Pediatric head injury caused by off-road vehicle accidents

Morbidity and mortality from pediatric head injuries associated with the use of off-road vehicles are increasing. We reviewed all such injuries admitted to acute care hospitals in the two largest urban centers in Manitoba between April 1979 and August 1986. Of 375 injured children, 83 suffered head injury, 70 boys and 13 girls. Ages ranged from 2 to 15 years, with a mean of 10.4 years. Head injury was defined as any injury involving face, scalp or nervous system. Dirtbikes were implicated in 34 accidents, snowmobiles in 28, 3-wheel ATV's in 19, and 4-wheel ATV's in 2. About 85% of accidents occurred in a rural setting. Loss of vehicle control was the most common cause of injury. Alcohol or drug abuse were not factors. Fifty (60.2%) patients suffered loss of consciousness, prolonged in 6 (7.2%). All head-injured children also suffered at least one associated injury, mainly involving the musculoskeletal system. Associated spinal injury occurred in 18%. The average hospital stay was 13 days. Three (3.6%) patients died as a result of head injury.     

Vomiting in children following head injury

The criteria for hospital admission of children who have suffered a minor head injury are highly subjective. Often the presence of post-traumatic emesis becomes an influential factor, but the mechanisms that trigger emesis following minor head injuries are not known. From a prospective study of 96 consecutive children with their first mild head injury (GCS 13–15) and a retrospective study of 29 consecutive more seriously injured children (GCS 8–12), we conclude that post-traumatic emesis is more common: (1) following minor head injuries than following more severe head injuries (P<0.05); (2) in children over 2 years old; (P<0.001); (3) in children injured within an hour of a meal or snack (p<0.001). The presence of a skull fracture or the site of the impact does not influence the incidence or duration of post-traumatic emesis. Retching and vomiting generally subside within 3 h in children injured within an hour of a meal or snack. When vomiting appears in children injured more than an hour after a meal or a snack, it may be quite protracted (mean=7.5 h). Children over 2 years of age with post-traumatic emesis who are neurologically stable following a mild head injury that occurred within an hour of a meal or snack can be expected to improve quickly. Their counterparts injured more than an hour after a meal or snack are likely to remain distressed much longer and are best admitted to hospital.     

The head-injured child who “talks and dies”

The phenomenon of talking and deteriorating after closed head injury exists in children. A variety of causes have been identified, few of which are operatively remedial. Four cases of children with head trauma are reported, in each of whom there was an interval during which the child verbalized to some degree. Rapid neurological decline then occurred approximately 30–50 h postinjury in each child, who subsequently died from their trauma. In all instances the children were injured in motor vehicle accidents or falls, had initial Glasgow Coma Scale ratings of 9 or better, and demonstrated irritability and restlessness just prior to their deterioration. In no circumstance was a space-occupying intracranial hematoma present. Post-mortem brain examinations in two of the children showed in common multiple cerebral contusions, brain edema with herniation phenomena and hypoxic-ischemic encephalopathy.Presented at the 17th Annual Meeting of the International Society for Pediatric Neurosurgery, Bombay 1989     

Pattern,management and outcome of cervical spine injuries associated with head injuries in paediatric patients

Introduction This study examines the management and outcome of cervical spine injuries in children with head injuries, to assess the need for surgical treatment. Material and methods We performed a retrospective analysis (1995–2005) of 445 children admitted intubated and ventilated to the intensive care unit with head injuries. Outcome measures: Frankel grade for spinal injuries and Glasgow Outcome Scale (GOS) for head injuries. Results Cervical spine injuries were detected in 11 patients (incidence 2.5%, mean age: 6.3 years, range: 21 months–15 years). The injuries were: C1/2 distraction: 2; C1/2 subluxation: 2; odontoid peg fracture with C1/2 dislocation and cord transection: 1; disruption of posterior longitudinal ligament at C2: 1; odontoid peg fracture with C2/3 distraction: 1; C2/3 subluxation: 1; C3 lamina fracture: 1; C3/4 facet fracture: 1; C6/7 fracture dislocation with cord transection: 1. One patient was managed operatively, ten patients nonoperatively, two with halo vests and eight with hard collars. There were three deaths (mortality 27%) associated with severe head injuries. At 6 months follow-up, two patients remained quadriplegic (Frankel Grade A), one of them ventilator dependent, one had residual motor function but of no practical use (Frankel Grade C), five had good spinal outcome (Frankel Grade E). Seven patients had good head injury outcomes (GOS 5), one remained disabled (GOS 3). Conclusion Most children with cervical injury can be managed nonoperatively with good outcomes. Surgical management may be necessary in severe unstable injuries.     

45例GCS 3分特重型颅脑伤病人临床救治经验

目的总结我科GCS 3分特重型颅脑伤病人的临床救治经验。方法对我科1995年1月~ 2001年1月收治的45例GCS 3分特重型颅脑伤病人进行回顾性总结。结果45例病人存活22例(48.9%)。其中恢复良好和中残10例(22.2%)、重残9例(20.0%)、植物生存3例(6.7%);另23例死亡(51.1%)。结论尽早清除颅内血肿、大骨瓣减压、早期亚低温治疗、呼吸机辅助呼吸、维持内环境稳定及防治并发症等措施,可显著改善GCS3分特重型颅脑伤病人的预后。     

The significance of skull fracture in mild head trauma differs between children and adults

Objective The objective was to determine whether the age of patients with mild head injury and skull fracture influences the level of risk for acute intracranial injuries.Method A study was conducted of 156 patients with skull fracture, 60 children (aged <14 years) and 96 adults, detected among 5,097 consecutive patients with mild head injury (Glasgow Coma Scale [GCS] score of 15–14 points) arriving at the Emergency Department of a Level I University Hospital Trauma Center during 1998. Acute intracranial injuries were defined as traumatic brain injuries identified by cranial computed tomography scan, excluding pneumocephalus.Results Compared with the children, this risk of intracranial injury was 13 times greater in the adults aged 14–54 years and 16 times greater in the over-54-year-olds. Besides age over 14 years (p<0.0001), compound skull fracture (p<0.001), and a GCS score of 14 (p<0.001) were factors significantly associated with intracranial injury in the logistic regression analysis.Conclusions Skull fracture in mild head injury implies a greater risk of intracranial injury in adults than in children.     

Pediatric head injuries caused by traffic accidents

In an unselected series of 488 patients with head injuries referred to a general surgical department, there were 126 children aged 0–19 years whose head injuries were a result of traffic accidents. In age group 0–4 years, only 23% of the head injuries were due to traffic accidents. In age groups 5–9, 10–14, and 15–19 years, however, traffic accidents were the main cause of the injuries, being responsible for 47%, 65% and 82% of the cases respectively. Both age groups 5–9 and 10–14 years had an unusually high proportion of bicycle injuries, while motorcycle and automobile accidents were the leading causes of injury in age group 15–19 years. Eight children (6%) died as a result of head trauma. Furthermore, among the survivors there were 8 children with severe head injuries (post-traumatic amnesia lasting 24 h), the rest being minor head injuries. All the survivors but one returned to school and achieved reasonable performances. Repeated follow-up studies at 3 months, 1 and 5 years, including interviews with the parents, disclosed that several of the children had headache, dizziness and other complaints. These subjective complaints subsided with time, but with different patterns, in the younger and older age groups. It is concluded that the postconcussional syndrome is not uncommon in children, but it may be better tolerated and resolves more completely with time than in adults. Eight children (7%) had one seizure or more during the 5-year follow-up period.     

Head injuries in children under 36 months of age

Head injuries in children under the age of 3 years have not been extensively studied, due in part to the lack of an objective tool for neurological assessment. We have developed a Children's Coma Scale (CCS) by modifying the verbal response subscore of the Glasgow Coma Scale (GCS) to overcome this limitation. When applied prospectively to children under 3 years of age, we found the CCS to be useful in predicting outcome. During the 5-year study period from 1981 to 1985, there were 738 patients with head injuries (0–16 years) admitted to the Children's Memorial Hospital in Chicago, including 318 (43.1%) less than 3 years of age. Initial data demonstrated the following observations. The most common mechanism of injury was a fall (75.5%). Although a brief loss of consciousness (LOC) was reported in three-fourths of the patients, prolonged LOC of more than 6 h was uncommon (16/318, 5.0%). The classically described lucid interval was seen in only 7 children (2.2%) and was not a reliable indicator of epidural hematoma. Post-traumatic seizures developed more commonly in children under 2 years of age (15.7%) than in older children (11.6% under 3 years of age, 9.6%, entire group), (P<0.001). Oculovestibular reflex and bilateral fixed dilated pupils had the most reliable correlation with outcome. Other brain-stem reflexes were less useful. Intracranial pressure greater than 40 torr in children with CCS scores of 3, 4 or 5 was inevitably fatal; however, 10 of 16 children with ICP less than 40 torr showed a good outcome.Presented at the 15th Annual Meeting, Section of Pediatric Neurosurgeons of the American Association of Neurological Surgeons, Pittsburgh, December 1986     

Penetrating head injury: a prospective study of outcomes

The purpose of our study was to describe the outcomes of persons with penetrating brain injury resulting from a gunshot wound to the head. It is a prospective study of 442 patients admitted with gunshot wounds to the head over a 7 year period to our University Trauma Center Emergency Department, an urban trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Measures and factors described include initial Glasgow Coma Scale score, Revised Trauma Score, the Disability Rating Scale, Functional Independence Measure, levels of cognitive functioning, patient demographics, length of stay, hospital charges, and discharge disposition. Initially 36% of patients expired in or were dead upon arrival to the Emergency Department; 64% of patients survived to be admitted for inpatient care. Of those admitted, 41% expired within the first 48 h of admission. Fifty-two percent of those admitted had severe injuries, 7% moderate injuries, and 42% had mild head injuries. Sixty-two percent of the survivors were discharged from acute care to private residences. The remaining 38% were discharged to programs providing varying levels of care depending upon their level of functioning and care needs. Patients sustaining severe injuries following gunshot wound(s) to the head have high early mortality. Survivors able to participate in an inpatient rehabilitation program have good potential for functional improvement.     

Head or brain injuries and Alzheimer's disease: A nested case-control register study

Introduction

Many previous studies have been limited by self- or proxy-reported injury or short follow-up. We investigated whether head or brain injuries are associated with Alzheimer's disease (AD), possible modifying factors and dose-response relationship.

重型颅脑损伤术中急性脑膨出的原因及处理

目的探讨重型颅脑损伤术中急性脑膨出的形成原因及处理措施。方法分析30例重型颅脑损伤患者术中出现脑膨出的原因及处理。结果本组病例经神经外科专科综合治疗并随防半年以上,出院时按格拉斯哥预后评分(GlasgowOutcome Scale,GOS)标准判断预后:恢复良好4例(13.3%),中度残疾10例(33.3%),重度残疾8例(26.7%),持续性植物状态2例(6.7%),死亡6例(20.0%)。结论重型颅脑损伤术中出现急性脑膨出的原因有多种,对重型颅脑损伤术中急性脑膨出及时采取相应措施可提高疗效。     

Delayed coma in head injury: Consider cerebral fat embolism

Objective

To describe a case of a young man with delayed coma after mild head injury, suggestive of cerebral fat embolism (CFE). To underline the value of MR imaging in the differential diagnosis of secondary deterioration in mild head injury.

Case report

A 21-year-old man admitted with mild head injury after a fall with facial fractures and long bone fractures. He was admitted to the intensive care unit and was mechanically ventilated. Weaning was not possible because of desaturations and pulmonary congestion. Low platelet count and anaemia developed. On several time points during his admission cerebral imaging data were obtained. Non-contrast CT on admission was normal while follow-up MRI showed extensive white matter abnormalities. These imaging abnormalities combined with the clinical presentation suggests cerebral fat embolism (CFE) as the most likely cause of secondary deterioration in our patient.

Conclusions

In head injured patients with long bone fractures one should consider cerebral fat embolism. When the classical clinical syndrome is not present, MR imaging is warranted for diagnosis and to exclude other causes of secondary deterioration.     

Features of pediatric head injury in Hong Kong

Head injury in children causes special concern in most communities. From 1989 to 1994, 2,785 children younger than 16 years old were admitted to our neurosurgical service because of head injury. Fall from a height was the major cause of head injury leading to admission in infants and children in preschool age groups, whereas traffic-related or bicycle-related accidents were more likely to be the cause of head injury for those aged 11–15 years. In all age groups there was a male preponderance. The overall mortality was 0.6%. Traffic-ralated accidents caused more severe injury and accounted for 67% of all fatalities. For patients under 6 years old, about 40% of head injuries occurred at home. Preventive measures for pediatric head injury in Hong Kong are suggested.     

Speeded performance following head injury in children

Fifty-one children who has sustained head injuries were divided into mildly, moderately and severely injured groups according to neurological criteria. The groups were matched for age, sex, and injury-test interval. Approximately 1 year after their injuries, patients were tested on speeded and nonspeeded measures of motor, visual-motor, and visual-spatial functioning as well as on the WISC-R. The performance of the mildly and moderately injured groups was similar, with both groups performing significantly faster than the severely injured group on measures of speeded performance. There were few significant differences between groups on measures requiring little speed. In contrast to the results for the other two groups, the severely head-injured group performed significantly worse on the highly speeded tests than on the low speed tests. The findings are discussed in relation to the literature on the cognitive sequelae of head injuries.     

Current incidence and management of children with traumatic head injuries: The Stockholm experience

Purpose: A traumatic head injury is one of the most common causes of morbidity and mortality among children, however few population-based studies in this area have been reported. Therefore, the aim of this study was to evaluate the incidence and management of traumatic head injuries in children at a level-one trauma centre in Stockholm, Sweden.

Participants: All children (n?=?3168) who visited the emergency department with a history of head injury during 1 year were included.

Method: The required information was collected retrospectively and the children's medical records were reviewed.

Results: The overall incidences of head injury were 865 per 100 000 children with the highest incidence (2379/10⁵ children) occurring among children younger than 18 months of age. Twelve per cent (n?=?396) were admitted to a hospital ward and CT scans were performed in 13% (n?=?412) of all children. During this year, 0.3% required a neurosurgical intervention and only 1% of all children had documentation of a planned follow-up appointment.

Conclusion: The findings indicate that clinical documentation as a part of the early management in children with a head injury is inconsistent and suffers from lack of valid criteria. Implementation of clinical guidelines during emergency care would help improve subsequent hospital care, as well as the planning of health care services for these children.     

Pediatric golf-related head injuries

Objectives Golf-related head injuries constitute an increasingly common mechanism of head trauma in children. We present our experience with 33 pediatric cases of golf-associated head injury, with special emphasis in the type of injury, management strategy, and outcome.Materials and methods A thorough review of all children admitted to our hospital with golf-related head injury during a period of 10 years (1 January 1994 to 31 December 2003) was undertaken. The patients’ charts, operative reports, imaging studies, and follow-up data were analyzed. A comparison of our findings with those described in the pertinent literature was subsequently performed.Conclusions Pediatric golf-related head trauma is a significant cause of sport-associated head injury, sometimes harboring a very dismal prognosis. The significance of establishing a task force for the prevention of these injuries cannot be overemphasized.     

Clinical outcome after head injury in children

For at least 1 year we have done a follow-up on 178 children under the age of 18 years with head injuries treated between 1981 and 1987. The Brussel Coma Scale and the Glasgow Outcome Score were used to determine neurological deficits and patient outcome. In children with coma, there was good recovery or moderate disability in 71.4%, severe disability in 6.1%, and death in 22.5%. When all head injuries were taken into consideration, a satisfactory outcome was found in 84.3%, severe disability in 3.3%, and death in 12.4%. The outcome mainly depended on the initial coma grade, but the duration of coma or advanced age were also negative factors for outcome. In 14.8%, intracranial mass lesions showed no significant correlation with outcome. In contrast to adults, diffuse brain swelling had a satisfactory outcome in 85.1%.Presented at the 11th Meeting of the European Society for Paediatric Neurosurgery, Naples 1988     

Brain CT scan for pediatric minor accidental head injury. An Italian experience and review of literature

Purpose

Every year 300,000 children with accidental head trauma are admitted to Italian emergency departments. Our aims were: (1) to describe patients with minor traumatic brain injury who were admitted to pediatric departments and underwent CT, and (2) to analyze the appropriateness of management according to current guidelines.

Methods

We retrospectively analyzed patients with minor head injury (median age 4.5?years, range 1?month to 16?years) who were admitted to the pediatric department of the Catholic Medical School of Rome, from January 2005 to September 2010, who performed head CT. Univariate analysis was performed using the Fisher’s exact test. Multivariate analysis was performed by logistic regression.

Results

One hundred and seventy-four patients were enrolled in the study. Fifty-four patients (31%) had pathological CT findings. Eight patients underwent neurosurgical treatments. Vomiting was the only symptom significantly prevalent in the infant group, compared to the children group (10.7% vs. 38.9%, p?=?0.007), while loss of consciousness in the children group (50.0% vs. 25.0%, p?=?0.040). The relationship between scalp swelling and CT abnormalities was statistically significant in the entire population. The incidence of head abnormalities was significantly higher in children with abnormal CT (92.6% vs. 72.5%).

Conclusions

The best way to manage children with minor head trauma is still matter of debate. Loss of consciousness and scalp swelling are risk factors predicting brain injury that deserve CT control. The radiation risks posed by CT scanning in children must be balanced by the benefits. We believe that even though CT scans may be clinically unnecessary in many cases, the rate of scanning is justified by the even limited number of abnormalities which require neurosurgical treatment.     

Presenting characteristics of children who required neurosurgical intervention for head injury

Purpose

The purpose of this study is to describe the presenting characteristics of a large group of children who required neurosurgical intervention (NSI) following a head injury and to retrospectively assess which of the criteria for imaging from Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), Pediatric Emergency Care Applied Research Network (PECARN), and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) clinical decision rules (CDRs) were met by these patients.

Study design

We retrospectively reviewed all patients undergoing NSI following a head injury, between 2000 and 2008, at a large tertiary pediatric trauma center. We excluded patients having non-accidental injury, other neurosurgical interventions, penetrating injuries, and patients with incomplete data. To those who presented initially with mild head injury (GCS 14–15), we retrospectively applied the criteria for imaging of the CHALICE, PECARN, and CATCH CDRs.

Results

Out of 289 patients undergoing NSI, 182 met inclusion criteria and comprised our cohort. Of the 72 (39.6 %) with mild head injury (GCS 14–15), 71 (98.6 %) met at least one criteria for imaging from each of the three CDRs, including severe mechanism of injury (68, 94.4 %), clinically evident skull fracture (35, 48.6 %), neurological deficit (19, 26.3 %), or severe headache (6, 8.3 %). Of the 182 patients in the entire cohort, only 1 (0.5 %) did not present with an obvious indication for CT on all three CDRs.

Conclusions

In a large sample of children requiring NSI after head trauma, the vast majority met CT criteria listed in each of the three CDRs. The most common indication for CT was a severe mechanism of injury. This, combined with clinically evident skull fracture, neurological deficit, and severe headache, identifies almost all patients requiring NSI.

     

轻型颅脑损伤分型初探

目的：评价轻颅脑伤病人伤情及结局,提出对其进一步分型方法,方法：应用GCS评分,头AIS分级,早期放射学检查及GOS分级回顾性分析956例GCS13－15的的轻型颅脑伤,结果,全组有头部较严重解损伤（头AIS3－5分）者占25．52％轻型 伤病人的GCS评分愈高,其解剖损伤程度愈低,需神经外科处理率愈小,预后愈好,重新分组后A组672例均列需神经外科处理,且预后良好,B组284例中13．03％需神经外科处理,且中,重残及死亡率分别为11．27％,2．46％,0．70％,两组需神经外科处理率及预后均相差显著（P＜0．001）,结论：GCS评分及早期放射学检查对病人危险性判断有意义,因此可将GCS15分,无放射沈阳 性征者称为I型轻型颅脑伤,而将GCS13或14分,及GCS15分并有早期放射学征阳性者称为11型轻型颅脑伤,II型轻型颅脑伤刘经外科处理的可能性明显较高,而预后较差,需引起医生的重视。