Pediatric head trauma and the battered child

FACTS and EPIDEMIOLOGY
1. leading cause of morbidity and mortality during infancy
2. vary considerably compared to adults in many aspects
3. type of injury varies in relation to age and physical activity
4. role of imaging is significant (CT-MRI) diagnosis, management and choice of treatment.
5. 90% are mild (no hospitalisation), primary cause of death in children and adolescents
6. the type and mechanics differ with age
  1. perinatal_period, falls(1-4y), vehicle_accidents(7-12y), abuse
Particularities
1. Biomechanical properties of the child skull
2. Head size
3. BRAIN water content and myelination
  1. neonatal unmyelinated brain contains high levels of water (89%)
    1. More susceptible to acceleration – deceleration trauma forces the unmyelinated regions are more prone to shear injuries
4. Face to cranium ratio
  1. 1:8 at birth, 1:2.5 in the adult
  2. Increased likelihood of skull and brain injury in children // Frontal skull and lobes are more susceptible
5. Neck musculature – cervical spine
  1. craniocervical stability depends more on ligaments than bones.
  2. Increased likelihood of craniocervical junction lesions
Imaging
1. Plain radiographs
  1. limited use
    1. Minor injuries when CT is not required // Suspicious cases of child abuse (skeletal survey) // fracture complications such as growing fractures
2. U/S
  1. 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
3. CT
  1. Fractures
    1. linear
      1. 75 % of all fractures in most cases no special treatment is required the use of 3D recon often helps in their evaluation
    2. depressed
      1. associated with injury of the dura, venous epidural hematoma or contusion require surgical treatment
      2. Ping-pong fractures
    3. basilar
      1. 6-14% of cases of pediatric trauma patients
      2. complications are frequent
        CSF rhinorrhea, CSF otorrhea, ecchymosis over the mastoid bone, periorbital ecchymosis, hemotympanum, cranial nerve VII palsy
        secondary meningitis (1-5%)
  2. Leptomeningeal Cyst
    1. growing fractures
    2. Tear in the underlying dura and the progressive leptomeningeal herniation through the widening of the skull defect
  3. Subdural hematoma
    1. more frequent in children than in adolescents
    2. not associated with a fracture
    3. may transverse the sutures
    4. nterhemispheric fissure and along the tentorium
  4. Subarachnoid hemorrhage
    1. rupture of the pial or the subarachnoid vessels
    2. circulation/redistribution of IVH
    3. rupture of an intracerebral contusion or hemorrhage into the subarachnoid space
    4. Intraventricular hemorrhage
      1. extension from intraparenchymal bleeding // deep penetrating wounds // tearing of subependymal veins // difussion from subarachnoid hemorrhage
  5. Cortical contusions – Intracerebral hematoma
    1. involve superficial gray matter with sparing of the subcortical white matter
    2. less common in children than in adults
    3. mainly located in the temporal poles and frontal and occipital lobes
    4. shearing – straining injury due to rupture of small intraparenchymal vessels
  6. Diffuse Axonal Injuries (DAI)
    1. SWI
      1. It has greater sensitivity than GRE in the detection of trauma related hemorrhagic lesions (esp. in DAI)
  7. Vascular Injuries
    1. primary
      1. 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
      2. Dissection of internal carotid / vertebral artery - thrombosis
        may be caused by a penetrating or blunt neck trauma
      3. Venous sinus occlusion
        direct damage or thrombosis
  8. Hydrocephalus
  9. Congestive brain / Cerebral edema
    1. Brain herniation
      1. subfalcine uncal transtentorial foramen magnum external
    2. expansion of brain tissue due to increased intravascular blood volume
    3. more frequent in children than in adults due to immature or impaired autoregulation of brain perfusion
    4. CT without findings during the first 12 hours
      1. - 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”
  10. Epidural hematoma
    1. less common than in adults
      1. better prognosis than in adults
    2. more frequently venous than arterial (tear of a dural sinus or diploic veins)
      1. Swirl sign: indicates active bleeding with risk of rapid expansion of the hematoma
4. Perinatal injuries
  1. during delivery and most specifically during the stage of active pushing, due to the mechanical forces exercised on it (i.e. compression, retraction)
  2. Extracranial hemorrhage
    1. Caput succedaneum
      1. serum blood collection above the periosteum
      2. compression of the protruding part of the fetal scalp // instrumenatal deliver
      3. transverses the cranial sutures
    2. Subgaleal hemorrhage
      1. between the periosteum of the skull and the galea aponeurotica
      2. may extend over the cranial sutures and may coexist with (40%) intracranial hemorrhage or skull fracture
      3. shock or hyperbilirubinaemi
    3. Cephalhematoma
      1. subperiosteal blood accumulation due to ruptured vessels
      2. limited by sutures especially in the parietal bone
      3. anaemia or blood pressure hypotension
      4. can calcify and form disfiguring masses visible on follow up
  3. Intracranial hemorrhage
    1. Subdural
      1. - subdural hematoma is the most common type and accounts for 73%
    2. Epidural
      1. rare in neonates
    3. Subarachnoid - intraventricular
      1. second most common type
    4. Parenchymal
  4. Fractures
    1. skull fractures are uncommon
Abuse or Accident
1. 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
  1. most children deaths worldwide are due to abuse inflicted by parents. -brain injury is the most common consequence of child abuse
    1. Major non-traumatic brain injuries
      1. 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
      2. intra-axial lesions
        diffuse cerebral edema
        brain contusion
        atrophy
        enchephalomalacia

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Pediatric head trauma and the battered child

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	Created by SEBASTIAN SIMONETTI over 10 years ago