the thecal sac

- may lie within the spinal canal

- or extend through the neural foramina

Pseudomeningoceles


Summary

traumatic brain injuries in children are unusualbut can be quit severe and with permanent damage

CT initial imaging modality, be liberal with MRI(include SWI)

- severity- predict outcome

multiple SDH of different age – child abuse???

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Summary

• important to have good knowledge about- pediatric spine anatomy- variants

• good quality images

• restrictive with CT in small children (radiation)

• liberal with MRI

• high incidence of dislocations and cord injury (<10 yrs)

• important to have good knowledge about- pediatric spine anatomy- variants

• good quality images

• restrictive with CT in small children (radiation)due three sets of plain X-rays

• liberal with MRI

• high incidence of dislocations and cord injury (<10 yrs)

Lund University / Faculty of Medicine / Department of Clinical Sciences / Radiology / ECNR / 2018 AntwerpPC Sundgren, Spine Infect… ASSR’ 12

Thank you

1/7/2018 Pediatric trauma - ESNR trauma Sundgren.pdf · pneumocephalus CSF leakage Classification...

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