HEAD INJURIES IN INFANTS (0-1 YEARS)

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2017 vol. 121, no. 2 SURGERY ORIGINAL PAPERS HEAD INJURIES IN INFANTS (0-1 YEARS) D. Voinescu 1, V. Saceleanu 2 *, I. Luca-Husti 3, I. Rusu 5, A.V. Ciurea 3,4 Carol Davila University of Medicine and Pharmacy Bucharest Faculty of Medicine 1. Elias Emergency Hospital Neurosurgical Department Lucian Blaga University, Faculty of Medicine 2. Neurosurgery Department 3. Sanador Clinical Hospital, Bucharest Carol Davila University of Medicine and Pharmacy Bucharest Faculty of Medicine 4. Neurosurgical Department 5. Bucharest Emergency University Hospital Neurosurgical Department *Corresponding author. vicentiu.saceleanu@gmail.com HEAD INJURIES IN CHILD (0-1 YEARS) (Abstract): Head injuries are one of the major causes of morbidity and mortality in children. The most common causes are falls from the same level. Boys are twice more prone to head injuries than girls. The traumatic pathology of the first 3 years of life is completely different when compared to that of adults. Material and methods: Retrospective study of all infants aged 0-1 years admitted for head injuries to the pediatric neurosurgery departments of Bagdasar-Arseni Hospital and Sanador Hospital in Bucharest. This 17-year study (January 1 st, 2000-December 31 st, 2016) included 509 patients aged 0 to 3 years. Results: Of these, 111 (21.8 %) were aged under 1 year, presented to the Emergency Department (ED), were hospitalized for at least 24- hour observation, and were diagnosed with at least one traumatic head injury visible on the imaging studies. The level of consciousness in infants was assessed by using a variant of the Glasgow Coma Scale (GCS) adapted to this age (0-1 years), namely Pediatric Glasgow Coma Scale (PGCS). CT with Bone-window is the first investigation in case of a head injury. Conclusions: Infants show a different pathology from that at other ages. Head injuries in infants pose multiple di f- ficulties related to diagnosis, complications and follow-up. The data obtained from unenhanced CT scans constitute an emergency assessment. Keywords: HEAD INJURY, CHILD 0-1 YEARS, CT SCAN, PEDIATRIC NEUROSURGERY, GLASGOW COMA SCALE, GLASGOW PEDIATRIC COMA SCALE Head injuries (HI) are one of the most important causes of mortality, morbidity and transient or permanent disability in the general population, both in adults and in children. In the USA, the incidence of HI among the children aged 0-4 years is about 1256/100,000 population (1, 2). The clinical manifestations of pediatric and adult HI differ even when they share a common cause. Raimondi (1998) emphasized the importance of the differences between adult and pediatric pathology concluding that the newborn is not a baby, the baby is not a school child, just the teenager is not a child and even more adults are completely different from children (3). 327

2 D. Voinescu et al. The most common causes of HI in infants are accidental falls from the same level or from height, traffic accidents in which children may be involved both as passengers and as pedestrians, accidents with various objects and child abuse (4). When an infant presents to the Emergency Department with head injury, unenhanced CT brain scan is the initial imaging modality of choice. This is the goldstandard investigation for head injuries, and is preferred due to its accessibility and good visualization of bleeding injuries, solutions of continuity in calvaria with or without dural or cerebral expansion in the bone gap or cerebral edema lesions (5). MATERIAL AND METHODS All patients with HI aged 0 to 3 years admitted to the departments of pediatric neurosurgery of Bagdasar-Arseni Hospital and Sanador Hospital in Bucharest between January 1 st, 2000 and December 31 st, 2016 were included in this 17-year study. Of the 509 pediatric patients, 111 (21.8 %) were aged under 1 year. In this study group, we encountered a category of injuries caused by obstetrical trauma related to fetal dystocia or instrumental delivery. All patients included in the study were admitted for at least 24-hour observation, and were diagnosed with at least one posttraumatic injury visible on imaging studies. To analyze patients state of consciousness, the authors used the Pediatric Glasgow Coma Scale (PGCS), a variant of the Glasgow Coma Scale (GCS) adapted for pediatric patients (6) (tab. I). TABLE I Pediatric Glasgow Coma Scale (6) Best verbal response Best eye response Best motor response No verbal response (1p) No eye opening (1p) No motor response (1p) Inconsolable, Agitated (2p) Eyes open to pain (2p) Extension to pain (2p) Inconsistently inconsolable, Moaning (3p) Eyes open to speech (3p) Abnormal flexion to pain (3p) Cries but consolable, abnormal interactions (4p) Eyes open spontaneously (4p) Infant withdraws from pain (4p) Smiles, orients to sounds, follows objects (5p) N/A Infant withdraws from touch (5p) N/A N/A Infant moves spontaneously (6p) RESULTS The level of consciousness determined with PGCS in the 0-1-year group is presented in Table II. As to the etiology of HI in infants the most common causes in this study group were falls from the same level or from another level and traffic accidents. A special category is represented by the injuries caused by physical aggression (tab. III). TABLE II PGCS evaluation of the level of consciousness in the 111 infants GPCS No. of cases Percentage points points <8 points Total

3 Head injuries in infants (0-1 years) TABLE III Causes of head injuries in infants (0-1 years) Cause No. of cases Percentage Fall from the same level Fall from another level Road accidents Accidents at play Aggression (Child abuse) 4 3. Other causes Total HIs are extremely varied, a frequent finding pallor, encountered in all study cases. Infants who were in pain were agitated and anxious. Another clinical category was the symptoms of increased intracranial pressure expressed by the anterior fontanelle bulging, vomiting, convulsive events, motor deficiencies or anisocoria and alteration of consciousness in various degrees (tab. IV). TABLE IV Clinical Symptomatology reported at Emergency Room Clinical symptomatology No. of cases Percentage Pallor skin Irritability with agitation Irritability and drowsiness Anterior fontanelle bulging Vomiting Convulsive seizures Motor deficits Anisocoria Impaired consciousness/coma state The post-traumatic injuries seen on CT scans most frequently encountered in the hospitalized patients (111 cases; 21.8%) were: skull fractures of several types, cephalohematoma, extradural hematomas and DAIs (tab. V). TABLE V Head injury types on CT-scan examination in patients aged 0-1 year Lesion type No. of cases Percentage Cephalohematoma Linear skull fracture Ping-pong fracture Progressive fracture Intrusive fracture Extradural hematoma Subdural hematoma Intraventricular hemorrhage Diffuse axonal injury Total

4 D. Voinescu et al. DISCUSSION All head injuries in child 0-1 years should be very carefully assessed, and if craniocerebral injury is suspected native CT-scan is mandatory. The first CT-scan in the emergency department is very important for the following neurological, neurosurgical steps. Complementarily, brain MRI can also be used to detect traumatic injuries in the adjacent soft tissue and brain substance. Unfortunately, access to this type of examination is limited, examination time is longer, general anesthesia is required, and bone lesions are poorly visualized (7). A distinct category of post-traumatic cerebro-ventricular injuries encountered in pediatric patients is represented by diffuse cerebral edema and diffuse axonal injury (DAI). These types of injuries significantly affect patient s consciousness. As in adults, physical examination of pediatric HI cases should include the assessment of vital signs, level of consciousness, focal post-traumatic injuries, possible cervical spine injuries and damage to other systems and organs (polytrauma), if the case. Neurological examination is aimed at identifying the possible motor or sensory segmentation deficits, and signs and symptoms suggestive of cranial nerve dysfunction, etc. The use of the Glasgow Coma Scale (GCS) is extremely difficult in the pediatric patients, particularly in preverbal children. For these reasons, over time, several coma scores have been developed specifically for children in attempt to compensate for their differences in verbal and motor capabilities, and the last and most useful is Pediatric Glasgow Coma Scale (GPCS) (Ong et al., 1996) (6). Other two pediatric coma scales used in practice are CHOP Infant Coma Scale (Durham et al., 2000) (8) and Starship Infant Neurological Assessment Tool (Birse, 2006) (9). We will present clinical manifestations and treatment of traumatic lesions in infants: Characteristic types of injuries encountered in patients younger than 1 year are the bleeding injuries-cephalohematomas (15 cases, 13.5%), caput succedaneum and subgaleal hematoma and fractures - progressive diastatic fracture and ping-pong fracture. Cephalohematoma is a post-traumatic collection of blood located between the skull and periosteum. The most clinically important feature is that it is limited by suture lines. The causes are related to obstetrical traumas or difficult vaginal deliveries when there is incompatibility between maternal pelvic size and fetal head size. Usually, cephalohematomas are detected during the first days of life and are reabsorbed spontaneously in few weeks. Sometimes, they are also associated with underlying linear fractures. They occur predominantly at parietal level. Surgery is indicated in case of ossified cephalohematoma for esthetic reasons (7), and all cases were operated with favorable neurological and aesthetic results. Among the types of fractures encountered there were linear fractures (58 cases, 52.2%) or intrusive comminuted fractures (6 cases, 5.4%) and particular types of fractures occurring only at this age, diastatic fractures due to the fact that suture fusion has not happened yet (5 cases) and the ping-pong fracture (11 cases, 9,9%), as the equivalent of greenstick fracture in the long bones. All the 11 cases were operated, immediately after diagnosis, with satisfactory results. In these ping-pong fractures, the individualized fracture paths cannot be detect- 330

$In all ping-pong skull fractures it is recommended elevation of depressed calvaria soon as possible (10,11).$ $In rare cases, this type of fracture may recover spontaneously (12).$ $Linear fractures not associated with other injuries do not require surgical treatment, but they do require$ $Liniar Fracture Left Parietal Bone A different type of calvaria fracture is represented by the diastatic$

5 Head injuries in infants (0-1 years) ed, not even by imaging methods. Solely skull deformation can be detected. In all ping-pong skull fractures it is recommended elevation of depressed calvaria soon as possible (10,11). In rare cases, this type of fracture may recover spontaneously (12). In case of linear fractures, hospitalization is required to monitor the patients. Linear fractures not associated with other injuries do not require surgical treatment, but they do require monitoring as an extradural hematoma may develop subsequently (fig. 1a and b). a. CT- scan b. CT with bone window Fig. 1. Liniar Fracture Left Parietal Bone A different type of calvaria fracture is represented by the diastatic fracture, meaning the fracture involving the suture lines of the skull (5 cases) (fig. 2a and b). a. Anteroposterior view b. Sagital Incidence Fig. 2. Right fronto-parietal-diastatic fracture 331

$D. Voinescu et al. One of the risks associated with a linear fracture, especially diastatic, is the potential transformation into a growing skull fracture (fig. 3)$

6 D. Voinescu et al. One of the risks associated with a linear fracture, especially diastatic, is the potential transformation into a growing skull fracture (fig. 3). Fig. 3. Left parietal progressive skull fracture In this cases, meningeal structures and brain tissue could interfere between the edges of the fracture, preventing the consolidation process of the fracture. This process causes brain herniation between bone edges. Growing skull fracture needs neurosurgical extensive approach, removing gliotic tissue, CSF restoration, closing dura, cranio plasty. All the cases were operated with this procedure, before CT-scan evaluation, and MRI- scan. There were no death patients, but 3 from 5 cases remained with neurological deficits and seizure (13,14). Comminuted skull fractures, with or without depressed bone fragments require surgery to reposition the fragments and to treat the underlying traumatic injuries, most likely related, because these fractures occur in case of high-energy trauma. Special attention is given to the management of comminuted fractures that are adjacent to or above the dural sinuses because of the major risk of important bleeding and hemorrhagic shock (15). All 6 cases (5.4%) were operated through a broad approach restoring cerebral structures, dural and skull, with favorable neurological outcomes; there was no postoperative death. Post-traumatic head injuries that may be encountered are hemorrhagic brain contusion, diffuse brain injury and extradural, subdural, subarachnoid and intraventricular hematic collections. Any extra cerebrally hematic collection with compressive effect requires surgical evacuation and an adequate hemostasis to reduce intracranial hypertension that develops secondarily, with important consequences for the neurological status of patients. In our study, were 7 cases (6.03%) of extradural hematoma diagnosed and operated in time (7). Results: 1 death patient, at the admission, CGS=3pts., with all the entire evacuation of the hematoma and intensive care measures could not be resuscitated, but rest of 6 cases (4 with good recovery and 2 with moderate disabilities (fig. 4). Acute Subdural hematoma was present in one case (0.9%) but neurosurgical intervention was one time and postoperative evolution was favorable. Convulsive syndrome preoperatively, was treated with appropriate therapy. In case of diffuse brain damage (DAIdiffuse axonal injury) (7 cases- 6,3%), which is usually associated with a poor neurological status and impaired consciousness, the aim of the initial treatment is to preserve the vital functions and minimize intracranial hypertension through nonsurgical methods. Unfortunately, these types of diffuse injuries have an extremely poor prognosis (with 2 died), despite all therapeutic measures taken (7). 332

obtained in 65 (57.8%) of the cases (tab. VI). The other 3 patients (2.

7 Head injuries in infants (0-1 years) a. preoperative appearance b. postoperative appearance Fig. 4. CT-scan: Extradural hematoma in a 4-month-old infant The Glasgow Outcome Scale (GOS) at 6 months was used for the assessment of functional outcome and prognosis, a favorable score (GOS = 5) being obtained in 65 (57.8%) of the cases (tab. VI). The other 3 patients (2.8%) died because of extremely serious diseases: (2 death cases involving Diffuse axonal injury) and 1 case extradural hematoma The authors draw attention on the unpredictability of clinical course in these patients, thus requiring a more complex and unitary therapeutic approach to maximize the probability of a favorable course due to the great functional resources of this patient population (7). Also, they emphasize that head injuries in infants is an important public health problem (4, 9). TABLE VI Outcome in Head Injuries of cases studied at 6 months Glasgow Outcome Scale (GOS) Number of cases Percentage 5 GR Good-recovery MD Moderate disability SD Severe Disability VS Vegetative state D Death Total CONCLUSIONS From the point of view of therapeutic solutions, difficulties arise regarding the patients youthful age, with multiple difficulties regarding diagnosis and monitoring of injuries, as patients have limited ways of expressing themselves. On the other hand, it is also necessary to adopt procedures that 333

8 D. Voinescu et al. limit blood loss, given the low capital of these patients, without neglecting the risks of significant neurologic deficits. Concerning the laboratory investigations, brain CT scan is the gold standard in case of emergency examinations, with a high degree of identification of lesions in a reduced examination time. Therefore, prevention of these head injuries by effectively supervising children and sending them in due time to a neurosurgical service, in case of signs and alarm symptoms, plays a very important role in achieving the most favorable results in terms of vital and functional prognosis of this category of patients. REFERENCES 1. Kurowski BG, Michaud L, Babcock L, Rhine T. Pediatric Traumatic Brain Injury: Special Considerations: Brain Injury Medicine: Principles and Practice 2 nd Edition. New York: Demos Medical Publishing, 2013, Sumich AI, Nelson MR, McDeavitt JT.TBI: a pediatric perspective. In: Brain injury medicine: principles and practice, Mobius-Lance, 2007, Raimondi AJ. Pediatric neurosurgery. Berlin Heidelberg: New York, Springer, Duhaine AC, Rindler RS. Special Considerations in Infants and Children. In: Handbook of Clinical Neurology, Traumatic Head Injury (First part): Elseiver 2015, Ciurea AV, Gorgan MR, Tascu A, Sandu AM, Rizea RE. Traumatic brain injury in infants and toddlers, 0-3 years, J Med Life 2011; 4(3): Ong L, Selladurai BM, Dhillon MK, Atan M, Lye MS. The Prognostic Value of the Glasgow Coma Scale, Hypoxia and Computerized Tomography in Outcome Prediction of Pediatric Head Injury. PediatNeurosurg 1996; 24: Mohan A, Husti Luca I, Ciurea AV. Management of an unusual pathology, Traumatic brain injury in infants and toddlers, 0-3 years. SNEPCAR 2015; 21(2): Durham SR, Clancy RR, Leuthardt E, Sun P, Kamerling S, Dominguez T: CHOP Infant Coma Scale ( Infant Face Scale ): a novel coma scale for children less than two years of age. J Neurotrauma 2000; 17: Birse J.Pilot testing of the starship infant neurological assessment tool. J. Neurosci. Nurs 2006; 38: Husti Luca I, Mohan A, Ciurea AV. Ping-pong depressed skull fractures. SNEPCAR 2016; 22(1): Fantacci C, Massimi L, Capozzi D, Romano V, Ferrara P, Chiaretti A. Spontaneous ping-pong fracture in newborns: case report and review of the literature. Signa Vitae 2015; 10(1): Sorar M, Fesli R, Gürer B et al. Spontaneous elevation of a ping-pong fracture: case report and review of the literature. PediatrNeurosurg 2012; 48(5): Arseni C, Ciurea AV. Clinico- theraputic aspects in the growing skull fracture. A review of the literature. Childs Brain 1981; 8: Ciurea AV, Iliescu A, Sandu AM, Gheorghita A. Grow Skull Fracture-Special Consideration on a 5- Week-Old Case. J PaedSurg Special; 2014; 8(3): Davidescu HB, Ciurea AV, Traumatismele cranio-cerebrale ale copilului, in: Tratat de Neurochirurgie volume. I editor AV Ciurea. București: Editura Medicală, 2010;

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