THERAPEUTIC APPROACH TO A SPECIAL PATHOLOGY: HEAD INJURIES IN CHILDREN AGED BETWEEN 0 AND 3 YEARS
Pathology of trauma in the first 3 years of life is completely different when it is compared to that of adults. Raimondi (1998) emphasized the importance of the differences between adult and paediatric pathology concluding that “children are not young adults”. During this period there is a specific traumatic pathology linked primarily to early stages of acquiring motor skills with frequent traumas, usually minor ones, due to falling from the same level, without posttraumatic lesions of the cervical spine. There are also cases where the posttraumatic brain lesions are more complex and sometimes more severe, being caused mostly by falls from heights, by traffic accidents, sports accidents, aggression etc. Regarding the epidemiology of cranio-cerebral traumatic lesions, the age distribution of cranio-cerebral trauma (CCT), there are two major risk groups: the first group from 0 to 4 years and the second one between 15 and 19, with boys being twice more likely than girls. The authors retrospectively reviewed all cases hospitalized for CCT aged between 0 and 3 years from the paediatric neurosurgery department of the hospital “Bagdasar-Arseni” Hospital and “Sanador”Hospital in Bucharest (509 cases). The period extends from 1 January, 1999 to 31 December, 2014 (16 years). The authors insist on those aspects of this age group, 0-3 years, which have a character of specificity, represented by the “ping-pong” fracture, the diastatic fracture and the progressive fracture. In the analyses of the patients, the authors have used the main scales used globally for traumatic and prognostic assessment, i.e. Paediatric Glasgow Coma Scale and Glasgow Outcome Scale, respectively. The overall results of the study, in terms of prognosis, showed a good recovery in 57.8% of cases, but unfortunately, there were also deaths in 14 cases (2.8% of the studied cases). The findings converge to the fact that prevention is the key to good results in terms of the therapy of cranio-cerebral traumas, which are so disabling in this age group.
In terms of causes of mortality, and morbidity and disability in the population of paediatric age, cranio-cerebral trauma (CCT) is one of the most important, if not the first. In the USA, the incidence of cranio-cerebral traumatic lesions in 0–4-year age group is about 1256 / 100,000 inhabitants .
When we face an injury, especially one of traumatic nature that affects the cerebral substance, we ask ourselves instinctively whether we can identify which of the brain anatomical structures are affected and what is their significance in terms of functionality, if it is situated in important cortical areas or not. If traumatic events occur in children younger than 3 years, these questions are more important because the brain is still immature and not all of the functional and anatomical structures are fully developed. In analysing a traumatic event occurred at this age, one should compulsorily assess both reactivity and the capacity to recover the damaged brain substance.
A CCT occurred in a patient of pediatric age is an event loaded with a large dose of stress for both the child and the parents together with their family. In addition, a trauma occurred in childhood can have significant effects on the subsequent quality of life through physical sequelae, emotional or behavioural disorders that may become important stigma of the suffered trauma. The attitude and the therapeutic strategies committed to the posttraumatic disabling injuries involve all health-care services, comprising many resources in the long-term, especially considering the age of the patients and their increased life expectancy.
Traumatic pathology in paediatric age and particularly in the first 3 years of life is completely different when it is compared to that of adults. Raimondi (1998) emphasized the importance of differences between adult and infant pathology saying that “a new-born baby is not a young child”, “the young child is not a child” in the same way as “the adolescent is not a child” either and the more so “adults are completely different from children”(2).
In terms of the frequency, the most common causes for CCT in children are falls from heights, traffic accidents, sports accidents, aggression or obstetrical trauma during birth. In terms of age distribution of CCT’s, there are two major risk groups: the first group from 0 to 4 years and the second one between 15 and 19 years old. Boys are more prone to injuries, yet, in the age group 0-4 years, the boys are followed at little distance by girls of the same age (incidence of 1,357, respectively 1,150 in100,000 inhabitants in the USA).
From the anatomical point of view, the brain an of individual, evolves from a volume of 365 cm3 and a weight of 372g at birth to 1,600 cm3, respectively 1450-1500g in adulthood with a cell population of about 1011 neurons. In addition, the degree of brain development is maximum during the first three years of life, which is reflected in the way of development of the skull, whose diameter increases from 35 cm at birth to 51 cm, that is almost the size of the adult, at the age 3 years.
The most common causes of cranio-cerebral traumatic lesions in this age group too are accidental falls from the same level or from a height, linked also to the period of learning to walk, road accidents in which children may be involved both as passengers and as pedestrians and traumas due to aggression. A special category of injuries is related to obstetrical trauma due to the instrumental birth, which includes distinct lesion types that are also related to the special anatomical features seen in this category of patients.
The types of most common injuries in patients aged up to 3 years are skull fractures that have certain special characteristics of the type of the “ping-pong” fracture, depressed fracture, diastatic fracture, and progressive fracture. In terms of post-traumatic haemorrhagic lesions, the characteristic lesions at this age are those of the type cephalhaematoma, subgaleal haematoma, Caput succedaneum, the latter two types of lesions are very common following obstetrical traumas. Another group of post-traumatic intracerebral lesions are diffuse lesions of the type of diffuse brain oedema and diffuse axonal injury.
The assessment of the state of consciousness of the paediatric patients is based on scales derived from the Glasgow Coma Scale, adapted according to the degree of language development in these patients. Such scales are the Paediatric Glasgow Coma Scale (PGCS), Children Coma Scale (CCS) , Infant and Toddler Coma Scale (Raimondi & Hirschauer, 1984)  and the like.
Material and Method
In the analysed period, there were 1,667 cases of head injury in children aged less than 3 years who were hospitalized for supervision, mostly for a period of 24 hours. The analysed cases were those that required more than 24 hours. The study examines 509 cases (30.5%) admitted consecutively over a period of 16 years from 1 January 1999 to 31 December 2014 in the Emergency Hospital “Bagdasar-Arseni” and Sanador Hospital in Bucharest. Inclusion criteria for the study were age from 0 to 3 years and cases with no history of previous head injury. Cases of obstetric trauma and those initially investigated and treated in other neurosurgical services were excluded.
The aetiology of traumatic injuries was as follows: in 121 cases (23.8%) there were road accidents, of which 92 cases (18.1%) as pedestrians and 29 cases (5.7%) as passengers; in 167 cases there were injuries caused by falls from another level (32.8%) and in 117 cases (22.9%), from the same level; in 63 (12.4%) cases there were accidental collisions with other objects and in 41 cases (8.1%) there were lesions cause by aggression.
There were 668 types of injuries encountered in the 509 patients enrolled in the study: various skull fractures in 443cases (66.3%), cephalhaematomas in 71 cases (10.6%), extradural haematomas in 36 cases (5.4% ), subdural haematomas in 6 cases (0.9%), intraventricular haemorrhage in 5 cases (0.7%), haemorrhagic cerebral contusions in 65 cases (9.7%), cerebral edema with diffuse axonal injury in 42 cases (6.3%), combined lesions were diagnosed in 159 patients (31.2%) of the 509 who had been analysed.
In a case of head injury in a child, as in an adult, clinical examination should include assessment of vital functions (respiratory and circulatory system), the consciousness, posttraumatic local injuries, possible traumatic injuries of the cervical spine, and lesions of other systems and organs, where appropriate (polytrauma). The neurological examination, in addition to examining the state of consciousness according to the scales commonly used in the department of neurosurgery (usually the Glasgow Coma Scale adapted to the age of patients) should also include the assessment of other signs and symptoms of neurological impairment (assessment of cranial nerve function, segmental motor or sensory deficits etc.). Together with the overall assessment of patients, a plan of laboratory imaging and laboratory examinations has to be established to objectify possible posttraumatic lesions located deeply as well as haematological and biochemical imbalances that may arise, to document the elaboration of an appropriate therapeutic strategy for the investigated case.
In matters of imagistic investigations, when a patient with head trauma is presented in the emergency room, the first step is to achieve a standard X-ray examination of the skull and, depending on the situation, of the cervical spine, too. Depending on the outcome of this examination, i.e. highlighting or not a fracture trajectory, and on the general and neurological condition of the patients, the next category of necessary imagistic investigations, sometimes adopted as first step, is to perform a cranio-cerebral Computed Tomography. It will highlight possible traumatic injuries in the calvaria, the brain substance or other intracranial structures. Cerebral CT scanning is the “gold-standard” investigation for cranio-cerebral injuries, being practically the most accessible and with the highest degree of visualisation of the haemorrhagic lesions, of the solutions of continuity in the calvaria and of the dural or cerebral expansions in the bone gap. Complementary, cerebral MRI examinations may be performed, which may highlight injuries of the adjacent soft tissue and of the brain substance, but accessibility to this type of examination is limited, it has a longer examination interval and a weaker view of the bone lesions.
Besides the lesions that are identical with those of adult patients, the characteristic types of lesions that are seen in patients younger than 3 years are the following: in terms of haemorrhagic injuries, cephalhaematoma, caput succedaneum and subgaleal hematoma and in terms of fractures, diastatic fractures, progressive fractures and “ping-pong” fractures. Of these, injuries of the caput succedaneum and subgaleal haematoma type were excluded, since they are mostly the result of obstetric trauma, with very low addressability.
Symptoms presented by patients with cranio-cerebral lesions are varied, a constant complaint being represented by paleness that was found in all studied cases. At this age category, complaints of the local painful type had the form of irritability and restlessness. Another semiological category was the one determined by the increase of the intracranial pressure. A statistical presentation of symptoms is shown in Table I.
In terms of patients’ state of consciousness at presentation, assessed according to Glasgow scale adapted to the paediatric age , the majority of patients were classified as having minor cranio-cerebral traumas (PGCS> 13pct) (Table II).
Traumatic disorders of the infant and young child under 3 years of age constitute a major chapter of cranio-cerebral pathology because the patients are in a period of rapid development of the functions of their central nervous system. On the one hand, in this category of patients, there is a great capacity for recovery and healing of the lesions of calvaria, but other regions and structures of the brain may be affected whose damage leads to important functional sequelae due to the lack of complete development of the functions controlled by the respective cortical areas considered eloquent [12,13]. The most frequent causes of cranio-cerebral traumatic lesions, as revealed in our study, were comparable to reports in the literature, being represented by falls from the same level and from a higher level, by road accidents, accidental knocks in a home environment or outdoors, as well as by aggressions. Among the lesions that can occur in obstetric traumas, in the study group we included only cephalhaematomas, the remaining lesion types (caput succedaneum and subgaleal hematoma) being lesions that are observed strictly in the immediate postnatal period.
Cephalhaematoma is a posttraumatic hemorrhage (a collection of blood) located sub periosteal. Its most clinically important feature is that it is limited by the skull sutures. The causes of the occurrence of this entity are related to obstetrical trauma or difficult vaginal births when there is an incompatibility between the dimensions of mother’s pelvis and the size of the foetal skull. Usually, cephalhaematomas are observed in the first days of life and reabsorb spontaneously in a few weeks. Sometimes they are also associated with subiacent linear fractures. They occur predominantly at parietal level. Surgical intervention in case of those injuries is recommended only if the collection becomes superinfected and has to be evacuated or whether it ossifies and an aesthetic correction of the skull is necessary. In our statistics, there were 71 cases (10.6%) of cephalhaematoma (Figure 1).
Figure 1 – Cephalhaematoma (CT aspect)
Skull fractures of various types were recorded in 443 cases (66.3%). Particular types of fractures in this age group are the diastatic fractures, occurring due to the skull sutures that are not fused yet; the “ping-pong” fractures, as equivalent of the “greenstick” fractures at the level of the long bones; and the progressive fractures. When cases of linear fractures are detected, hospitalization is required for these lesion types, for their monitoring. Linear fractures that are not associated with other injuries do not require surgery, but need careful supervision because an extradural haematoma may develop further. In the study group, there were 153 linear fractures. Comminuted fractures are usually associated with lesions of the subiacent cerebral contusion type and with the unevenness of calvaria, which require a surgical therapeutic attitude. The cranial fracture that involves the inward buckling of the skull bones to resemble a “ping-pong ball” shape, is equivalent to the “greenstick” fracture occurring at the level of the diaphysis of long bones. It is a deformation of the calvaria, virtually with no continuity solution at the level of the periosteum. This type of fracture requires surgery for the recovery of calvaria (Figure 2).
Figure 2 – Schematic representation of surgery for the “ping-pong” fracture
A special type of skull fracture is the diastatic fracture that occurs when the fracture line crosses one or more skull sutures, causing their disjunction. This type of fracture is usually with no indication for surgery, but it needs close monitoring as one of the risks associated with the existence of a linear fracture trajectory, especially one of the diastatic type, is the potential for transformation into a progressive skull fracture. Progressive fractures are frequently localized into the parietal portion of the calvaria. At local examination, they are characterized by a swelling of the scalp supraiacent the fracture . The anatomic substrate of this swelling is the presence of a protruding leptomeningeal cyst formed by the Cerebrospinal Fluids (CSF) accompanied or not by brain matter through the edges of the fracture (Figure 3).
Fig. 3 – Progressive cranial fracture
The consequence of the presence of meningeal and brain structures is, on the one hand, the prevention the process of fracture healing and, on the other hand, a gliotic type brain damage in the areas involved. From the clinical point of view, this type of fracture can occur with focal neurological deficits caused by the brain areas involved or with seizure symptoms. Progressive fractures require a surgical therapeutic attitude where the excision of the gliotic brain tissue is necessary together with the restoration of the continuity of dura mater through duraplasty with or without cranioplasty .
Comminuted fractures of the skull, with or without the depression of the bone fragments require surgery to reposition fragments and to treat the underlying traumatic injuries, most likely related, since this type of fracture occurs in high-energy trauma (Figure 4).
Figure 4 – Median frontal comminuted fracture located above the superior longitudinal sinus(a. – preoperative aspect; b – postoperative aspect)
The management of comminuted fractures that are adjacent to or above the dural sinuses requires particular attention because of the major risk of important bleeding associated with haemorrhagic shock. In these cases, sinus patency must be assessed preoperatively. During surgery, patency of sinuses should be maintained, and they should be protected to avoid risks of ischemic or haemorrhagic complications with important functional consequences for patients.
Traumatic intracranial injuries that may be found in case of cranio-cerebral traumas, both in adults and in children under 3 years are haemorrhagic brain contusion, diffuse brain lesions and extradural, subdural, subarachnoid and intraventricular haematic collections. Any haematic collection, be it extracerebral or intracerebral, require surgical evacuation and adequate haemostasis to reduce secondary intracranial hypertension which develops their existence, with important consequences for the neurological status of the patients. In case of diffuse brain lesions that are usually associated with a poor neurologic status with impairment of consciousness, the initially adopted therapeutic solutions are meant to maintain the vital functions and reduce intracranial pressure with non-surgical methods, following that after stabilization of vital functions, if focal, localized lesions develop, surgical therapeutic solutions might be adopted, too. Unfortunately, these types of diffuse lesions had an extremely severe prognosis, despite all therapeutic measures taken.
The assessment of the gravity of cranio-cerebral trauma, globally, in terms of effects on the central nervous system is done mainly by assessing the patients’state of consciousness after the trauma is produced. The most common rating scale used worldwide is the Glasgow Coma Scale that was developed more than 40 years ago by Graham Teasdale and Brian Jennett , whose principles were adapted according to the degree of development of the nervous system at the time of trauma in order to assess the responsiveness of paediatric patients. A first adjustment was made by even one of the “fathers” of the basic scale, B. Jennett, in 1975 , who called it Paediatric Glasgow Coma Scale (PGCS) (Figure 5).
Figure 5 – Paediatric Glasgow Coma Scale
Of the most popular other adaptations of Glasgow Scale for patients of small paediatric age, infants and young children under 2 years are those proposed by Simpson and Reilly in 1982  and that proposed by Raimondi and Hirschauer  in 1984.
Figure 6 – Simpson & Reilly Scale (1982)
Figure 7 – Raimondi & Hirschauer Scale(1984)
Child traumatic pathology, and especially that of the small child, has always been a challenge for the medical world since the therapeutic approach should be based on history data obtained indirectly from parents or other adults in the child’s social environment and based on direct evidence resulting from clinical and laboratory investigations [10, 12, 13]. As with non-traumatic disorders, traumatic pathology of the child should benefit from the human and material resources dedicated to this age group in hospitals specialized in treating paediatric impairment that are equipped with surgical wards and adapted specific facilities, especially compartments dedicated to anaesthesia and intensive care. All these things must be made available for the best results in treating trauma cases, in particular, those with head trauma, to maximize favourable prognosis.
We conclude that cranio-cerebral traumatology in infant and young child under the age of 3 years is a significant public health problem.
In terms of therapeutic solutions, difficulties come from the young age of patients with multiple difficulties related to diagnosis and monitoring of lesions, patients having limited means of communication. On the other hand, there is a need to establish procedures that should limit blood loss significantly, given the small weight of these patients, without neglecting the risk of important neurological sequelae.
In terms of laboratory investigations, CT scan of the brain is the gold standard for examinations that may be performed in emergency, having a high degree of identification of lesions with a reduced examination time.
On the other hand, cranio-cerebral injuries have a major and important emotional impact on the family environment involved, given the fact that some of the injuries occur under the supervision of adult persons in the entourage who, at the time of the occurrence, were not very attentive. The identification of suggestive symptoms for significant posttraumatic cranio-cerebral injuries is very important in terms of primary health care both at family level and at the family physician level.
Therefore, prevention of such injuries through effective supervision of the children and their guidance in case of early warning signs and symptoms by a neurosurgical service play a very important role in obtaining favourable results in terms of vital and functional prognosis of this category of patients.
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