Head injury in children: From Lumps and Bumps to Bolts

Arno H. Fried, MD, FACS Pediatric 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 postconcussive symptoms after 8 weeks  Possibility of permanent cognitive effects after 2 concussions  When to return to playing  Amount of cerebral reserve Glascow Coma Scale (Modified for Young Children)

 Best verbal response (1-5)

1 none 2 restless, agitated 3 persistently irritable 4 consolable crying 5 appropriate words,smiles, fixes + follows Age and Mortality

 Mortality less the younger the age, except 1st year of life  Only 10% incidence of surgical hematoma (50% in adults) Outcome severe childhood head trauma

Outcome in children following severe head injuries J Neurosurg 1978 May;48(5):679-88

Bruce DA, Schut L, Bruno LA, Wood JH, Sutton LN.

 8% mortality; GCS 5 and above all survived Time Line to Recovery After Severe Head Injury

 Eye opening first – 1 to 2 months  Follow commands  Speech – can be 6 months Newborn Head injury

 Cephalohematoma  Tentorial posterior fossa subdural hematoma  Subgaleal hemorrhage  Ping pong fracture Skull fracture

 Linear  Basal  Ping pong  Depressed Closed Open Ping Pong Fracture

 Early infancy  Elevate through burr hole only Growing skull fracture

 Leptomeningeal Cyst  Infancy  Skull fracture with dural tear  Sac of CSF and brain develops into fracture line  Re-examine infants after skull fracture Growing skull fracture Leptomeningocele cyst Depressed skull fracture

 Double density  Open vs. closed  Dural tear  Epilepsy  Operate when open and > 5 mm. Posterior Fossa Subdural Hematoma

 Occurs in newborns  Follow Hgb  Rarely needs surgery  May develop hydrocephalus  Full term babies Subdural hematoma

 Follows contour of brain  Associated with brain contusion and burst lobe  Higher mortality and morbidity Subdural hematoma Subdural hematoma

 Bridging veins into sagittal sinus Subdural hematoma removal Epidural hematoma

 Little brain injury  Time is critical  Middle meningeal artery  Skull fracture  Shock in infants Epidural hematoma Epidural hematoma

 Lens shaped  + /- Skull fracture  Shift Epidural hematoma Subdural versus Epidural Contusion

 Basal frontal and temporal lobes  Can develop into a hematoma  Increased ICP Contusion

 Coup – contra coup injury Focal Injury – Basal Contusion

 Is usually frontal or temporal lobe Tentorial herniation

 Uncus of temporal lobe compresses brain stem  3rd nerve  Kernohan’s notch Cerebellar herniation

 Cerebellar tonsils herniated through foramen magnum  Medullary failure and respiratory arrest  Posterior fossa mass Cerebral herniation

 Duret hemorrhage  Caused by brain stem distortion Diffuse axonal shear injury

 Common in children  Tiny axonal tears and hemorrhage through white matter , corpus callosum, cerebellar peduncle Cerebral swelling

 Increased blood volume, Not edema  Usually transient  ICP increased  “childhood concussion syndrome”  CT – ground glass appearance Cerebral edema

 Increased brain tissue water  Vasogenic  Cytotoxic  Increased ICP Cerebral edema Shaken baby syndrome

 Severe shaking and impact – acceleration / deceleration  Intracranial hemorrhage and edema  Retinal hemorrhages Shaken baby syndrome

 Subdural most common, often bilateral  Posterior interhemispheric SDH  Severe cerebral edema Non-accidental head trauma Shaken baby syndrome

Bilateral subdural hematomas Subdurals drained with atrophy Fat Embolism

 Diffuse white matter petichae  Long bone fracture  Increased ICP MTBI and Football

 60’s work of Dr. Schneider  Transmitted force from vertex impact - “spearing”  changed helmet design  rule changes  Cervico-medullary and C spinal cord injuries Postconcussive syndrome

 Headache, irritability, inability to concentrate, sleep abnormalities, dizziness  Resolves over 6 to 8 weeks Cumulative Injury

 Effect of concussion more pronounced after second MTBI  Timing between 2 concussions important to development of long lasting effects  Boxing injuries - “dementia pugilistica” progressive dementia, movement disorder, tremor, cognitive and psychiatric symptoms Concussion classification

 Grade 1 - Mild confusion, No LOC, resolves in 15 minutes  Grade 2 - Amnesia, No LOC, symptoms > 15 minutes  Grade 3 - LOC > 5 minutes, or amnesia >24 hours Second impact syndrome

 potentially fatal  athlete sustains second blow to the head before completely recovering from a first concussion  Diffuse swelling, loss of autoregulation  Pt. Collapses with dilated pupils and herniation after walking around dazed  children and teenagers more susceptible Return to Competition

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

 Grade 2 terminate play return after 1 asymptomatic week at rest and with exertion after 2nd MTBI, hold for 2 asymptomatic weeks or for season if any MRI abnormalities Return to Competition

 Grade 3 terminate play go to hospital can return to play after 1 asymptomatic week or 2 weeks if symptoms were prolonged After 2nd , hold for 1 asymptomatic month After 3rd, consider no further contact sports Pediatric Head Trauma

 Coma due to: Brainstem compression due to increased ICP Bilateral cerebral injury – diffuse axonal injury Metabolic etiology Seizure Intracranial pressure

 Cushing’s triad Bradycardia Hypertension Elevated ICP Pressure volume curve

 Exponential  High compliance at low ICP  Low compliance at higher ICP (tight brain)  Volume buffering capacity Pressure Volume Index

 PVI is theoretical volume needed to raise ICP 10 fold  Linear relationship between volume and ICP  Useful clinical measuring tool to determine brain tightness ICP Waves

 A Wave Plateau wave 50 to 100 mm Hg 10 to 20 minutes Vasodilatation Low compliance Can be fatal Origin of “A” Waves

 Low compliance – tight brain  ICP goes up  Cerebral perfusion pressure falls  Vasodilatation to compensate blood flow  ICP de-stabilizes ICP Waves

 B Waves Occur at elevated baseline ICP 10 to 40 mm Hg One per minute Cheyne stokes respiration? Severe head injury – ICP monitoring

 GCS 8  DAI  Baseline ICP 18- 20  Low PVI (tight brain)  Plateau occurs ICP Monitoring

 Multiple “A” Waves  Very low compliance  Often uncontrollable and fatal Hyperventilation

 Lower CO2 results in lower CBF and ischemia  Can be used as emergency measure  Consider xenon CT or jugular venous O2 monitor Hyperventilation and Ischemia

Xenon CT scans

Normocapnia – normal blood flow Hyperventilation – Ischemia PCO2= 38 PCO2=24 Management of Increased ICP

 Sedation and paralysis Propofol and Sevoflurane  Controlled ventilation  Normal CO2 – Eucapnia  Normovolemia  Controlled hypothermia  No steroids  Pain control Management of Increased ICP

 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 surgery Decompression Hemicraniectomy Lobectomy Hematoma evacuation Management of Increased ICP

 Pentobarbital Coma Maximal conventional intervention EEG suppression BP and cardiac output support Brain Compliance and ICP

 Child normally has steeper pressure- volume curve  Trauma shifts curve to left (steeper)  Rx shifts PV curve back to right Aggressive treatment of severe head trauma

 Ventricular drainage  Mannitol  Paralysis  Normalization of PVI  Pentobarb coma Aggressive treatment of severe 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’s cervical spine

 Normal neuro exam  Lack of pain  Good quality lateral cervical spine Xray Lack of fx or subluxation no signs of ligamentous instability No prevertebral swelling Normal C spine Open mouth C2 views

A-O junction

C1

Dens

C2 C spine open mouth view Atlanto-occipital dislocation

Basion to tip of dens < 12 mm Odontoid growth center C2 - C3 Pseudosubluxation SCIWORA

 Spinal cord injury without radiologic abnormality  Mostly young children, 8 yrs or less  Upper cervical cord injury, can be thoracic also  High percentage of complete cord injuries Correctable problems

 Epidural hematoma  Ruptured disc  Correct instability  Associated pathology (pathologic fracture) C1/C2 Rotatory subluxation

 Minor mechanism of injury  Torticollis; “cock-robin” head position  Traction, analgesia Lap belt injuries

 Upper lumbar  Lap belt without shoulder strap  Associated with small bowel rupture  Horizontal fracture (Chance) Clearing cervical spine in children

 Awake; no pain - simple C series  Awake, pain - C spine series, then consider flexion extension views, +/- CT scan  Not awake - C spine series normal, CT scan normal - spine cleared. If questionable finding consider flexion - extension under fluoro. Clearing cervical spine in children

 Mechanism of injury evaluated first  Awake or lethargic or unconscious  Exam - pain, tenderness, neurologic  SCIWORA - full evaluation, Xrays, CT, MRI, flex-extension  If intubation needed proceed before C spine evaluation. Rehabilitation

 Spasticity - Intrathecal baclofan pump  Spinal cord rehab center  Cardiovascular - autonomic  Prevention Think first for kids