Craniocerebral injuries in pediatric patients Eva Brichtova, MD., Ph.D., Pediatric injuries – global problem mapa svět úrazy Injury related mortality Not known WHO 2002 Mortality (per 100 000) - the most common cause of death in children under 14 years - craniocerebral injuries represent the most serious injuries with possibly lifelong consequences Pediatric injuries in Czech republic Graf urazovost 2005 WHO Injury related mortality in children in European countries (WHO Mortality Database 2005) Pediatric Traumatology Center, Faculty Hospital Brno (ISO 9001/2000 certified) 7000 injuries/year 400 head injuries/year 88% - cerebral concussion and superficial head injury FOTO FDN 002 Factors determining the specificity of craniocerebral injuries (CCI) in children under 2 years of age The immaturity of the nervous system - ongoing myelination - proliferation of glial cells - integration of the blood-brain barrier Physical properties of the skull - thinner and more flexible skull - persisting cranial sutures - smoother topography of the skull base Head-Trauma-Child The aetiology of craniocerebral injuries in children under 2 years of age Crashes (from the changing table or stroller, walking) Car accident (unrestrained in a car seat) Birth trauma (instrumentation using birth) Child abuse („shaken baby“) Patients hospitalized with severe CCI in the Faculty Hospital Brno DSCN6760 Haemostasis should be very carefull due to increased risk of hemorrhagic shock Specifics of the CCI in children under 2 years of age Injuries to scalp DSCN6760 Patients weighing 5 kg - 400ml blood volume 100 ml blood loss = 25% blood volume! Hypovolemic shock Subperiostal bleeding due to perinatal injury Increased pressure on the neonatal head passing through the birth canal The incidence in newborns from 0.2% to 3.0% Using birth instrumentation (forceps birth, vacuumextractor) Predominantly parietal location DSCN0016 Specifics of the CCI in children under 2 years of age Cephalhaematoma (KDCHOT FN Brno) More than 80% of cephalhaematomas spontaneously resorbe within 3 weeks In the absence of spontaneous and rapid absorption, calcification and ossification of the cephalhaematoma surface create bone crest, which distorts the shape of the head Calvarial bones resorbtion under the ossificated cephalhaematoma 080220101141 Specifics of the CCI in children under 2 years of age Cephalhaematoma Figure 3 Cephalhaematoma treatment - punction Specifics of the CCI in children under 2 years of age Cephalhaematoma Ossified cephalhaematoma in CT and 3D CT Kefalhematom 3D otočený Cephalhaematoma Specifics of the CCI in children under 2 years of age Ossified cephalhaematoma treatment - early neurosurgery at the age of 1-3 months Specifics of the CCI in children under 2 years of age Cephalhaematoma Figure 9 Figure10 1 week after the surgery 18 months after the surgery Specifics of the CCI in children under 2 years of age Cephalhaematoma Linear fracture - The most common type of fracture - Conservative treatment (observation in hospital for 5 days) - To rule out serious intracranial complications - brain sonography over a large fontanel Fisura kalvy Spiříková Klára, 3 měsíce Specifics of the CCI in children under 2 years of age Skull fractures Growing fracture (leptomeningeal cyst) -occurs rarely (less than 1%), predominantly in the parietal localization -rupture of the dura mater leads to leptomeningeal cyst -filled with cerebrospinal fluid -progressive dilatation of the fissure edges Rostoucí fraktura Rotsoucí fraktura 2 Specifics of the CCI in children under 2 years of age Skull fractures Growing fractrure Marinová Kristina 3D 1 měsíc Growing fractrure Marinová Kristina 1 měsíc Growing fracture in CT and 3D CT Specifics of the CCI in children under 2 years of age Skull fractures DSCN3360 Growing fracture surgery treatment Specifics of the CCI in children under 2 years of age Skull fractures DSCN3369 Specifics of the CCI in children under 2 years of age Skull fractures Growing fracture surgery treatment DSCN3374 Specifics of the CCI in children under 2 years of age Skull fractures Growing fracture surgery treatment DSCN3377 Specifics of the CCI in children under 2 years of age Skull fractures Growing fracture surgery treatment Impressive fracture Ping-pong fracture Causes: birth trauma or fall on the edge of the object ping pong Specifics of the CCI in children under 2 years of age Skull fractures ping pong CT 3DCT Ping-pong fracture in CT and CT 3D Specifics of the CCI in children under 2 years of age Skull fractures Ping pong otočený ping poing operační Ping-pong fracture – before and during surgery Specifics of the CCI in children under 2 years of age Skull fractures Specifics of the CCI in children under 2 years of age Epidural haematoma Bleeding into epidural space (between the cranial bones and dura mater) Skull X-ray finding of skull fracture represents an increased risk of epidural hematoma absence of fracture does not preclude the development of epidural hematoma! In newborns and infants with non-ossified skull sutures increased intracranial volume symptoms appear much more later! EDH SDH po Bleeding into subdural space (between hard and soft mater) Acute subdural hematoma akutní SDH Specifics of the CCI in children under 2 years of age Subdural haematoma isodensní SDH Isodense subdural haematoma Specifics of the CCI in children under 2 years of age Subdural haematoma Collection of blood or cerebrospinal fluid in the subdural or subarachnoideal space (differentiation is difficult) Includes concepts of chronic subdural hematoma, hygroma or effusion Benign extraaxial collection - mostly bifrontal - mostly spontaneous regression Obr Specifics of the CCI in children under 2 years of age Extraaxial collection Symptomatic extraaxial collection - intracranial hypertension syndrome SD efuze, symptom Symptom efuze Specifics of the CCI in children under 2 years of age Extraaxial collection Mládenka DSCN0456 (5) Treatment of symptomatic extraaxial collections - Puncture over a large fontanel - Trepanation and evacuation - Temporary external drainage - Subduro-peritoneal shunt sono extraax kolekce Puncture over a large fontanel Control ultrasound Specifics of the CCI in children under 2 years of age Extraaxial collection Specifics of the CCI in children under 2 years of age Abused child syndrome (Battered child) Serious social and legal problem The discrepancy between the anamnestic data and severe clinical findings Multiple fractures, retinal haemorrhage, subcutaneous ahematoma, intracranial haemorrhage of various ages Deep structures minor haemorrhage or interhemispheric subdural hematoma („Shaken baby“) Battered child Craniocerebral trauma in children older than 2 years Skull fully ossified, the lesions are more similar to adults Simple skull fractures without any other traumatic intracranial lesions occur less often than in children under 2 years of age The most frequent cause of hospitalization is cerebral concussion Different aetiology of injuries, increasing number of traffic and sports accidents child_bicycle Strucked by vehicle Fall in motion Car accident Falling Fall from height Impact of object Impact against hard obstacles Child abuse Other Patients hospitalized with severe CCI in the Faculty Hospital Brno Traffic accidents 56% ! Craniocerebral trauma in children older than 2 years Craniocerebral trauma in children older than 2 years Cerebral concussion Functional, fully reversible impairment of brain function without detectable morphological changes The most common type of craniocerebral injury in children older than 2 years Short-term unconsciousness, amnesia for trauma Nausea, vomiting Headache Treatment: 2-day observation in the hospital, bedrest Regimen serves as a prevention of further difficulties (post-concussion syndrome) (Autonomic dysfunction, fatigue, impaired concentration, sleep disturbances and headaches) 110520101243 Usually associated with intracranial injury Linear fractures Craniocerebral trauma in children older than 2 years Skull fractures Simple impressive fractures CT 3Dimprese linear Surgical treatment for inverted over the thickness of the cranial bones Impresivni faktura A Craniocerebral trauma in children older than 2 years Skull fractures Comminuted impressive fracture Impr frakt tříst CT Tříst fraktura perope modif Fracture - open - closed Fracture - penetrated - non-penetrated Craniocerebral trauma in children older than 2 years Skull fractures Impressive fracture in the venous sinuses Bobista před Bobista Craniocerebral trauma in children older than 2 years Skull fractures Impressive fracture in the posterior cranial fossa Prokupek Branka impr freakt ZJ Craniocerebral trauma in children older than 2 years Skull fractures Fractures of the Skull Base anterior fossa middle fossa posterior fossa • art-nf436107 Craniocerebral trauma in children older than 2 years Skull fractures Fractures of the anterior, middle and posterior cranial fossa in CT and 3D CT Fraktura base 7 let 012Kontuse Pneumocefalus Dudek Patri 02 Craniocerebral trauma in children older than 2 years Skull fractures Fractures of the Skull Base Fraktura pravé pyramidy Petrošová Markéta 4 roky Transverse fracture of the pyramid can cause othorea More frequent type of liquorrhoea in children than in adults Nearly 100% resolve spontaneously Craniocerebral trauma in children older than 2 years Skull fractures Fractures of the Skull Base Abnormal communication between the subarachnoidel space and the nasal cavity or tympanomastoideal space Defect of the normal barrier between the CNS and the external environment, threatening infections of the CNS By location: - Rhinorrhoea - unilateral - Otorea - bilateral - Paradoxical rhinorrhoea Posttraumatic liquorrhoea in children is less frequent than in adults - Greater flexibility of baby skull - Smaller paranasal sinus pneumatization Liquorrhoea in children usually heals spontaneously Liquorrhoea Craniocerebral trauma in children older than 2 years Skull fractures Fractures of the Skull Base Craniocerebral trauma in children older than 2 years Epidural haematoma The typical clinical course with loss of consciousness, lucid interval and the development of ipsilateral mydriasis and contralateral hemiparesis due to bleeding from a. meningica media in pediatric patients is rare. EDH 2 The most common cause of epidural haematoma is bleeding from diploe blood vessels in cranial bone fracture. 014 EDH konsrvativně Baberad Antonin 95 Epidurál 2 Craniocerebral trauma in children older than 2 years Epidural haematoma Frontopolar epidural haematoma develops slowly and spreads more equally than in adults because of less adherent dura mater Epidurál 3 epidurál 4 Frontopolar epidural haematoma Craniocerebral trauma in children older than 2 years Epidural haematoma Infratentorial epidural haematoma Posterior fossa epidural haematomas occur more frequently than in adults Symptoms: repeated vomiting, sudden deterioration of consciousness EDH zadní jáma, D Craniocerebral trauma in children older than 2 years Epidural haematoma EDH oper poop epidurál Space occupying, expansive haematoma are treated by acute surgery Craniocerebral trauma in children older than 2 years Epidural haematoma Acute subdural haematoma Akutní SDH A common cause is bleeding from bridging veins Craniocerebral trauma in children older than 2 years Subdural haematoma Occurs very rarely in children, there is a hematoma discoloration and subdural hygroma formation chronický SDH Chron SDH 2 Craniocerebral trauma in children older than 2 years Subdural haematoma Chronic subdural haematoma Craniocerebral trauma in children older than 2 years Subarachnoideal haemorrhage Traumatic subarachnoideal bleeding mostly accompanies brain contusion Typically occurs along the falx or tentorium 013 SAK Rampula Dominik 91 Bez názvu 6 Bez názvu 7 Intraventricular haemorrhage is caused by injuries of intraventricular veins or by the choroid plexus rupture Threat of posthaemorrhagic hydrocephalus Craniocerebral trauma in children older than 2 years Intraventricular haemorrhage Focal bruising of brain tissue in place of direct impact or at the site opposite to impact (mechanism par contre coup) Contusion in cortical, subcortical or deep brain structures 011Kontuse Pneumocefalus Dudek Patri 02 kontuse 1 Craniocerebral trauma in children older than 2 years Cerebral contusion Treatment of brain contusion in children is predominantly conservative Multiple cerebral contusion kontuse vícečetné kontuse vícečetné 2jpg Craniocerebral trauma in children older than 2 years Cerebral contusion Craniocerebral trauma in children older than 2 years Haemorrhagic contusion Bleeding to contusion causes traumatic intracerebral haematoma 008Kontuse Hradil Jakub 94 Primary diffuse brain injury resulting from rotational, acceleration and deceleration mechanism Microscopic level of axonal injury The clinical picture is varied, the main symptom is coma of varying depth and duration Delayed MRI shows a T1 hypointense lesions mostly in corpus callosum and mesencefalon Craniocerebral trauma in children older than 2 years Diffuse axonal injury Craniocerebral trauma in children Penetrating Brain Injury Gunshot wounds Cutting injury Střelné poranění L Sečné poranění sekačkou, Andrlová Anna Marie 6 let Obr Obr Stub injury Craniocerebral trauma in children Penetrating Brain Injury Stab injury - preoperative and postoperative X-ray and CT škrabka RTG škrabka po operci Craniocerebral trauma in children Penetrating Brain Injury Kazuistika4b Dog bite Craniocerebral trauma in children Penetrating Brain Injury Posttraumatic skull defects in children Obr Result of extensive comminuted fractures, where primary cranioplasty is not possible DSCN6772 Kazuistika4 The specific topic of skull defects treatment in children with incomplete growth of the skull Development of porous biomaterials, which allow host tissue ingrowth Computer 3D processing, modeling and production of custom implants Kazuistika4a Posttraumatic skull defects in children Thank you for your attention