Pediatric Emergencies: Imaging of Pediatric Head Trauma

A Systematic Review and Meta-Analysis on the Management and Outcome of Isolated Skull Fractures in Pediatric Patients

BACKGROUND

The impact of traumatic brain injury (TBI) on the pediatric population is profound. The aim of this study is to unveil the state of the evidence concerning acute neurosurgical intervention, hospitalizations after injury, and neuroimaging in isolated skull fractures (ISF).

MATERIALS AND METHODS

This systematic review was conducted in accordance with PRISMA guidelines. PubMed, Cochrane, Web of Science, and Embase were searched for papers until April 2023. Only ISF cases diagnosed via computed tomography were considered.

RESULTS

A total of 10,350 skull fractures from 25 studies were included, of which 7228 were ISF. For the need of acute neurosurgical intervention, the meta-analysis showed a risk of 0% (95% CI: 0-0%). For hospitalization after injury the calculated risk was 78% (95% CI: 66-89%). Finally, for the requirement of repeated neuroimaging the analysis revealed a rate of 7% (95% CI: 0-15%). No deaths were reported in any of the 25 studies.

CONCLUSIONS

Out of 7228 children with ISF, an almost negligible number required immediate neurosurgical interventions, yet a significant 74% were hospitalized for up to 72 h. Notably, the mortality was zero, and repeat neuroimaging was uncommon. This research is crucial in shedding light on the outcomes and implications of pediatric TBIs concerning ISFs.

Utility of three-dimensional and reformatted head computed tomography images in the evaluation of pediatric abusive head trauma

Skull fractures are common in the pediatric population following head trauma and are estimated to occur post head trauma in 11% of children younger than 2 years. A skull fracture indicates potential underlying intracranial injury and might also help explain the mechanism of injury. Multiple primary and accessory sutures complicate the identification of non-depressed fractures in children younger than 2 years. Detection of linear skull fractures can be difficult on two-dimensional (2-D) CT and can be missed, particularly when the fracture is along the plane of image reconstruction. Knowledge of primary and accessory sutures as well as normal anatomical variants is of paramount importance in identifying pediatric skull fractures with a greater degree of confidence. Acute fractures appear as lucent cortical defects that do not have sclerotic borders, in contrast to sutures, which might demonstrate sclerotic margins. Three-dimensional (3-D) CT has increased sensitivity and specificity for detecting skull fractures and is essential in the evaluation of pediatric head CTs for distinguishing subtle fractures from sutural variants, especially in the setting of trauma. In this review, we present our experience of the use of 3-D reformats in head CT and its implications on the interpretation, especially in the setting of accidental or abusive head trauma.

[Top ten pediatric radiological emergencies]

Pediatric emergencies encompass a wide range of different findings. These include injuries to the child's body due to high-energy trauma or abuse, unclear limitations of consciousness and primarily unspecific abdominal or thoracic pain as well as swallowing or inhalation of foreign bodies. Detailed knowledge of the various imaging methods and the correct application are important. This article gives an overview of the significance of imaging techniques for emergency diagnostics in childhood and adolescence.

MRI Findings in Pediatric Abusive Head Trauma: A Review

Trauma is the most common cause of death and significant morbidity in childhood; abusive head trauma (AHT) is a prominent cause of significant morbidity and mortality in children younger than 2 years old. Correctly diagnosing AHT is challenging both clinically and radiologically. The primary diagnostic challenges are that the abused children are usually too young to provide an adequate history, perpetrators are unlikely to provide truthful account of trauma, and clinicians may be biased in their assessment of potentially abused children. The main radiological challenge is that there is no single imaging finding that is independently specific for or diagnostic of AHT. The radiological evaluation should be based on the multiplicity and severity of findings and an inconsistency with the provided mechanism of trauma. While the most common neuroimaging finding in AHT is subdural hemorrhage, other less well-known magnetic resonance imaging (MRI) findings such as the "lollipop sign" or "tadpole sign," parenchymal or cortical lacerations, subpial hemorrhage, cranio-cervical junction injuries including retroclival hematomas, as well as diffuse hypoxic brain injury have been identified and described in the recent literature. While AHT is ultimately a clinical diagnosis combining history, exam, and neuroimaging, familiarity with the typical as well as the less-well known MRI findings will improve recognition of AHT by radiologists.

[Necessity for radiological examinations in children : Children in two levels]

The diagnostics and treatment of pediatric skeletal trauma can be fundamentally different from adults. Based on in-house data the diagnostic approach to the most frequently encountered pediatric injury patterns is discussed. The necessity for a primary X‑ray imaging or computed tomography examination is questioned. Both diagnostic methods cause stochastic radiation damage. Therefore, it is important to perform the safest examination for the child while injuries are correctly diagnosed.

Delayed evolving epidural hematoma in the setting of a depressed skull fracture: A case report and review of the literature

Background

Historically, in the pediatric population, there is a highly selective approach for repeat imaging given the risk of radiation and costs. In the lieu of this, frequent neurological checks and even ICP monitoring has been used as an adjunct, although not always successful. We present a case of a pediatric patient with a late evolving epidural hematoma in the setting of a depressed skull fracture, and present an argument for serial CT imaging in a select patient population similar to his.

Objective

Discuss the unique presentation, diagnosis, and management of an expanding epidural hematoma in a pediatric patient with a depressed skull fracture and the need for aggressive repeat imaging in this setting.

Case report

Patient is a 15-year-old boy who presented to our trauma bay after being the victim of a hit and run while skateboarding. His injuries included a depressed comminuted skull fracture and bilateral SDH. Additionally, a stat CT angiogram was obtained due to a basilar skull fracture. A rapidly evolving EDH with impending herniation was found, which was nearly fatal and was not present on the initial CT scan. He required emergent evacuation with a hemi-craniectomy where he was found to have a laceration of his dural vessels as well as his middle meningeal artery. Post operatively he did well and regained full neurologic function.

Conclusion

We presented a case of a pediatric patient with a late evolving epidural hematoma seen on repeat CT imaging. In the setting of a depressed skull fracture, hemorrhage from this source is likely to be missed on initial CT imaging. Frequent neurochecks or ICP monitoring may not be possible in this population encouraging the need for more aggressive repeat imaging.

Child Maltreatment Red Flags: Two Cases of Bruising in Premobile Infants

Child maltreatment is a serious public health concern in the United States. Young infants and children younger than 3 years are at the highest risk of being abused and can experience both acute injuries and long-term developmental, behavioral, and mental health problems. Health care providers are mandated reporters of suspected abuse but may misdiagnose potentially abusive injuries because of lack of knowledge in recognizing maltreatment. Premobile infants rarely have bruising or intraoral injuries without a reported accident or underlying systemic disease and should raise concern for abuse. It is not uncommon for an abused child to present with an injury that at first glance may seem trivial but is actually suspicious for physical abuse and later be found to have abusive fractures or head trauma. The following case presentations show the importance of recognizing sentinel injuries and red flags for maltreatment in young, premobile infants with unexplained bruises.