Craniocerebral trauma

Dr lokesh kumar meena

HEAD INJURY

•Major cause of mortality and morbidity in children.

•Leading cause of death in children > 1year is trauma.

•Head injury is responsible for most trauma deaths approximately 80%. (50% in adults)

ETIOLOGY• Road traffic accidents

Severe head injuries• Falls

Usually in children <4years and usually mild• Recreational activities

Bicycle accidents• Assaults/NAI

Most head injuries in kids <1yr

are from falls and NAI

What are the names of these signs?

SKULL FRACTURES

• ANY skull fracture can cause underlying ICH, but 50% of bleeds have no fracture

• Skull films are of little use - if suspect skull fracture or bleed, get non contrast CT

QuickTime™ and a decompressor

are needed to see this picture.

SKULL FRACTURES•Linear(3/4)- outpatient observation OK, but get neurosurgical evaluation and f/u if under age 2

•Can develop leptomeningeal cyst if dural tear•Depressed - require neurosurgical evaluation possible repair if depression>skull thickness

•More often develop seizures•Often get prophylactic

•Basilar (Battle’s sign, haemotympanum, raccoon eyes) - head CT with inpatient observation, neurosurgical evaluation.

Skull Fracture

Fracture•Smooth or jagged edge

•Straight line

•Angular turn

•Darker on X-ray

•Any locations

Suture•Serrated edge

•Curvilinear

•Curvilinear

•Lighter

•Lesser width

•Specific anatomic

•location

Axial CT: linear non-depressed fracture (red arrows) of left parietal bone. Note soft tissue hematoma overlying the fracture.

Retrospective review of the skull x-ray shows faint fracture line.

Case 1

•A 2 year-old comes in after falling approximately 3 feet from her parent’s bed. The CT scan shows the following:

What is your diagnosis?

1. Epidural hematoma

2. Subdural hematoma

3. Diffuse axonal injury

4. Contusion

Subdural

Subdural Hematoma

•More common than epidural in children

•Tears in parasagittal bridging veins

•Concave shape/

•Often associated with more diffuse shear injury

•Immediate surgical tx if pt is unconscious and has subdural bleed

Case 2

•A 5 year old girl falls from a second story window. You find the following on CT scan:

What is your diagnosis?

1. Epidural hematoma

2. Subdural hematoma

3. Diffuse axonal injury

4. Contusion

Epidural Hematoma

Epidural Hematoma• Caused by tears of

meningeal vessels• Convex shape• Often associated bone

fracture (up to 75%)• Typically few hours of

lucidity followed by rapid deterioration

• Need close observation and often surgical evacuation

• Good prognosis if recognized and treated

SUBDURAL VS. EPIDURAL

SUBDURAL HEMATOMA

WebPath: University of Utahhttp://www-medlib.med.utah.edu

EPIDURAL HEMATOMA

WebPath: University of Utahhttp://www-medlib.med.utah.edu/

SUBDURAL vs EPIDURAL HEMATOMA

•EPIDURAL

•Requires linear force

•Associated with skull fracture and torn artery. Brain often uninjured

•“Lucid” interval common

•Common in accidental trauma

•SUBDURAL

•Requires significant rotational forces

•Associated with brain injury and torn bridging veins

•Neurologic symptoms from the start

•Common in infants with NAI.

TYPE Clinical Signs CT signs

EPIDURAL Lucid interval followed by deteriorating mental status

biconvex (lentiform) confined by sutures

SUBDURAL Altered consciousness, pupil abnormalities, can be gradual in onset

Bi concave, not confined by sutures

SUBARACHNOID “Worst headache of life” more often associated with aneurysm, HTN

Hyperdensities in cisterns (star pattern)

PARENCHYMAL Behavioural and cognitive changes, coup countercoup injuries

round or irregular hyperdense lesions

Thank you…………and …………

Secondary Injury•Subsequent factors that secondarily cause brain tissue damage

•Intracranial

•Hemorrhage/Ischemia•Edema•Increased ICP

•Systemic

•Hypoxia/hypercapnia•Hypotension•Hyperglycemia

SUBFALCIAL HERNIATION

•Subfalcial: displacement of the cingulate gyrus under the free edge of the falx along with the pericallosal arteries.

•Can lead to anterior cerebral artery infarction

UNCAL HERNIATION

•Displacement of the medial temporal lobe through the tentorial notch

•Displacement of the midbrain

•Effacement of the suprasellar cistern

•Displacement of the contralateral cerebral peduncle against the tentorium

•Widening of the ipsilateral cerebello pontine angle

•Compression of the posterior cerebral artery

DOWNWARD HERNIATION•Caudal displacement of the thalamus and midbrain

•Effacement of the perimensencephalic cistern and 4th ventricle.

•Can cause a 3rd nerve palsy and disrupt pontine vessels leading to brainstem hemorrhage

UPWARD HERNIATION

•Due to posterior fossa mass causing superior displacement of the vermis through the tentorial incisura

•Compression of the 4th ventricle and effacement of the quadrigeminal plate cistern.

•Compression of the superior cerebellar artery

Severe Traumatic Brain Injury (TBI)

•Definition: Head trauma associated with a Glasgow Coma Score of ≤ 8

Best Eye Response

Best Verbal Response

Best Motor Response

1. No eye opening2. Eye opening to

pain3. Eye opening to

verbal command4. Eye opening

spontaneously

1. No verbal response2. Incomprehensible

sounds3. Inappropriate words4. Confused words5. Appropriate verbal

responses

1. No motor response2. Extension to pain3. Flexion to pain4. Withdrawal from

pain5. Localizing to pain6. Obeys commands

Defining Severity

•Mild Brain Injury

•GCS = 13-15•Limited impaired consciousness (<30

min)•Normal CT scan•Shows signs of a concussion• Vomiting• Lethargy• Dizziness• Lacks recall about injury

Defining Severity• Moderate Brain Injury

• GCS = 9 - 12• Impaired Consciousness (<24)• CT scan Evidence

• Severe Brain Injury• GCS = 3 - 8• Impaired Consciousness

(> 24 hours)

CAUTION!!

• GCS of 13 may not be so “mild”

• SC Stein, J Trauma. 2001;50:759-760• Reviewed 14 studies

(1047 adult patients with GCS

of 13) • 33.8% had intracranial lesions• 10.8% required surgery

Defining Severity

• GCS, hypoxemia and radiologic evidence of SAH, cerebral edema and DAI are predictive of morbidity.

• GCS alone does not predict morbidity. Ong et al. (1996) Pediatric Neurosurgery, 24(6)

• Hypotension is predictive of morbidity.

• GCS and Pediatric Trauma Score are

not predictive of outcome. Kokoska et al. (1998), Journal of Pediatric Surgery, 33(2)