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.     

Paediatric head trauma: influence of age and sex

A consecutive unselected series of 1812 children (up to 15 years old) admitted for head injuries over a period of 8.5 years was studied. The cases were divided up according to five categories of pathology: benign injury, extradural haematoma, subdural haematoma, open brain laceration and brain contusion in a broad sense. All cases of benign injury were from the Geneva area (57 000 children) and 52% of the cases of severe injury were referred from other places. To these 1812 cases were added those of 23 children who died before admission recorded by the police. In the Geneva area the mortality was 6.8/100 000 per year. Patients were divided into three age groups: I (0–3 years), II (3–9 years), and III (9–15 years); group I was further subdivided into subgroups I a (0–1 year) and I b (1–3 years). The incidence of each type of accident was calculated for each age group, separately for girls and boys. Each type of pathology was correlated, sex by sex and for different ages, with the type of accident. Overall, two boys were injured for each girl. Road accidents were responsible for 15% of head injuries in group I girls, 17% in group I boys, 43% in group II girls, 45% in group II boys, 50% in group III boys and 61% in group III girls. They were responsible for 94% of all deaths and 85% of deaths of hospitalized patients. Falling was the most frequent cause of injury. Benign injuries were more frequent in group I. Only 1 of 25 patients with extradural haematomas died, and there were only 8 patients with subdural haematomas, 4 in subgroup I a (babies aged less than 1 year).     

华东六省一市颅脑创伤合并颅面损伤住院患者调查

目的掌握华东六省一市颅脑创伤合并颅面损伤住院患者临床流行病学特点。方法从《2004年华东六省一市颅脑创伤住院患者》数据库中整群抽取合并颌面损伤患者,用SPSS13.0统计软件包分析。结果15611例颅脑创伤患者中合并颌面损伤患者占40.37%,男女比3.59：1,平均年龄（38.70±16.93）岁,17～58岁患者占所有年龄组的80.04%,各年龄组上性别对于颅脑创伤合并颅面损伤的发病有统计学意义（P〈0.01）。主要受害者是农民（46.11%）、工人（28.07%）、学生及儿童（9.08%）,文化程度以中学（55.16%）、小学（29.50%）和文盲（6.22%）最多。公路（67.22%）、公共场所（11.35%）和矿山工地（9.46%）是主要发生地点;主要致伤原因是车祸伤（66.20%）、击打伤（12.20%）和高处坠落伤（10.71%）,而且在各年龄组中车祸伤都是主要致伤原因（P〈0.01）。颅脑创伤合并颅面损伤较其他颅脑创伤病情重,合并伤多,预后差。结论颅颌面损伤是颅脑创伤中最常见的合并症,多为中青年男性,且文化层次相对较低,这类患者较其他损伤病情重,预后差,在检查、诊断和治疗上需要各学科通力合作。     

How should we manage children after mild head injury?

There are many controversies concerning the management of children after mild head injury. Most of these patients achieve a full recovery without medical or surgical intervention. A small percentage of them deteriorate owing to intracranial complications. The goal of this study was to identify significant factors that might allow the identification of patients at risk of subsequent deterioration. Its secondary goal was to establish a clinical protocol for the management of mild head injuries in children. We retrospectively reviewed the records of 166 children and adolescents with head trauma who had Glasgow Coma Scale (GCS) or Children Coma Scale (CCS) scores of 13–15 at the time of admission. The patients were divided into five age categories: babies younger than 1 year, children 1–3, 4–6, and 7–14 years old, and adolescents 15–17 years of age. The largest age group consisted of children 7–14 years old (83 cases). There was a male predominance (2:1). The main causes of injury were traffic accidents (55 cases) and falls (53 patients). Neurosurgical procedures were required in 93 of the 166 patients (56%). The most common intracranial lesion was subdural and epidural hematoma (60 cases). In 26 children (15.6%) diffuse brain swelling was the only lesion. A skull fracture was found in 103 cases and was accompanied by epidural hematoma (HED) in 19 cases (18%) and by subdural hematoma (HSD) in 12 cases (12%). However, the 63 children without a fracture also included 18 (29%) who had HSD and 11 (17%) who had HED. In our population 165 (99%) of the patients obtained a very good or good result. None was left severely disabled or in a vegetative state. One patient with GCS 13 died of an infection. We concluded that skull X-ray examination is not sufficient to rule out intracranial hematoma. We recommend CT scanning and admission to hospital for 24-h observation for all children with minor head injury, because of the risk of delayed hematoma. Received: 8 September 1999     

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.     

3000 head injuries: a prospective study of patients admitted to Brisbane neurosurgical units

A prospective epidemiological study of 3095 patients with head injury admitted to Brisbane neurosurgical units is presented. Falls were the commonest cause of injury overall (42%) but traffic accidents were the leading cause of severe head injury Glasgow Coma Scale ([GCS] 8 or less) and had a higher mortality (5.6%). Outcome was closely related to GCS, presence or absence and type of skull fracture, computed tomography (CT) scan findings and age. Overall mortality was 4.4%. Mortality for mild head injury (GCS 13-15) was 0.4%, moderately severe head injury (GCS 9-12) 10.5% and severe head injury (GCS 3-8) 34.5%. The poor outcome in old patients who fall and sustain a mild head injury is highlighted. Low risk criteria are identified and recommendations regarding admission and management policies are made.     

小儿交通事故伤致颅内血肿及多发伤28例临床分析

目的 总结小儿交通事故伤致颅内血肿合并多发伤的诊治体会。方法 28例小儿交通事故伤致颅内血肿合并其他部位损伤。年龄1-14岁。均行头部开颅手术及其他部位损伤的处理。结果 本组病人中共治愈23例。治愈率82.3%,中残2例。死亡3例。死亡原因主要为重型颅脑损伤。其次为失血性休克和其它内脏并发症。小儿交通伤的临床表现严重而复杂，主要特点有：（1）头部损伤程度重；（2）合并伤多；（3）容易漏误诊。结论 小儿交通伤致颅内血肿合并其他部位损伤的病情凶险而复杂。应根据患儿伤情程度及局部情况及时手术及处理。早期诊断和及时治疗是治愈本病的关键。     

Management and classification of children with head injury

Background Traumatic brain injury is the most common cause of morbidity and mortality during childhood.Aim This study was conducted to describe the primary management and classification of children admitted to the emergency department for head trauma.Series All children (0–15 years) with a history of head injury who were admitted to the outpatient emergency department at a single paediatric trauma centre in the Stockholm region during 1 month were included.Results There were 242 children (137 girls and 105 boys; mean age 5.3±4.4 years) who fulfilled the inclusion criteria. Based on the Scandinavian Head Injury Classification, 73% were classified as minimal, 17% mild and 2% moderate head injury. This classification seemed to be more accurately reflective than the ICD-10-based classification in the management of the children with head trauma.     

Early post-traumatic seizures in children with head injury

Post-traumatic seizures (PTS) can be a serious complication of head injury, because they can cause secondary brain damage through increased metabolic requirements, raised intracranial pressure, cerebral hypoxia, and/or excessive release of neurotransmitters. In children, early PTS are more frequent than late ones. In this retrospective study we conducted an epidemiological analysis and tried to identify potential risk factors for the onset of early PTS in children hospitalized for head injury in our Paediatric Intensive Care Unit. The severity of injury was assessed using the Glasgow Coma Scale (GCS), while the outcome of traumatized children was defined using the Glasgow Outcome Score (GOS). Early PTS were diagnosed in 15 out of the 125 children hospitalized (12%). Most of the children (73.3%), developed seizures within 24 h of the trauma (immediate PTS). Among the risk factors, a very important role was played by the severity of the injury; in fact, the incidence of early PTS among patients with GCS≤8 was ten times greater than that among children with GCS 13–15. Other risk factors that significantly influenced the onset of early PTS, were age (60% of children with early PTS were less than 3 years old) and severe cerebral edema. Overall, children with early PTS had a worse outcome than the other patients. In fact, 53% had a GOS of ≤3 compared to 19.1% of those without early PTS (P<001). In particular, considering children with severe head injury, 80% of those with early PTS had a GOS of ≤ 3, compared to 41% of those without early PTS (P<0.05). In conclusion, PTS can be a serious complication of head injury in children, because they can worsen secondary brain damage. Appropriate management of head-trauma patients must include suitable and immediate prophylaxis with anti-epileptic drugs. Received: 27 April 2000 Revised: 7 June 2000     

Pediatric traumatic brain injuries in Taiwan: an 8-year study.

Background. This study is intended to determine the causes of pediatric traumatic brain injuries (PTBI) in children aged 14 years or less, and to identify various types of craniocerebral damage resulting from different mechanisms of injury.Methods. From July 1, 1993 to June 30, 2001, a survey on PTBI was conducted in Taiwan. The data of patients used in this study were collected from 56 major hospitals among the age group of 0-14 years. The items in the traumatic brain injury survey included sex, age, causes of injuries, severity, and the eventual outcome.Results. A total of 5349 cases were identified. The male-to-female ratio was 1.69: 1. The incidence rate was higher in the age groups of 4-9 years and 10-14 years. The main cause of PTBI was traffic injury, which accounted for 2537 of the cases (47.3%), followed by falls, 2160 (40.3%). Of all traffic injuries, motorcycle-related injury had the highest incidence, followed by the pedestrian and bicycle-related injury. This study also showed that 83.2% of the patients had mild injury, 9.8% had moderate injury, and 7.0%, severe injury.Conclusions. The results of this study suggest that it is important to decrease all the risk factors in the environment of homes and public areas as much as possible. Helmet wearing and the development of public transportation are essential for the prevention of head injury.     

Mild head injury in preschool children: evidence that it can be associated with a persisting cognitive defect.

This study describes the effect of mild head injury in preschool children on aspects of their cognitive performance in the year after injury and at the age of 6.5 years, with particular reference to the development of reading skills. Mild head injury was defined by diagnosis at a hospital emergency department of a head injury which was not severe enough to need admission for observation. Seventy eight such children were compared with a group of 86 with a minor injury elsewhere. The groups had similar developmental, family, and socioeconomic status. There were no differences in cognitive tests soon after the injury, but at six months and one year children with mild head injury scored less than controls on one test, solving a visual puzzle (visual closure); they were also more likely to have had another mild head injury. At 6.5 years of age they still scored less than controls, reading ability was related to their visual closure score at one year, and they were more likely to have needed help with reading. Mild head injury seems to be able to produce subtle but significant changes which can affect school performance.     

Closed head injury: comparison of children younger and older than 6 years of age

The outcomes of 97 children with severe closed head injuries referred to a regional rehabilitation center were studied. Patients were divided according to referral source and age (less than 6 and greater than or equal to 6 years). Patients referred from more distant sources had worse outcomes in terms of cognition, motor ability, and brain atrophy for both age groups. Children 6 years of age and older had better cognitive, motor, and brain atrophy outcomes than younger patients for each referral origin. These results do not support the hypothesis that the youngest children have the best recovery after profound closed head injury. All abused children were younger than 6 years of age; compared to other age-matched, closed head injury patients, these children had significantly worse cognitive and motor abilities.     

Chronic posttraumatic headache in children and adolescents

Little is known about chronic posttraumatic headache (PTH) in children and adolescents. In this study we report on symptoms, clinical findings, and management of all children seen in our headache clinic who presented with recurrent headache following head injuries. A total of 23 children were identified over a period of 4 years. Twenty-one children (13 male, eight female; mean age 11.2 years, age range 3.3 to 14.9 years, median 12.1 years) fulfilled the International Headache Society's clinical criteria for the diagnosis of chronic PTH. Mean duration of headache was 13.3 months (range 2 to 60 months, median 7 months). Children were followed up for a period of 5 to 29 months (mean 12.5 months, median 9 months). Head injuries were classified as serious in four patients and minor in 17. Clinical variables were compared between children with PTH and those without a history of head injury. The headaches were migraine in five patients, tension type in 13, and mixed in three patients. Tension-type headache was significantly more common in children with chronic PTH than in those with no history of head injury, but the clinical course was comparable in the two groups.     

Age differences in brain injury characteristics

Purpose: Traumatic brain injury (TBI) is an important cause of morbidity and mortality in children. Despite the high incidence of head injury among children, the mortality rate is low. There is a lack of studies that describe children's age-specific symptoms in relation to outcome. The purpose is to investigate if other described symptoms could be used as a predictor of intracranial injury in children.

Methods: Retrospective review of data from all children who during 1 year were admitted due to a brain injury.

Results: During 1 year 724 children visited the ED due to a brain injury. A significant difference was found between age groups and other documented initial symptoms, but no single symptoms could be used as a predictor for intracranial injury.

Conclusion: Unconsciousness as a predictor for brain injury should be used with caution in children. Significant differences were found in other documented symptoms between age groups.     

Spinal cord trauma in children under 10?years of age: clinical characteristics and prevention

Purpose

This study analyzed the clinical characteristics of spinal cord injury (SCI) in children 10?years of age and younger, forms of prevention, and ways to improve treatment.

Methods

Ninety-three children were reviewed between 1996 and 2009. The variables studied were type, age, cause, neurological level, association between SCI and traumatic brain injury (TBI), arthrodesis surgery, time elapsed between trauma and diagnosis, and causes of death. The statistical evaluations were done using the chi-square and ANOVA scales, in the SPSS program version 11.0.

Results

The most common cause was automobile crash accidents. Getting run over by a car was second (29.1?%), followed by firearm injuries (11.8?%). The thoracic spine was the most commonly impacted area. Evaluation showed that 83.9?% had complete neurological injury. Associated TBI was present in 35.5?% of the cases. Only 21.5?% of the patients required arthrodesis of the spine. In 31.2?% of the cases, myelopathy was not diagnosed at the time of the accident. There was no statistical correlation between TBI and a delayed diagnosis of SCI (p?=?0.231). Five children (5.4?%) died.

Conclusions

The study showed that the cause of the trauma is associated to the child's age and that prevention is important. Trauma from automobile crash accidents was the main cause, and, in older children, firearm injuries are an important risk. Spinal cord injury was not always diagnosed in children at the time of accident. Educating family members and training emergency teams to adequately treat children with multiple traumas are measures that can help reduce the incidence of SCIs and neurological damage.     

Our experience with surgically treated epidural hematomas in children

Objective

Traumatic epidural hematomas (EDHs) in children are a relatively unusual occurrence. The cause and outcome vary depending on period and region of study. The aims of this analysis were to review the cause and outcome of pediatric EDHs nowadays and to discuss outcome-related variables in a large consecutive series of surgically treated EDH in children.

Methods

This is a retrospective review of 29 patients with surgically treated EDHs between Jan 2000 and February 2010. Patients'' medical records, computed tomographic (CT) scans, and, if performed, magnetic resonance imaging (MRI) were reviewed to define variables associated with outcome. Variables included in the analysis were age, associated severe extracranial injury, abnormal pupillary response, hematoma thickness, severity of head injury (Glasgow Coma Scale score), parenchymal brain injury, and diffuse axonal injury.

Results

The mean (SD) age of the patients was 109 months (0-185 months). Most of the injuries with EDHs occurred in traffic accident (14 cases, 48.2%) and followed by slip down in 6 cases and falls in 6 cases. There were one birth injury and one unknown cause. EDHs in traffic accidents occurred in pedestrians hit by a motor vehicle, 9 cases; motorbike and car accidents, 5 cases and bicycle accidents, 1 case. The locations of hematoma were almost same in both sides (left side in 15 cases). Temporal lobe is the most common site of hematomas (13 cases, 44%). The mean size of the EDHs was 18 mm (range, 5-40 mm). Heterogeneous hematomas in CT scans were 20 cases (67%). Two patients were referred with unilateral or bilateral dilated pupil(s). There was enlargement of EDH in 5 patients (17%). All of them were heterogeneous hematomas in CT scans. Except for 4 patients, all EDHs were associated with skull fracture(s) (87%). There was no case of patient with major organ injury. CT or MRI revealed brain contusion in 5 patients, and diffuse axonal injury in one patient. The mortality was zero, and the outcomes were excellent in 26 and good in 2 patients. None of the tested variables were found to have a prognostic relevance.

Conclusion

Regardless of the EDH size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the patients with EDH were excellent.     

Long term psychosocial outcomes after mild head injury in early childhood

OBJECTIVES: The question of whether any adverse cognitive or psychosocial outcomes occur after mild head injury in early childhood has evoked considerable controversy. This study examined mild head injury before age 10 and potential differences in late childhood/early adolescence as a function of severity of mild injury and age at injury. METHODS: A fully prospective longitudinal design tracked a large birth cohort of children. Confirmed cases of mild head injury before age 10 were divided on the basis of outpatient medical attention (n=64-84) or inpatient observation (hospital overnight; n=26-28 ) and compared with the non-injured remainder of the cohort (reference group; n=613-807). A range of pre-injury and post-injury child and family characteristics were used to control for any potential confounds. Outcome after injury before and after age 5 was also assessed. RESULTS: After accounting for several demographic, family, and pre-injury characteristics, the inpatient but not the outpatient group displayed increased hyperactivity/inattention and conduct disorder between ages 10 to 13, as rated by both mothers and teachers. Psychosocial deficits were more prevalent in the inpatient subgroup injured before age 5. No clear effects were evident for various cognitive/academic measures, irrespective of severity of mild injury or age at injury. CONCLUSIONS: Most cases of mild head injury in young children do not produce any adverse effects, but long term problems in psychosocial function are possible in more severe cases, perhaps especially when this event occurs during the preschool years. The view that all mild head injuries in children are benign events requires revision and more objective measures are required to identify cases at risk.     

汶川地震后颅脑损伤儿童36例临床分析

目的 探讨汶川大地震后儿童颅脑损伤的临床特点.方法 收集汶川大地震后四川大学华西医院神经外科住院的36例地震致颅脑损伤儿童的临床资料(男21例,女15例;年龄3月～14岁.平均年龄8.1岁;轻型30例,中型4例,重型2例;建筑物倒塌砸伤30例,切割伤3例,逃生跌伤3例),对其伤情分类、致伤原因、治疗方法 及预后等进行回顾性分析.结果 36例颅脑损伤儿童中出院(或转院)时GOS评分为恢复良好33例,中残3例.结论 汶川大地震后建筑物倒塌砸伤为主要致伤原因,颅脑损伤儿童以轻型居多,要注意颅骨骨折的治疗,多数可恢复良好.