Pediatric head trauma and the battered child

Pediatric head trauma and the battered child

1. FACTS and EPIDEMIOLOGY

   • leading cause of morbidity and mortality during infancy
   • vary considerably compared to adults in many aspects
   • type of injury varies in relation to age and physical activity
   • role of imaging is significant (CT-MRI) diagnosis, management and choice of treatment.
   • 90% are mild (no hospitalisation), primary cause of death in children and adolescents
   • the type and mechanics differ with age
     • perinatal_period, falls(1-4y), vehicle_accidents(7-12y), abuse

2. Particularities

   • Biomechanical properties of the child skull
   • Head size
   • BRAIN water content and myelination
     • neonatal unmyelinated brain contains high levels of water (89%)
       • More susceptible to acceleration – deceleration trauma forces the unmyelinated regions are more prone to shear injuries
   • Face to cranium ratio
     • 1:8 at birth, 1:2.5 in the adult
     • Increased likelihood of skull and brain injury in children // Frontal skull and lobes are more susceptible
   • Neck musculature – cervical spine
     • craniocervical stability depends more on ligaments than bones.
     • Increased likelihood of craniocervical junction lesions

3. Imaging

   • Plain radiographs
     • limited use
       • Minor injuries when CT is not required // Suspicious cases of child abuse (skeletal survey) // fracture complications such as growing fractures
   • U/S
     • limited to the neonatal period for as long as the fontanels are still open // demonstrates only the peripheral lesions or the extra-axial hematomas along the convexity // Doppler technique may indicate increased intracranial pressure
   • CT
     • Fractures
       • linear
         • 75 % of all fractures in most cases no special treatment is required the use of 3D recon often helps in their evaluation
       • depressed
         • associated with injury of the dura, venous epidural hematoma or contusion require surgical treatment
         • Ping-pong fractures
       • basilar
         • 6-14% of cases of pediatric trauma patients
         • complications are frequent
           • CSF rhinorrhea, CSF otorrhea, ecchymosis over the mastoid bone, periorbital ecchymosis, hemotympanum, cranial nerve VII palsy
           • secondary meningitis (1-5%)
     • Leptomeningeal Cyst
       • growing fractures
       • Tear in the underlying dura and the progressive leptomeningeal herniation through the widening of the skull defect
     • Subdural hematoma
       • more frequent in children than in adolescents
       • not associated with a fracture
       • may transverse the sutures
       • nterhemispheric fissure and along the tentorium
     • Subarachnoid hemorrhage
       • rupture of the pial or the subarachnoid vessels
       • circulation/redistribution of IVH
       • rupture of an intracerebral contusion or hemorrhage into the subarachnoid space
       • Intraventricular hemorrhage
         • extension from intraparenchymal bleeding // deep penetrating wounds // tearing of subependymal veins // difussion from subarachnoid hemorrhage
     • Cortical contusions – Intracerebral hematoma
       • involve superficial gray matter with sparing of the subcortical white matter
       • less common in children than in adults
       • mainly located in the temporal poles and frontal and occipital lobes
       • shearing – straining injury due to rupture of small intraparenchymal vessels
     • Diffuse Axonal Injuries (DAI)
       • SWI
         • It has greater sensitivity than GRE in the detection of trauma related hemorrhagic lesions (esp. in DAI)
     • Vascular Injuries
       • primary
         • Carotid-cavernous fistulas
           • communication between the internal carotid artery and one of the cavernous sinuses, due to a tear of the artery or the sinus wall
           • pulsation exophthalmus, occulomotor dysfunctions dilatation and tortuosity of the superior ophthalmic vein enlargement of the cavernous sinus
         • Dissection of internal carotid / vertebral artery - thrombosis
           • may be caused by a penetrating or blunt neck trauma
         • Venous sinus occlusion
           • direct damage or thrombosis
     • Hydrocephalus
     • Congestive brain / Cerebral edema
       • Brain herniation
         • subfalcine uncal transtentorial foramen magnum external
       • expansion of brain tissue due to increased intravascular blood volume
       • more frequent in children than in adults due to immature or impaired autoregulation of brain perfusion
       • CT without findings during the first 12 hours
         • - blurring between gray and white matter // - compression of the ventricular system // compression of the basal cisterns and the peripheral subarachnoid spaces // enhancement of subarachnoid spaces (vascular stasis) // “white cerebellum sign” // “reversal sign”
     • Epidural hematoma
       • less common than in adults
         • better prognosis than in adults
       • more frequently venous than arterial (tear of a dural sinus or diploic veins)
         • Swirl sign: indicates active bleeding with risk of rapid expansion of the hematoma
   • Perinatal injuries
     • during delivery and most specifically during the stage of active pushing, due to the mechanical forces exercised on it (i.e. compression, retraction)
     • Extracranial hemorrhage
       • Caput succedaneum
         • serum blood collection above the periosteum
         • compression of the protruding part of the fetal scalp // instrumenatal deliver
         • transverses the cranial sutures
       • Subgaleal hemorrhage
         • between the periosteum of the skull and the galea aponeurotica
         • may extend over the cranial sutures and may coexist with (40%) intracranial hemorrhage or skull fracture
         • shock or hyperbilirubinaemi
       • Cephalhematoma
         • subperiosteal blood accumulation due to ruptured vessels
         • limited by sutures especially in the parietal bone
         • anaemia or blood pressure hypotension
         • can calcify and form disfiguring masses visible on follow up
     • Intracranial hemorrhage
       • Subdural
         • - subdural hematoma is the most common type and accounts for 73%
       • Epidural
         • rare in neonates
       • Subarachnoid - intraventricular
         • second most common type
       • Parenchymal
     • Fractures
       • skull fractures are uncommon

4. Abuse or Accident

   • Discrepancy between trauma history and imaging findings // hemorrhage of different age // unusual findings (e.g burns or bruises) // retinal hemorrhage is present (shaken baby) // if the child has evidence of poor care
     • most children deaths worldwide are due to abuse inflicted by parents. -brain injury is the most common consequence of child abuse
       • Major non-traumatic brain injuries
         • extraaxial lesions
           • fractures (parietaloccipital or growing)
           • acute with chronic subdural hematoma
             • most common finding in child abuse
             • parietooccipital convexity – interhemispheric fissure
             • nterhemispheric subdural hematoma  shaken baby
             • hemorrhage of different age  repetitive trauma
           • interhemispheric or infratentorial subdural hematoma
           • subarachnoid hemorrhage
           • enlargement of the subarachnoid spaces
         • intra-axial lesions
           • diffuse cerebral edema
           • brain contusion
           • atrophy
           • enchephalomalacia

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