Case
Presentation
R.S. is a four-year old,
right-handed child without any significant past medical history who
had been in her usual state of health until 12-hours prior to her
presentation, when she slipped in her home, landing on an 8x2x2 inch
metal display stand meant for a doll. The object appeared to pierce
only her scalp. The child cried immediately, and the object was quickly
dislodged by the child’s parent. Removal of the object was initially
associated with bleeding from the puncture site, which resolved with
the application of pressure.
The parent was concerned
about the child and brought her in for evaluation. On presentation
to the emergency department, the child was afebrile, and with normal
vital signs. She was very active, and could recount the event in its
entirety. Additional history from the child’s parent confirmed that
the child did not have any altered consciousness, neurologic focality,
or seizure activity prior to her arrival in the emergency department.
Her physical examination, including full neurological assessment,
was appropriate for age except for a 1-millimeter puncture site on
the left temporal region of the skull, associated with a small amount
of dried blood. There was also a 5-millimeter hematoma, which was
slightly tender to palpation, surrounding the wound.
TOP
A
Four-year Old With An Injury After Playing With A Barbie®
Doll
Introduction
Background,
Risk Factors, Epidemiology
Acute
head trauma in children is a common reason for presentation to the
emergency department. It is estimated that the
frequency traumatic brain injury (TBI) in the pediatric population
is approximately 180-300 per 100,000 pediatric patients per year (1-5).
In
its most general sense, TBI can be defined as “any physical damage
to, or functional impairment of the cranial contents by acute mechanical
energy exchange”(4). Penetrating head trauma (PHT) represents
a small fraction of this group.
Modern discussion of the evaluation and treatment of PHT dates
back to World War I (6).
While this type of injury and its management have been well
described in the adult literature-especially in the adult military
population (6-10) -there are few comprehensive studies on this topic
in pediatrics (11-18). A
practice guideline published as a joint project of the Brain Trauma
Foundation and the American Association of Neurologic Surgeons, Joint
Section of Neuro Trauma, addresses key management issues of adult
patients with severe TBI (39). This parameter is evidence based, using
scientific evidence rather than expert opinion in the formulation
of the guideline. Unfortunately,
the care of children is not reviewed.
In
August 2001, The Journal of Trauma published a guideline on penetrating
head injury which is the most complete review of this topic to date
(41-49), reviewing both civilian and military injuries.
This work includes contributions from the International Brain
Jury Association, the Brain Injury Association USA, and members of
The American Association of Neurologic Surgeons, and the Congress
of Neurologic Surgeons. Among
the recommendations of this report are:
-
the
liberal use of CT scan (rather than MRI) for the evaluation of
PBI
-
Angiography
is recommended for when a vascular injury is suspected
-
Early
intracranial pressure (ICP) monitoring should be considered when:
-
clinical
assessment of the patient is not reliable
-
when
ICP elevation is suspected
-
possibly
in helping determine the need to evacuate a mass lesion.
-
The
use of broad-spectrum antibiotics is recommend for all PBI patients.
-
Anti-seizure
medications are recommended for the first week to prevent seizures,
but is not recommended beyond the first week.
For
a number of reasons, the adult literature on this subject may not
be generalizable to pediatrics.
The types of injuries sustained by children are quite different
those sustained by adults, and the mechanisms to adapt those injuries
may also vary.
A
recent practice parameter, entitled “The Management of Minor Closed
Head Injury in Children” was published in 1999 by the American Academy
of Pediatrics and the American Academy of Family Physicians (40). The parameter deals with children above the age of two years
with isolated minor closed head injury.
The parameter is meant to evaluate children who have normal
mental status at the initial examination, who have no abnormal or
focal findings on neurologic examination, and who have no physical
evidence of skull fracture. Penetrating head injury is not reviewed
by the parameter.
TBI
is exceedingly common in children (1-5). PHT
represents a small fraction of these cases, although the exact incidence
is not known. 54 cases
of PHT in children were reported from two South African hospitals
over a 25-year period (12).
This and other reports have presented cases of the penetration
of a child’s skull by a pencil (11,12,14,16), a metal rod/ wire (11,12,14,15),
a nail/ needle (11,12), a table knife/ fork (11,12,14,19), lawn darts
(13,17), scissors (12), hair accessories (18), a garden rake (12),
and by bullets/ pellets (12,14).
Although these injuries are widely recognized, little has been written concerning the approach to the evaluation,
management, and follow-up of pediatric patients with PHT.
Much of the current practice in this area is based on extrapolation
from case studies in adults, which may not be appropriate in many
cases. These differences
impact not only the extent of initial injury with PHT, but also the
incidence of early and late complications from these injuries.
In
adults, PHT generally involves intentional injury with high velocity
projectile objects such as knives, bullets, and shrapnel, often during
wartime (9,12,15). PHT
in children is generally less severe in impact and involves household
items such as children’s toys, kitchen utensils, writing instruments,
and hair accessories (11-18).
Since the skull is not completely ossified until about age
two years, children are at greater risk for penetration of the skull
and the dura after minimal force than are adult patients under similar
circumstances (11). This
is especially true in the region of the orbit, where the fragility
of the bone in that area of the skull permits penetration of the cranial
vault by projectile objects with less force than in other areas of
the skull.
Emergency Department Presentation and Evaluation
The
clinical examination of children after TBI, and specifically after
PHT, is unreliable and insensitive to identifying intracranial injury
(2,5,11-13,21,22). Specifically,
since the projectiles involved in childhood PHT may deeply penetrate
the skull and brain parenchyma,
leaving trivial appearing entrance wounds and normal neurological
examinations, significant head trauma can be sustained without evidence
of intracranial injury on clinical examination (9,11-13,16).
As a result, in the immediate post-injury period, the clinician
may strikingly underestimate the severity of brain injury in children
with PHT and fail to anticipate the possible early and late complications
of this type of injury. As
evidenced with this case, a trivial appearing entrance wound can be
associated with significant radiographic evidence of brain injury.
A
number of scoring systems have been created to quickly and reproducibly
estimate the neurological status of patients with general TBI (23).
These include the Glasgow Coma Scale (GCS), the Trauma Score,
the Injury Severity Score, and the Abbreviated Injury Scale (20,23,25).
The
most widely recognized of these scales, the GCS, is most helpful in
predicting outcome in adult patients with severe head trauma (24).
The scale loses its predictive value, however, in children,
since very young pediatric patients lack the higher integrative brain
functions essential to generate the “best” responses for the GCS (25).
Hennes et al. noted that 25% or more pediatric patients who
sustain TBI have minimal or no neurologic signs and have GCS scores
of 12 or more (2). In
another study, Dietrich et al. noted that of children with normal
neurologic examinations and GCS scores of 15 after TBI, five percent
had abnormal CT scans (21).
Given
the poor predictive value of the GCS in young children, a group in
Adelaide, South Africa created another tool, the Pediatric Glasgow
Coma Scale, with realistic age-related responses. It has been used
to assess the level of consciousness in young children in whom the
normal verbal and motor responses of the unmodified GCS are not achievable
(25). Two additional tools
were also created to assess young patients after TBI: The Child’s Coma Scale of Raimondi and Hirschauer and Hahn’s
Child’s Coma Scale.
However, no studies have reliably predicted ultimate outcomes
of children who have sustained PHT using any of these scales.
Dietrich
et al. noted
that certain clinical parameters are more specific and sensitive indicators
of intracranial injury after TBI in children (21). Amnesia for the traumatic
event, focal neurological signs, loss of consciousness, and GCS score
less than 15 were the most common clinical findings in children with
TBI. Of these parameters,
amnesia for the traumatic event was the most sensitive predictor of
general intracranial injury, and focal neurological signs and seizures
were the most specific predictors of those parameters studied.
No one single clinical characteristic consistently identified
children with intracranial injury after TBI.
Additionally, the presence of emesis, loss of consciousness,
and headaches, were useful for predicting significant head injury
in adults, they were not discriminating features in the evaluation
of very young children.
This study, however, does not specify the mechanisms of injury
that contributed to the TBI in these patients.
Therefore, the results of this study may not be entirely generalizeable
to pediatric patients with PHT.
Since
the clinician’s history and examination often underestimates the significance
of brain injury in children, the clinician must rely upon other modalities
to evaluate TBI, and specifically PHT.
Since Dietrich found a significant number of children who had
intracranial complications after TBI that were not predicted by clinical
evaluation, he and his colleagues recommend a low threshold for CT
scanning to evaluate children after TBI (2,21).
CT scan is particularly useful in the initial evaluation of
PHT in children and adults because it can readily determine the extent
of intraparenchymal injury, locate the offending object, plot its
trajectory, and identify most bony defects in the skull (28).
It is also useful and recommended to evaluate late complications
of penetrating head injury, and in the follow-up of existing intracranial
lesions after the primary injury (12,13,15,21,26-8).
Complications
The
sequelae of PHT include:
-
Intraparenchymal
lesions: subdural and epidural hematoma, cerebral edema, cerebral contusions,
pneumocephaly, skull fracture;
-
Infectious
complications: brain abscess, CSF fistulae, encephalitis, meningitis, otitis,
scalp sepsis;
-
Vascular
complications: aneurysm,
arteriovenous malformation;
-
Neurologic
complications: seizures, focal neurological defects.
-
Specific
management issues include the role
of antimicrobial prophylaxis, wound debridement, prophylactic
antiepileptic therapy, agents to prevent vasospasm, and the use
of intracranial imaging to identify post-traumatic vascular malformations.
Initial
Care: Antibiotic Prophylaxis/ Debridement
The
use of antimicrobial prophylaxis after PHT is an area that has undergone
some scrutiny (7,11-14,16). While
the incidence of septic complications after PHT was estimated in one
study to occur in between zero and 25% of adult patients (7), this
rate was quoted in two separate studies as over 40% in children (12,16).
This
discrepancy is thought to occur because those objects that contribute
to penetrating injury in children (e.g. household items, children’s
toys) are more likely to be composed of organic materials.
Specifically, organic materials (e.g. wood, bone) are more
likely than are inorganic projectiles (e.g. glass, metal bullets),
to fragment within the skull and become
superinfected due to their porous nature.
These fragments can later act as a nidus for early and late
septic complications (16).
Based
on these findings, in separate studies Domingo and Miller stated
that antimicrobial agents should be a mainstay of therapy in pediatric
patients with PHT (12,16). In
fact, in their care of patients with PHT, 87% of neurosurgeons who
participated in a 1990 study stated that they routinely initiate antimicrobial
prophylaxis in patients who have sustained PHT (7).
In
addition to antibiotic prophylaxis, most authors also recommend the
rapid debridement of these wounds, based on both the extent of such
injuries and the likelihood of identifying bone fragments or intracranial
residua of the projectile object (7,12,16). In
our patient antimicrobial prophylaxis was initiated, but because of
the modest size of the actual puncture wound and the nature of the
projectile, it was elected to simply irrigate the wound site without
any surgical debridement.
Initial Care: Anticonvulsant Prophylaxis
The
use of prophylactic antiepileptic medications after PHT is another
area of interest. Post-traumatic epilepsy (PTE) is
relatively common in patients after TBI, and specifically after PHT
(8,29-33). In the setting
of PHT, seizures are thought to occur secondary to direct traumatic
injury to brain tissue, which leads to hyperexcitability of intracranial
neurons, and the subsequent formation of an epileptiform focus.
Antiepileptic medications administered in the immediate post
injury period are believed to temper the neuronal hyperexcitability
and reequilibrate the seizure threshold (29).
While
the estimates of early PTE, those seizures occurring within one week
of injury, in all age groups ranges from three to ten percent, the
estimates of late PTE approximates 30% or more, being especially common
after PHT (8,29-32).
While early PTE is more common in children, especially
within the first 24 hours after injury, late PTE is more often a sequela
of TBI and PHT in adults (30-32). Intracerebral hemorrhage,
subdural hematoma, depressed skull fracture, prolonged post-traumatic
amnesia, and focal neurological deficits are thought to predict the
highest risk of subsequent epilepsy in effected patients.
While
a number of studies suggest a beneficial role of prophylactic antiepileptics
to prevent the occurrence of early PTE, the evidence for their use
in preventing late post- traumatic seizures is much less convincing
(29). Specifically,
Temkin’s research illustrated that prophylactic phenytoin was useful
in preventing early, but not late, PTE in adolescent and adult patients
(33). Other studies have
suggested that these results may also be generalized to children after
TBI and PHT (30-32). In
a survey studying the clinical practice of neurosurgeons in the setting
of PHT, 87% stated that they would initiate antiepileptic drug therapy,
typically with phenytoin or less commonly with phenobarbital (7).
Although the physicians involved with this case elected to
discontinue antiepileptic drug therapy after one loading dose, the
literature favors the use of these medications in children especially
in the week following the PHT.
Initial Care: Vasospasm
Another
sequelae of traumatic brain injury is the spasm of large capacity
arteries at the base of the brain following subarachnoid hemorrhage,
often secondary to the rupture of an intracranial aneurysm, with subsequent
relative intracerebral ischemia.
The risk of vasospasm is greatest in the three weeks beyond
the traumatic event (34). Most
of the research in this area is not specific to post-traumatic subarachnoid
hemorrhage, nor are there prospective studies in pediatrics.
Nimodipine has been shown to be beneficial in preventing vasospasm
in the setting of known subarachnoid hemorrhage in adolescent and
adult patients (34,35). It
is still unclear whether vasospasm plays a significant role in TBI/
PHT in children. Whether
nimodipine has a beneficial effect in PHT in children also remains
to be elucidated.
Initial Care: Vascular Evaluation
A
well-described and relatively late occurring sequela of TBI is the
formation of intracranial pseudoaneurysms and arteriovenous fistulae.
While rare in the context of PHT, these lesions, when present,
may contribute to significant morbidity and mortality (9,10,12,19).
This complication is more likely to occur in the face of PHT with
low velocity vascular injury, as is often seen in childhood PHT (10,19).
In a study of PHT in children, vascular complications were
estimated to occur in approximately nine percent of
patients (12).
Of
the modalities that are available to evaluate such injuries, angiography
is the gold standard (9,10,37). Many authors recommend vascular evaluation
in all PHT patients, especially those with stab wounds to the brain,
to rule out post-traumatic vascular complications, since these complications
are rarely obvious on clinical examination, and their late consequences,
including secondary hemorrhage, can be catastrophic (9-11,19). This is especially important in children who have the potential
to live many years beyond their traumatic injuries, and therefore
have a greater opportunity
to succumb to the late complications of growing vascular malformations.
However, there appears to be no consensus in the literature regarding
the timing of vascular evaluation in pediatric patients after PHT
or if these patients require any follow-up if their initial examination
is negative.
In
addition to angiography, magnetic resonance angiography (MRA) is quickly
gaining favor in the evaluation of intracranial, vascular abnormalities,
especially in children (36). MRA
is noninvasive, does not require the administration of contrast, does
not involve exposure to ionizing radiation, and can be performed with
greater speed than traditional angiography (36-7).
There have been no studies that have directly compared MRA
vs. angiography in the evaluation of PHT.
Since MRA lacks the spatial resolution of angiography, MRA
may be less useful in cases where the suspicion for a vascular malformation
may be high and may also be less accurate in identifying the presence
of cerebral vasospasm.
Conclusions
PHT
in children is a relatively uncommon but significant cause of morbidity
and mortality in this age group.
Outcomes can be altered with prompt diagnosis of intracranial
injury and appropriate management.
This case illustrates that significant intracranial injury
may be overlooked in pediatric patients if the practitioner relies
solely on history and physical examination, as many of these injuries
are trivial appearing and not associated with any initial signs of
symptoms. Given the increased
incidence of significant complications associated with PHT in pediatric
patients and the difficulty of using clinical examination alone to
predict the amount of intracranial injury, we propose a multidisciplinary
and conservative approach to the management of these patients.
We suggest that the management of these patients focus on primary
prevention of PHT and that practitioners maintain a low threshold
for the evaluation of potential complications.
We advocate the routine use of CT scanning and antimicrobial
prophylaxis in these patients.
In those patients with hard
neurological signs or evidence of intracranial injury on CT scan,
the addition of at least short-term antiepileptic prophylaxis should
be strongly considered. Vascular evaluation with angiography also
seems warranted in these cases.
TOP
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TOP
Annotated
Bibliography
1.
Hennes H, Lee M, Smith D, et al.
Clinical predictors of severe head trauma in children.
Am J Dis Child. 1988;
142:1045-1051.
A retrospective
review of 55 children who had CT scans for head trauma that concludes
that clinical findings are predictive of CT scan findings.
2.
Emanuelson I, L v Wendt.
Epidemiology of traumatic brain injury in children and adolescents
in southwestern Sweden. Acta
Paediatr. 1997; 86(7):730-5.
Outline
the epidemiology and early outcome of children with TBI in Sweden
using discharge hospital information and found a low incidence of
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Br Med J. 1918;
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Among
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36(5):370-7.
A survey
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Du-Trevou MD, van-Dellen JR.
Penetrating stab wounds to the brain:
the timing of angiography in patients presenting with the weapon
already removed. Neurosurgery. 1992; 31(5):905-11.
A prospective
study from South Africa of 330 patients with penetrating stab wounds
to the head that suggested that angiography should be done immediately
following the injury.
6.
Levy M, Rezai A, Masri L, et al.
The significance of subarachnoid hemorrhage after penetrating
craniocerebral injury: Correlations
with angiography and outcome in a civilian population.
Neurosurgery. 1993;
32:532-40.
A report
of 100 cases of cerebral gunshot wounds of which 31 had SAH and underwent
angiography. SAH was
predictive of a poor outcome but intracerebral hemorrhage was not.
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Domingo Z, Peter JC, deVilliers JC.
Low velocity penetrating craniocerebral injury in childhood. Pediatr Neurosurg. 1994;
21(1):45-49.
A case
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the infectious complications.
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Sotiropoulos SV, Jackson MA, Tremblay GF, et al.
Childhood lawn dart injuries:
Summary of 75 patients and patient report. Am J Dis Child. 1990;
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A report
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The sales of lawn darts were banned just before the publication
of this report.
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Dietrich AM, Bowman MJ, Ginn-Pease ME, et al.
Pediatric head injuries:
can clinical factors reliably predict an abnormality on computed
tomography? Ann Emerg
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A prospective
study of 322 children with closed head injury presenting to a trauma
center at an urban children's hospital which found a poor correlation
between clinical symptoms and CT scan findings.
10.
Narayan RK, Greenberg RP, Miller JD, et al.
Improved confidence of outcome prediction in severe head injury.
J Neurosurg. 1981;
54:751-762.
This
case series of 133 patients found that clinical features were the
best prognostic predictor, but that imaging also helped.
11.
Hahn YS, Fuch S, Flannery AM, et al.
Factors influencing post-traumatic seizures in children.
Neurosurgery. 1988;
22:864-7.
An
analysis of 937 patients who presented to Northwestern University's
Children's Memorial Hospital, which head injuries.
One in ten developed posttraumatic seizures in the case series.
The authors conclude by recommending the prophylactic use of
anti-seizure meds in children at higher risk for post-traumatic seizures
(generally those with more severe injury).
12.
James CA.
Magnetic resonance angiography in trauma.
Clin Neurosci. 1997; 4(3):137-45.
The
author suggest that MRA may be useful in selecting patients for angiography,
and may also be used to follow up those patients who have already
had angiography performed in a non-invasive fashion.
13.
Management and Prognosis of Severe Brain Injury. A joint project
of Brain Trauma Foundation and American Association of Neurologic
Surgeons, Joint Section of Neuro
Trauma and Critical Care. Available
at http://www.braintrauma.org/index.nsf/Pages/Guidelines-main.
This
important work from the Brain Trauma Foundation and the American Association
of Neurologic Surgeons addresses specific management concerns of adult
patients which TBI and a GCS of 3-8.
Extremely through and scientifically based, this publication
is a meaning reference for all that care for adults with severe head
injuries.
14.
The Management of Minor Closed Head Injury in Children. Committee
on Quality Improvement, American Academy of Pediatrics, Commission
on Clinical Policies and Research, American Academy of Family Physicians.
Pediatrics 1999;104:1407-1415.
This
joint report of the AAP and AAFP deals with children over the age
of two years with minor closed head injury and is meant to help the
clinician determine which of these children would benefit from neuroimaging.
Penetrating head injury is not included, nor is specific recommendation
for treatment.
15.
The Management and Prognosis of Penetrating Head Injury.
Available without charge at http://www.jtrauma.com.
August 2001 Supplement to The Journal of Trauma.
References
41-9 represent the most complete discussion of penetrating head injury
in civilian and military populations.
A complete review of the literature is included, as are specific
recommendations for both evaluation and treatment.
The second section includes a through review of the prognostic
factors in penetrating head injury.
This is a must read for anyone interested in this topic.
The specific concerns of children with penetrating head injuries
are not addressed.
TOP
Questions
1.
Select the most accurate statement about penetrating head trauma in
children:
a. it is the most common form of
traumatic brain injury in children
b. it is usually caused by "bb-guns"
c. it is more common in young children
because of their hard skulls
d. the history and physical examination
may be unremarkable
e. it is associated with epilepsy
in most cases
2. Which statement regarding
antibiotics in penetrating head trauma in children is most accurate:
a. antibiotics should be routinely
be administered to most children
b. antibiotics should only be used
to treat a brain abscess
c. antibiotics are only necessary
if there is a CSF leak
d. antibiotics should only be used
in proven cases of meningitis
e. adults are more likely to benefit
from antibiotics because of their higher infection rate
3. Which of the following
are potential sequelae of penetrating head trauma in children:
a. subdural/epidural hematomas
b. cerebral edema
c. brain abscess
d. AV malformations
e. all of the above
4. Regarding the use of
anti-seizure medications in chidren with penetrating head trauma:
a. anti-seizure medications are
not necessary
b. more severe brain injuries are
associated with a lower chance of seizures
c. phenytoin is the most commonly
used anti-seizure medication used
d. anti-seizure medications are
required for life after a PHT
e. anti-seizure medications are
only required if an AV malformation is present
5. Which of the following
statements concerning children with penetrating head injury is most
accurate:
a. vasospasm is an important cause
of cerebral ischemia in this population
b. nimodipine should be used routinely
for all children
c. vasospasm is often induced by
antibiotics thus limiting their effectiveness
d. the role of nimodipine and the
significance of vasospasm in children are not known
e. immediate angiography is always
indicated
6. The role of MRI in
children with penetrating head trauma is best stated as:
a. MRI is required for the initial
evaluation of all children
b. MRI/MRA may be helpful in defining
the vascular anatomy and delineating any
vascular injuries
c. MRI is commonly used to help
clip cerebral aneurysms
d. MRI should be limited to children
who have had seizures
e. MRI is a very good test of cerebral
function in children
Answers
1.
Answer D. The
history and physical exam may be completely normal.
Significant intracranial injury can occur in this setting without
any clinical manifestations.
2.
Answer A. Antibiotics should be routinely administered to most
children with PHT. Since
approximately 40% of children develop infections after a PHT, routine
antibiotic use and surgical debridement (if necessary) are advisable.
3.
Answer E.
All of the above. PHT
can have a variety of complications.
Among these are intraparenchymal lesions (subdural and epidural
hematoma, cerebral edema, cerebral contusions, pneumocephaly), infectious
complications (brain abscess, CSF fistulae, encephalitis, meningitis,
otitis, scalp sepsis), vascular
complications (aneurysm, arteriovenous malformation) and neurologic
complications (seizures, focal neurological defects).
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