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.

[Pineal cyst in MRI: clinical symptoms and analysis]

Application of magnetic resonance imaging (MRI) in radiology allows to estimate and analyse pineal gland and pineal region pathology more precisely. We report 47 MRI brain studies of patients in whom pineal cyst was recognized as the only pathologic finding. MRI of the brain was performed because of clinical symptoms as headaches (32%), vertigo (26%) and altered behaviour (13%). Because of the common occurrence of pineal cyst in MRI brain imaging it seems to be important to decide whether these patients need neurosurgical intervention, especially if together with morphologic abnormality definite clinical symptoms exist.

Surgery or conservative treatment in children with traumatic intracerebral haematoma

In contrast to the case of extracerebral haematomas, the criteria for operative treatment of traumatic intracerebral haematoma (TIH) are not clear. The purpose of this study was to find factors that would be helpful in reaching a decision for surgical or conservative treatment of TIH. We performed a retrospective analysis of 31 consecutive cases of TIH treated in our department. The following factors were estimated: age, mechanism of injury, initial GCS or CCS score, neurological deficits, coexistence of arterial hypotension and respiratory disturbances, and localisation and size of the haematoma. The outcome was evaluated according to a modified GOS. Treatment was surgical for 20 patients and conservative for 11. Patients with GCS or CCS scores of 3-8 were treated surgically significantly more often than those with higher scores. The other factors did not correlate with type of treatment. It seems, then, that the clinical status of the patient, especially the level of consciousness according to the GCS or CCS score, is the most important predictor of the need for surgery in children with TIH.

[Head injuries in pediatric age]

Head trauma is the leading cause of morbidity and death in paediatric population. The authors present an outline of contemporary knowledge on the paediatric head injury on the ground of literature and own experience. The value of Glasgow Coma Scale, its modifications and other prognostic factors in children's population after head trauma is discussed. The management of mild head injury is also disputed. In conclusion it is stressed that since many differences in epidemiology, mechanism, pathophysiology and outcome of head injury in childhood and adults exist the separation of "paediatric neurotraumatology" is reasonable.

[Epidermoid cysts in the area of the pontocerebellar angle]

Five cases of epidermoid tumours in the vicinity of the pontocerebellar angle were treated surgically. The mean age of the patients was 31 years. Four were women, one man. Good and very good result was achieved in 80%. The surgical technique and difficulties in cases of epidermoids in this situation are described. The own experience of the authors is compared with the reports of other authors and the need for radical removal of the lesion is stressed since malignant transformation is possible, even long after operation.

[Growth of intracranial meningiomas after trauma. A case report]

A case is described of intracranial meningioma development in a woman aged 69 who had craniotomy 28 years earlier. The meningioma grew at the site of previous craniotomy. Documented cases from the literature are quoted in which craniocerebral trauma was unequivocally related to meningioma development, although the coincidence of trauma with meningioma is still controversial.

[Two cases of intracranial lipomas]

The authors report two rare cases of intracranial lipomas recognized in CT of the head. The tumours were situated in the corpus callosum in one case, and in the posterior fossa in the other case. Both cases were thought unsuitable for surgical intervention, and one of the patients was given only anticonvulsant treatment.

[Certain problems of surgical treatment of third ventricle tumours]

The authors present an outline of the modern knowledge on the surgery of third ventricle tumours. Both anatomy and most common pathology of the third ventricle is discussed. The operative procedures are divided on the basis of tumour localisation into anterior or posterior third ventricle ones. In conclusion it is stressed that in spite of existing controversies these operative procedures are now performed with good results in many neurosurgical centers.

[A case of large myelomeningocele complicated with liquorrhoea in a 32-year old man]

A case is presented of a 32-year-old man with giant myelomeningocele situated in the lumbosacral segment of the spine. The patient was admitted to the department with manifestations of active liquorrhoea from the dorsal surface of the hernial sac. An X-ray examination was performed which demonstrated an extensive spina bifida from L3 to S2. The patient was operated on preparing the myelomeningocele gate. In the described case the attention is paid to the lack of other developmental anomalies of the nervous, urinary, and osteoarticular system.

[Primary sclerosing cholangitis and primary biliary liver cirrhosis as the causes of intrahepatic cholestasis]

Primary sclerosing cholangitis and primary biliary cirrhosis are rarely diagnosed diseases which should, however, be considered in the diagnosis of cholestasis. The authors present an outline of the modern knowledge on these diseases with particular reference to differential diagnosis.