1. MILD HEAD INJURY IN
PEDIATRIC AGE
GROUP,
AN OVERVIEW OF
CURRENT
MANAGEMENT
STRATEGIES

2. NABIL HASSAN M.KHALIL
Emeritus Professor in Neurosurgery Department
Faculty of Medicine Suez Canal University ,Ismailia
Honorary president of ESNS
Chief of Egyptian accreditation council
for assigning neurosurgery university staffs
Egypt
Tel.+20663234244, Mobile.+20103732045
Email: nabilkh@hotmail.com

3. INTRODUCTION

4. In the spectrum of all patients suffering
neurotrauma, children with serious brain
and spinal cord injuries represent a
relatively a small portion of the population.
However when one considers this problem
only within the pediatric age group, these
injuries, especially traumatic brain injury,
are now common cause of death and
disability.

5. Differences in the characteristics of traumatic brain
injuries between children and adults;
• Expected distribution of injury severity.
• Occurrence and characters of skull fractures.
• Incidence and type of traumatic mass lesions.
• Occurrence and characters of brain swelling, post
traumatic epilepsy.
• Associated systemic complications.
•The different expected outcomes.
• Injury-related pathophysiological responses of the very
immature brain are different from the more mature one.

6. MILD OR MINOR HEAD INJURY
DEFINITON,
brain injured patients are generally categorized
clinically as having sustained mild, moderate or
severe brain injury, based mostly on the Glasgow
Coma Scale (GCS):
Mild 13-15
Moderate 9-12
Severe 3-8

7. EPIDEMIOLOGY
•Mild closed head injury is one of the most
common causes for seeking urgent medical
attention, representing over 10% of all
emergency room visits for pediatric patients.
•So it is important to detect the subpopulation
that harbor a potentially life threatening or
disabling brain injury.
•Boys are twice as likely as girls to suffer from
head injury.

8. Aetiology and mechanism of head injury in
pediatrics
1- Aetiology:
In older children the causes are;
•RTA
•Accidental falls
•Child abuse
In neonates;
•Birth injuries
•Accidental falls
•RTA
•Child abuse

9. Mechanism of head injury;
Mechanical inputs can be 1-static loading
2-dynamic loading
Most head injuries are due to:
1-Contact injuries:
Local contact e.g fissure # , depressed #
Remote contact e.g # base
2-Acceleration injuries:
Transitional
Rotational Angular (most frequent)

10. Special Attributes of the Pediatric
Nervous System
•The pliable thin immature skull of pediatrics.
•The smaller subarachnoid space in infancy.
•The soft texture of the immature
brain.(contrecoup injury incidence).
•The size of the head in relation to the size of the
body.(rate of growth of brain to the skull).
•The chemical composition of the brain.
•The developing brain.(development and
cognition).

11. •The cerebral blood flow differences.
•The blood brain barrier of the immature brain.
•Functional differences in neuroplasticity.

12. CHILD ABUSE
Many cases of unexplained developmental
delay and retardation are the result of abuse related
injuries in infancy.
Child Abuse Syndromes:
1-The Battered-Child Syndrome.
2-The Shaking Impact Syndrome.

13. CLINICAL EVALUATION
• Assessment of the airway, breathing, circulation,
and evaluation of other body systems.
• History of mechanism and severity of trauma.
• Duration of loss of consciousness, post-traumatic
amnesia, vomiting and seizures.
• Examination of the head for scalp injuries,
evidence of skull base fractures.
• Assessment of the conscious level according to
the GCS for pediatrics.

14. GCS FOR INFANTS AND OLDER CHILDREN
TToottaallOOllddeerr cchhiillddrreenniinnffaannttssffuunnccttiioonn
44ssppoonnttaanneeoouussssppoonnttaanneeoouuss
33TToo ccoommmmaannddssTToo ssoouunnddss
22TToo ppaaiinnTToo ppaaiinn
11NNoonneeNNoonnee
EEyyee ooppeenniinngg
55oorriieenntteeddAApppp.. FFoorr aaggee
44DDiissoorriieenntteeddCCrriieess bbuutt
ccoonnsscciioouuss
33IInnaapppprroopprriiaatteePPeerrssiisstteennttllyy
iirrrriittaabbllee
22IInnccoommpprreehheennssiibbll
ee
RReessttlleessss,, lleetthhaarrggyy
11NNoonneeNNoonnee
BBeesstt vveerrbbaall
rreessppoonnssee
66OObbeeyy ccoommmmaannddssSSppoonnttaanneeoouuss
55SSaammeeLLooccaalliizzeess ppaaiinn
44SSaammeeWWiitthhddrraawwss
33SSaammeeFFlleexxiioonn
22SSaammeeEExxtteennssiioonn
11SSaammeeNNoonnee
BBeesstt mmoottoorr
rreessppoonnssee
1155TToottaall

15. CLINICAL PRESENTATION
• Concussion.
• Post-traumatic vomiting.
• Post-traumatic headache.
• Traumatic seizures and post-traumatic
epilepsy.
• Focal neurological signs.
• Deterioration.
• Intracranial hematomas
• Infection.

16. DIAGNOSTIC EVALUATION
PLAIN RADIOGRAPHY:
Plain X-ray of the skull is essential and
mandatory investigation for any patient with head
trauma, especially who may be fully conscious
(GCS= 15) at the time of examination.
Expected findings;
1-linear skull fracture.
2-Depressed skull fracture.

17. FINDINGS:
linear skull fractures;
•They constitute 3/4 of all fractures, the diagnosis
is suspected when significant scalp swelling is
present. (figs.)
•A special type of linear skull fracture is the
diastatic sutural fracture in which the suture is
disrupted and becomes widely separated
complications of linear skull fractures:complications of linear skull fractures:
• intracranial hematomas
• growing skull fractures

19. GROWING SKULL FRACTURE
Also known as a “leptomeningeal cyst”.
In this lesion, a dural tear occurs with a
linear fracture and usually a brain injury
deep to the site of the fracture is present.
Because the gliotic cortex adheres to the
edges of the dural lacerations, the dura
does not heal. (fig.)

22. DEPRESSED SKULL FRACTURE
Occurs when an object of a small surface area
impacts the skull with a high kinetic force (fig.)
It may be 1- closed.
2- open.
A variant in pediatrics is the ping pong fracture

26. BASILAR SKULL FRACTURE
•Occurs in 5% of pediatric head trauma, (fig.)
•Clinically: fracture anterior cranial fossa.
fracture petrous.
•CT here is helpful for diagnosis
•Risk of complications
CSF fistula
meningitis
cranial nerve deficits

28. COMPUTERIZED TOMOGRAPHY
Patients with mild head injury may harbor a
potentially life threatening or disabling brain
injury.
Considering this, it seems likely that an acceptable
practice parameter must include the very liberal
and early use of CT scanning for those patients.
Findings: focal contusions (fig.)
intracranial hematomas (fig.)
pneumocephalus (fig.)
fracture base of the skull (fig.)
diffuse brain edema or swelling (fig.)

34. MAGNETIC RESONANCE IMAGING
It has limited value in the initial evaluation of
mildly head-injured children. It is mainly
valuable in follow up evaluation and
prognostication.

35. TREATMENT OF MILD HEAD INJURIES IN
PEDIATRICS
*Aim: to prevent secondary complications.
prediction of long term out-come.
*Careful observation for signs of neurological
deterioration when admission occurs.
*Criteria for admission:
Patient with linear or depressed fracture.
Patient with clinical or radiological evidence
of basilar skull fracture.
Amnesia. (con.)

36. *Con.criteria of admission,
Unconsciousness for any length of time.
Marked headache or vomiting or any
neurologic deficit.

37. NEUROBEHAVIORAL OUTCOME
Pre-existing neuropsychiatric disorders such as
attention deficit, hyperactive disorder and
learning disability.
Long-term neurobehavioral outcome after mild
head injury.

38. THANK YOU