A brief review on paediatric head injury.

1. Pediatric Head Injury
Momen Ali Khan
Neurosurgery Resident
Department Of Neurosurgery
Dhaka Medical College Hospital

2. Pediatric Head Injury
General information
1. CNS injuries are the most common cause of pediatric traumatic death.
2. 75% of children hospitalized for trauma have a head injury.
3. Although most pediatric head injuries are mild and involve only evaluation or brief
hospital stays

3. Contd.
Pediatric head injury comparison to adults
1. Children often have milder injuries than adults
2. Lower chance of a surgical lesion in a comatose child than in an adult
3. Response to injury
a. Responses to head injury of older adolescents are very similar to those of adults
b. “Malignant cerebral edema”: acute onset of severe cerebral swelling (probably due to
hyperemia) following some head injuries, especially in young children (may not be as
common as previously thought7)
c. Posttraumatic seizures: more likely to occur within the first 24 hrs in children than in adults
[Handbook of Neurosurgery 10th Greenberg 1098]

4. Injuries peculiar to pediatrics
1. Birth injuries
a. Skull fractures
b. Cephalhematoma
c. Subdural or epidural hematomas,
d. Brachial plexus injuries
2. Perambulator/walker injuries
3. Nonaccidental trauma (NAT) (formerly child abuse): shaken baby syndrome…
4. Injuries from skateboarding, scooters…
5. Injuries related to the easier penetrability of the pediatric skull: e.g., recreational lawn darts
6. Leptomeningeal cysts, aka “growing skull fractures”
7. Retroclival hematoma
[Handbook of Neurosurgery 10th Greenberg 1098]

5. Paediatric CT Scan Indication
The PECARN (Pediatric Emergency Care Applied Research Network) traumatic brain injury algorithm
indication of CT scan -
Children < 2 years of age
1. GCS = 14 or other signs of altered mental status
2. Palpable skull fracture
3. Occipital or parietal or temporal scalp hematoma
4. History of LOC ≥ 5 seconds
5. Severe mechanism of injury
6. Not acting normally according to the parent
7. Physician experience
8. Parental preference
Children ≥ 2 years age
1. GCS = 14 or other signs of altered mental status
2. Signs of basilar skull fracture
3. History of LOC
4. History of vomiting
5. Severe mechanism of injury
6. Severe headache
7. Physician experience
8. Parental preference
[Handbook of Neurosurgery 10th Greenberg 1098]

6. In PECARN, Altered Mental Status defined as
1. GCS 14 or agitation
2. Somnolence
3. Repetitive questioning
4. Slow response to verbal communication.
Severe mechanism of injuries :
1. Motor vehicle crashes with patient ejection
2. Death of another passenger, or rollover
3. Pedestrian or bicyclist without helmet struck by a motorised vehicle
4. Falls
a. More than 1.5 m (5 feet) for patients aged 2 years and older
b. More than 0.9 m (3 feet) for those younger than 2 years
5. Head struck by a high-impact object

7. Pediatric Skull fractures
Cranial vault fracture
1. Linear/ Fissure fracture
2. Depressed fracture
3. Elevated fracture
4. Comminuted fracture
5. Pond fracture
6. Gutter fracture
7. Diastatic fracture
8. Basilar fracture
9. Growing skull fracture
10. Cranial burst fracture
Fracture of skull base
1. Ring fracture
2. Hinge fracture
3. Anterior cranial fossa fracture (ACF)
4. Middle cranial fossa fracture (MCF)
5. Posterior cranial fossa fracture (PCF)

8. Simple depressed skull fractures
There was no difference in outcome (seizures, neurologic dysfunction or cosmetic appearance) in surgical
vs. nonsurgical treatment in 111 patients < 16 yrs of age. In the younger child, remodelling of the skull as a
result of brain growth tends to smooth out the deformity.
Indications for surgery for pediatric simple depressed skull fracture:
1. Definite evidence of dural penetration
2. Persistent cosmetic defect in the older child after the swelling has subsided
3. Focal neurologic deficit related to the fracture
[Handbook of Neurosurgery 10th Greenberg 1101]

9. Ping-pong ball fractures
[Handbook of Neurosurgery 10th Greenberg 1101]
Ping pong skull fracture or pond skull fracture refers to a depressed skull fracture of the infant skull
caused by inner buckling of the calvarium. A green-stick type of fracture → caving in of a focal area
of the skull as in a crushed area of a pingpong ball.
Indications for surgery
1. Radiographic evidence of intraparenchymal bone fragments
2. Associated neurologic deficit (rare)
3. Signs of increased intracranial pressure
4. Signs of CSF leak deep to the galea
5. Situations where the patient will have difficulty getting long-term follow-up

10. Cephalhematoma
1. Accumulation of blood under the scalp.
2. Occurs almost exclusively in children.
3. Infants may develop jaundice (hyperbilirubinemia) as blood is
resorbed, occasionally as late as 10 days after onset
4. Two types: Subgaleal & Subperiosteal Hematoma

11. Subgaleal hematoma
1. May occur without bony trauma, or may be associated with linear nondisplaced skull fracture
(especially in age < 1 yr.).
2. Bleeding into loose connective tissue separates galea from periosteum.
3. May cross sutures.
4. Usually starts as a small localized hematoma, and may become huge (with significant loss
of circulating blood volume in age < 1 year, transfusion may be necessary).
Inexperienced clinicians may suspect CSF collection under the scalp which does not occur.
5. Usually presents as a soft, fluctuant mass
6. These do not calcify
[Handbook of Neurosurgery 10th Greenberg 1099]

12. Subperiosteal hematoma
1. Most commonly seen in the newborn
2. associated with parturition, may also be associated with neonatal scalp
monitor
3. Bleeding elevates periosteum, extent is limited by sutures.
4. Firmer and less ballotable than Subgaleal hematoma
5. Scalp moves freely over the mass.
6. 80% reabsorb, usually within 2–3 weeks.
7. Occasionally may calcify
[Handbook of Neurosurgery 10th Greenberg 1099]

13. Treatment of cephalohematoma
1. Treatment beyond analgesics is almost never required
2. Most usually resolve within 2–4 weeks.
3. Avoid the temptation of percutaneously aspirating these because the risk of infection
exceeds the risk of following them expectantly, and in the newborn removal of the blood
may make them anemic.
4. Follow serial hemoglobin and hematocrit in large lesions.
5. If a subperiosteal hematoma persists > 6 weeks, obtain a skull film. If the lesion is
calcified, surgical removal may be indicated for cosmetic reasons (although with most of
these the skull will return to normal contour in 3– 6 months).
[Handbook of Neurosurgery 10th Greenberg 1100]

14. Skull fractures in child abuse
1. The parietal bone was the most common site of fracture in both groups (≈ 90%)
2. Depression of skull fractures was frequently missed clinically due to overlying
hematoma
3. Characteristics more frequently seen after child abuse than after other trauma:
a) Multiple fractures
b) Bilateral fractures
c) Fractures that cross sutures
[Handbook of Neurosurgery 10th Greenberg 1104]

15. Growing skull fractures
General information
Growing skull fractures AKA Posttraumatic leptomeningeal cysts (PTLMC) (sometimes just traumatic
leptomeningeal cysts)
1. PTLMC consists of a fracture line that widens with time.
2. Usually requires both a widely separated fracture AND a dural tear
3. Mean age at injury: < 1 year; Over 90% occur before age 3 years
4. Although it is often referred to as a “cyst,” it is not a true cyst, but focal herniation of an area of
encephalomalacia.
Definition
An enlarging skull fracture that occurs near post traumatic encephalomalacia.

16. Contd.
There are 3 types of growing skull fracture
1. Leptomeningeal cyst
2. Encephalocele
3. Porencephalic cyst.
The most frequent location is the parietal bone.

17. Presentation of growing skull fractures
1. Most often presents as scalp mass (usually subgaleal)
2. Headache
3. Epilepsy
4. The cyst may cause mass effect
5. Progressive neurologic deficit.

18. Contd.

19. Differential Diagnoses of growing skull fractures
1. Posttraumatic intradiploic leptomeningeal cyst (PTIDLC):
2. Intradiploic arachnoid cyst
3. Osteolytic lesions
a. Metastasis
b. Epidermoid cyst
c. Eosinophilic granuloma
d. Myeloma
https://www.ajnr.org/ajnr-case-collections-diagnosis/growing-skull fracture#:~:text=There%20are%203%20types%3A%20leptomeningeal,location%20is%20the%20parietal%20bone.

20. Treatment
1. Duro-cranioplasty was the correct treatment in type
2. A shunting procedure required as an initial or definitive management for type II and III
fractures with raised intracranial pressure.
3. Resection of herniated gliotic tissue
4. Closure of the dural defect is necessary to prevent recurrence for the growing fracture.
5. Primary closure rarely possible, so some graft material must be used. Several options are
available for bone coverage, the most frequently used of which are
a. Split-thickness calvarial grafts
b. Full thickness calvarial autografts
c. Synthetic materials
d. Split rib grafts.
6. VP Shunt
[Handbook of Neurosurgery 10th Greenberg 1100]

21. Repair of Growing Skull Fractures

22. Procedural Steps
Several bur holes are placed at the periphery of the bony defect, overlying normal dura.
The exact position of the bur holes in relation to the defect depends on the anticipated
dural retraction beneath the bone edges.
Typically, larger lesions are associated with greater retraction of the dura beneath the
bone edges.
Preserve the periosteum overlying the bone to use as a dural graft.
A dissector is introduced through each bur hole and used to separate the dura from the
overlying bone. A craniotome then is used to connect the bur holes, creating a “ring”
bone flap (including the defect) that, in turn, is elevated away from the underlying dura.

25. Pearls
The margin should be several centimeters from the edge of the bony defect or
approximately 50% of the width of the defect, to create a bone flap that can be used to
cover the defect.
Prior MRI may give the surgeon an approximation of this distance; however, often it is
the surgeon’s judgment based on the size of the defect.
The dural edges are adherent to the underlying gliotic brain and must be separated from it
circumferentially
[Atlas of Emergency Neurosurgery 464-466]