Head injury in children: From Lumps and Bumps to Bolts

Head injury in children: FromLumps and Bumps to BoltsArno H. Fried, MD, FACSPediatric Neurosurgery

Head Injury in Children• 300/100,000 per year• Leading cause of death in children• Car accidents most common• Falls, bike, skateboard, sports• Non-accidental Trauma

Mild head Injury (MTBI)• “Ding” - mild concussion• 50 to 70% have postconcussivesymptoms after 8 weeks• Possibility of permanentcognitive effects after 2concussions• When to return to playing• Amount of cerebral reserve

Glascow Coma Scale(Modified for Young Children)• Best verbal response (1-5)1 none2 restless, agitated3 persistently irritable4 consolable crying5 appropriate words,smiles, fixes + follows

Age and Mortality• Mortality lessthe younger theage, except 1 styear of life• Only 10%incidence ofsurgicalhematoma (50%in adults)

Outcome severe childhoodhead traumaOutcome in children following severehead injuriesJ Neurosurg 1978 May;48(5):679-88Bruce DA, Schut L, Bruno LA, WoodJH, Sutton LN.• 8% mortality; GCS 5 and above allsurvived

Time Line to RecoveryAfter Severe Head Injury• Eye opening first– 1 to 2 months• Followcommands• Speech – can be6 months

Newborn Head injury• Cephalohematoma• Tentorial posteriorfossa subduralhematoma• Subgalealhemorrhage• Ping pong fracture

Skull fracture• Linear• Basal• Ping pong• DepressedClosedOpen

Ping Pong Fracture• Early infancy• Elevate throughburr hole only

Growing skull fracture• LeptomeningealCyst• Infancy• Skull fracture withdural tear• Sac of CSF andbrain develops intofracture line• Re-examine infantsafter skull fracture

Growing skull fracture

Leptomeningocele cyst

Depressed skull fracture• Double density• Open vs. closed• Dural tear• Epilepsy• Operate whenopen and > 5mm.

Posterior Fossa SubduralHematoma• Occurs innewborns• Follow Hgb• Rarely needssurgery• May develophydrocephalus• Full term babies

Subdural hematoma• Follows contourof brain• Associated withbrain contusionand burst lobe• Higher mortalityand morbidity

Subdural hematoma

Subdural hematoma• Bridging veinsinto sagittalsinus

Subdural hematomaremoval

Epidural hematoma• Little brain injury• Time is critical• Middlemeningeal artery• Skull fracture• Shock in infants

Epidural hematoma

Epidural hematoma• Lens shaped• + /- Skullfracture• Shift

Epidural hematoma

Subdural versus Epidural

Contusion• Basal frontaland temporallobes• Can develop intoa hematoma• Increased ICP

Contusion• Coup – contracoup injury

Focal Injury – Basal Contusion• Is usuallyfrontal ortemporallobe

Tentorial herniation• Uncus oftemporal lobecompressesbrain stem• 3 rd nerve• Kernohan’snotch

Cerebellar herniation• Cerebellartonsils herniatedthrough foramenmagnum• Medullary failureand respiratoryarrest• Posterior fossamass

Cerebral herniation• Durethemorrhage• Caused by brainstem distortion

Diffuse axonal shear injury• Common inchildren• Tiny axonaltears andhemorrhagethrough whitematter , corpuscallosum,cerebellarpeduncle

Cerebral swelling• Increased blood volume, Notedema• Usually transient• ICP increased• “childhood concussionsyndrome”• CT – ground glass appearance

Cerebral edema• Increased braintissue water• Vasogenic• Cytotoxic• Increased ICP

Cerebral edema

Shaken baby syndrome• Severe shakingand impact –acceleration /deceleration• Intracranialhemorrhage andedema• Retinalhemorrhages

Shaken baby syndrome• Subdural mostcommon, oftenbilateral• PosteriorinterhemisphericSDH• Severe cerebraledema

Non-accidental headtrauma

Shaken baby syndromeBilateral subdural hematomasSubdurals drained with atrophy

Fat Embolism• Diffuse whitematter petichae• Long bonefracture• Increased ICP

MTBI and Football• 60’s work of Dr. Schneider• Transmitted force from verteximpact - “spearing”• changed helmet design• rule changes• Cervico-medullary and C spinalcord injuries

Postconcussive syndrome• Headache, irritability, inability toconcentrate, sleep abnormalities,dizziness• Resolves over 6 to 8 weeks

Cumulative Injury• Effect of concussion morepronounced after second MTBI• Timing between 2 concussionsimportant to development of longlasting effects• Boxing injuries - “dementiapugilistica”progressive dementia, movementdisorder, tremor, cognitive andpsychiatric symptoms

Concussion classification• Grade 1 - Mild confusion, NoLOC, resolves in 15 minutes• Grade 2 - Amnesia, No LOC,symptoms > 15 minutes• Grade 3 - LOC > 5 minutes, oramnesia >24 hours

Second impact syndrome• potentially fatal• athlete sustains second blow to thehead before completely recoveringfrom a first concussion• Diffuse swelling, loss ofautoregulation• Pt. Collapses with dilated pupils andherniation after walking around dazed• children and teenagers moresusceptible

Return to Competition• Grade 1observe for 20 minutes.Return if all symptoms are goneif not gone in 20 minutes, no playfor 1 week and if asymptomatic

Return to Competition• Grade 2terminate playreturn after 1 asymptomatic weekat rest and with exertionafter 2nd MTBI, hold for 2asymptomatic weeks or for seasonif any MRI abnormalities

Return to Competition• Grade 3terminate playgo to hospitalcan return to play after 1 asymptomaticweek or 2 weeks if symptoms wereprolongedAfter 2nd , hold for 1 asymptomaticmonthAfter 3rd, consider no further contactsports

Pediatric Head Trauma• Coma due to:Brainstem compression due toincreased ICPBilateral cerebral injury – diffuseaxonal injuryMetabolic etiologySeizure

Intracranial pressure• Cushing’s triadBradycardiaHypertensionElevated ICP

Pressure volume curve• Exponential• High complianceat low ICP• Low complianceat higher ICP(tight brain)• Volumebufferingcapacity

Pressure Volume Index• PVI is theoreticalvolume needed toraise ICP 10 fold• Linear relationshipbetween volumeand ICP• Useful clinicalmeasuring tool todetermine braintightness

ICP Waves• A WavePlateau wave50 to 100 mm Hg10 to 20 minutesVasodilatationLow complianceCan be fatal

Origin of “A” Waves• Low compliance –tight brain• ICP goes up• Cerebral perfusionpressure falls• Vasodilatation tocompensate bloodflow• ICP de-stabilizes

ICP Waves• B WavesOccur at elevatedbaseline ICP10 to 40 mm HgOne per minuteCheyne stokesrespiration?

Severe head injury – ICPmonitoring• GCS 8• DAI• Baseline ICP 18-20• Low PVI (tightbrain)• Plateau occurs

ICP Monitoring• Multiple “A”Waves• Very lowcompliance• Oftenuncontrollableand fatal

Hyperventilation• Lower CO2 resultsin lower CBF andischemia• Can be used asemergencymeasure• Consider xenon CTor jugular venousO2 monitor

Hyperventilation andIschemiaXenon CT scansNormocapnia – normal blood flowPCO2= 38Hyperventilation – IschemiaPCO2=24

Management of IncreasedICP• Sedation and paralysisPropofol and Sevoflurane• Controlled ventilation• Normal CO2 – Eucapnia• Normovolemia• Controlled hypothermia• No steroids• Pain control

Management of IncreasedICP• Mannitol - .25 to 2 grams per kg,Q 4-6 hrs.Keep serum osm 310 to 315• 3% hypertonic saline• Lasix• Lidocaine• Normal serum glucose• Ventricular drainage

Management of Increased ICP• Brain surgeryDecompressionHemicraniectomyLobectomyHematoma evacuation

Management of Increased ICP• Pentobarbital ComaMaximal conventional interventionEEG suppressionBP and cardiac output support

Brain Compliance and ICP• Child normally hassteeper pressurevolumecurve• Trauma shiftscurve to left(steeper)• Rx shifts PV curveback to right

Aggressive treatment ofsevere head trauma• Ventriculardrainage• Mannitol• Paralysis• Normalization ofPVI• Pentobarb coma

Aggressive treatment ofsevere head trauma

Types of spine injuries• SCIWORA• Atlanto-occipital• Odontoid, Dens• C1/C2 rotatory subluxation• Lower cord injury• Fracture +/- subluxation• Hematoma• Disc herniation

Clearing the child’scervical spine• Normal neuro exam• Lack of pain• Good quality lateral cervicalspine XrayLack of fx or subluxationno signs of ligamentousinstabilityNo prevertebral swelling

Normal C spine

Open mouth C2 viewsA-O junctionC1DensC2

C spine open mouth view

Atlanto-occipitaldislocationBasion to tip ofdens < 12 mm

Odontoid growth center

C2 - C3 Pseudosubluxation

SCIWORA• Spinal cord injury withoutradiologic abnormality• Mostly young children, 8 yrs orless• Upper cervical cord injury, canbe thoracic also• High percentage of completecord injuries

Correctable problems• Epidural hematoma• Ruptured disc• Correct instability• Associated pathology(pathologic fracture)

C1/C2 Rotatorysubluxation• Minormechanism ofinjury• Torticollis;“cock-robin”head position• Traction,analgesia

Lap belt injuries• Upper lumbar• Lap belt withoutshoulder strap• Associated withsmall bowelrupture• Horizontalfracture(Chance)

Clearing cervical spine inchildren• Awake; no pain - simple C series• Awake, pain - C spine series, thenconsider flexion extension views, +/-CT scan• Not awake - C spine series normal, CTscan normal - spine cleared. Ifquestionable finding consider flexion- extension under fluoro.

• Mechanism of injury evaluatedfirst• Awake or lethargic orunconscious• Exam - pain, tenderness,neurologic• SCIWORA - full evaluation,Xrays, CT, MRI, flex-extension• If intubation needed proceedbefore C spine evaluation.Clearing cervical spine inchildren

Rehabilitation• Spasticity - Intrathecal baclofanpump• Spinal cord rehab center• Cardiovascular - autonomic• PreventionThink first for kids