1. Minor Head Trauma in Children and Adolescents William Ahrens The University of Illinois at Chicago

2. MHT An extraordinarily common problem An extraordinarily common problem Obvious sequelae are uncommon Obvious sequelae are uncommon All it takes is one All it takes is one Recommendations characterized by Recommendations characterized by lack of standard definition lack of standard definition lack of prospective studies lack of prospective studies

3. MHT For the purposes of this lecture MHT will be considered to involve: For the purposes of this lecture MHT will be considered to involve: a relatively trivial mechanism of injury a relatively trivial mechanism of injury a patient with a GCS of 15 on arrival to the ED a patient with a GCS of 15 on arrival to the ED no evidence of skull fracture no evidence of skull fracture May be retrograde/posttraumatic amnesia May be retrograde/posttraumatic amnesia ??? Brief LOC ??? ??? Brief LOC ???

4. MHT Key questions for the physician include: Key questions for the physician include: What is the appropriate evaluation? What is the appropriate evaluation? What radiographic studies are necessary? What radiographic studies are necessary? What is the disposition of the patient? What is the disposition of the patient? When can the patient resume activity? When can the patient resume activity? Are there sequelae? Are there sequelae?

5. MHT Radioimaging in the ED: the goal is to diagnose neurosurgical emergencies Radioimaging in the ED: the goal is to diagnose neurosurgical emergencies Skull Films Skull Films CT Scanning CT Scanning

6. MHT: Cases A 6 month old boy with a chief complaint of fever, and by the way he hit his head against the coffee table. A 6 month old boy with a chief complaint of fever, and by the way he hit his head against the coffee table. PE remarkable for: PE remarkable for: 1) left parietal swelling– no palpable fx 1) left parietal swelling– no palpable fx 2) normal neurological exam 2) normal neurological exam

7. MHT: Cases A 3 year old boy presents with forehead swelling after a fall sustained when he tripped; no loc; vomited x one. A 3 year old boy presents with forehead swelling after a fall sustained when he tripped; no loc; vomited x one. PE remarkable for PE remarkable for 1) An alert happy child 1) An alert happy child 2) A forehead contusion 3) A normal neurological exam 3) A normal neurological exam

8. MHT What is known (more or less) What is known (more or less) Intracranial lesions ( per CT scanning) are not rare in pediatric patients with MHT Intracranial lesions ( per CT scanning) are not rare in pediatric patients with MHT A normal neurologic exam does not exclude an injuryespecially in infants A normal neurologic exam does not exclude an injuryespecially in infants The overwhelming majority of intracranial lesions in children with MHT are nonoperative The overwhelming majority of intracranial lesions in children with MHT are nonoperative

9. MHT Infants are different: Infants are different: Both skull fractures and intracranial injuries are more common in patients less than 2 years old Both skull fractures and intracranial injuries are more common in patients less than 2 years old Infants less than 12 months of age are probably exceptionally vulnerable to injury Infants less than 12 months of age are probably exceptionally vulnerable to injury Babies bones break Babies bones break

10. MHT Skull X-Rays: Skull X-Rays: Intracranial injuries are associated with skull fractures Intracranial injuries are associated with skull fractures Skull fractures are usually associated with swelling Skull fractures are usually associated with swelling The parietal bone is the most common site of a skull fracture in infants The parietal bone is the most common site of a skull fracture in infants Whether skull films can be used as a screening tool is controversial Whether skull films can be used as a screening tool is controversial

11. MHT Indications for CT scanning: Indications for CT scanning: Any patient with altered mental status or an abnormal neurological exam Any patient with altered mental status or an abnormal neurological exam Patients less than 2 years of age with symptoms such as vomiting or irritability Patients less than 2 years of age with symptoms such as vomiting or irritability Patients less than 2 years old with large scalp hematomas, especially non-frontal swelling Patients less than 2 years old with large scalp hematomas, especially non-frontal swelling Infants less than 3 monthsespecially if a scalp hematoma is present Infants less than 3 monthsespecially if a scalp hematoma is present

12. MHT Disposition: Patients with minor head trauma and a normal CT scan may be safely discharged– delayed bleeds are extremely rare Disposition: Patients with minor head trauma and a normal CT scan may be safely discharged– delayed bleeds are extremely rare What to do with patients with linear skull fractures? What to do with patients with linear skull fractures? Remember it only takes one Remember it only takes one

13. MHT: Cases A 6 month old boy with a chief complaint of fever, and by the way he hit his head against the coffee table. A 6 month old boy with a chief complaint of fever, and by the way he hit his head against the coffee table. PE remarkable for: PE remarkable for: 1) left parietal swelling– no palpable fx 1) left parietal swelling– no palpable fx 2) normal neurological exam 2) normal neurological exam

14. MHT: Cases A 3 year old boy presents with forehead swelling after a fall sustained when he tripped; no loc; vomited x one. A 3 year old boy presents with forehead swelling after a fall sustained when he tripped; no loc; vomited x one. PE remarkable for PE remarkable for 1) An alert happy child 1) An alert happy child 2) A forehead contusion 3) A normal neurological exam 3) A normal neurological exam

15. MHT: Cases A 17yo male presents because he needs a note to return to baseball; he had a concussion one week prior. A 17yo male presents because he needs a note to return to baseball; he had a concussion one week prior. PE remarkable for PE remarkable for 1) An alert oriented patient 1) An alert oriented patient 2) Normal neurological exam 2) Normal neurological exam

16. MHT: Concussion a clinical syndrome characterized by the immediate and transient post-traumatic impairment of neural function such as alteration of consciousness, disturbance of vision or equilibrium etc. due to brainstem involvement a clinical syndrome characterized by the immediate and transient post-traumatic impairment of neural function such as alteration of consciousness, disturbance of vision or equilibrium etc. due to brainstem involvement

17. MHT: Concussion Results from acceleration-deceleration forces applied to a moving brain Results from acceleration-deceleration forces applied to a moving brain Shearing forces disrupt normal neurological elements Shearing forces disrupt normal neurological elements Axonal injury, biochemical abnormalities, or microvascular injury may result Axonal injury, biochemical abnormalities, or microvascular injury may result

18. MHT: Concussion Prospectively Validated Signs and Symptoms: Prospectively Validated Signs and Symptoms: Loss of Consciousness ( less than 10%) Loss of Consciousness ( less than 10%) Amnesia (Retrograde---Posttraumatic) Amnesia (Retrograde---Posttraumatic) Attention Deficit Attention Deficit Headache, Dizziness, Blurred Vision Headache, Dizziness, Blurred Vision

19. MHT: Concussion Subjective findings: Subjective findings: Vacant Stare, Impaired Coordination Vacant Stare, Impaired Coordination Emotional Lability, Sleep Disturbance Emotional Lability, Sleep Disturbance Lethargy, Behavioral Disturbance Lethargy, Behavioral Disturbance Altered Sense of Taste or Smell Altered Sense of Taste or Smell

20. MHT: Concussion Grading the Severity of Injury: Grading the Severity of Injury: There are over 25 published injury severity scales; many are sport-specific There are over 25 published injury severity scales; many are sport-specific Many rely on history of and duration of LOC and duration of Posttraumatic Amnesia Many rely on history of and duration of LOC and duration of Posttraumatic Amnesia Current recommendations disregard these grading scales and divide concussion into Current recommendations disregard these grading scales and divide concussion into simple and complex simple and complex

21. MHT: Concussion Simple concussion: symptoms resolve in 7- 10 days Simple concussion: symptoms resolve in 7- 10 days Complex concussion: Complex concussion: Symptoms persist Symptoms persist Symptoms may be specific Symptoms may be specific May include athletes with multiple concussion May include athletes with multiple concussion

22. MHT: Concussion Sequelae of Concussion: Sequelae of Concussion: There is evidence for neuropsychiatric deficits during the first week following mild concussive injury in some patients There is evidence for neuropsychiatric deficits during the first week following mild concussive injury in some patients After one week there is no consensus regarding time frame for full neurologic recovery: each patient is different After one week there is no consensus regarding time frame for full neurologic recovery: each patient is different Risk of Second Impact Syndrome (SIS) ? Risk of Second Impact Syndrome (SIS) ?

23. MHT: Concussion Second Impact Syndrome Second Impact Syndrome Thought to occur when an athlete sustains a second head injury prior to recovery from an initial head injury, usually a mild concussion Thought to occur when an athlete sustains a second head injury prior to recovery from an initial head injury, usually a mild concussion Severe cerebral swelling occurs, which has been reported to be fatal Severe cerebral swelling occurs, which has been reported to be fatal May be similar in pathology to malignant brain edema that is know to occur in children May be similar in pathology to malignant brain edema that is know to occur in children

24. MHT: Concussion Second Impact Syndrome (cont) Second Impact Syndrome (cont) The pathology of malignant brain edema is thought to involve disordered cerebral autoregulation The pathology of malignant brain edema is thought to involve disordered cerebral autoregulation Fear of SIS used to guide recommendations regarding the management of concussion Fear of SIS used to guide recommendations regarding the management of concussion In fact the role of repeated concussion as a cause of SIS is questionable In fact the role of repeated concussion as a cause of SIS is questionable

25. MHT: Concussion Post (complex) concussion Syndrome Post (complex) concussion Syndrome Clinically characterized by multiple physical and cognitive complaints Clinically characterized by multiple physical and cognitive complaints Etiology is controversial: physical damage vs emotional sequelae– also possible genetic vulnerability Etiology is controversial: physical damage vs emotional sequelae– also possible genetic vulnerability Cannot be predicted in the immediate postconcussion period Cannot be predicted in the immediate postconcussion period New data suggests headache is associated with incomplete recovery New data suggests headache is associated with incomplete recovery

26. MHT: Concussion Sequelae of Multiple Concussions: Sequelae of Multiple Concussions: There is evidence that there is cumulative impairment from repeated mild head trauma, especially in cognitive function There is evidence that there is cumulative impairment from repeated mild head trauma, especially in cognitive function Damage may be subtle and can involve deficits in verbal skills, memory processing, spatial relationships, and coordination Damage may be subtle and can involve deficits in verbal skills, memory processing, spatial relationships, and coordination Do some patients have a predestined trauma reserve? Do some patients have a predestined trauma reserve?

27. Concussion Is the recovery from concussion age- dependent? Gender dependent? Is the recovery from concussion age- dependent? Gender dependent? Recent data suggests that high school athletes recover more slowly from concussion than college students Recent data suggests that high school athletes recover more slowly from concussion than college students The brain is a constantly evolving organism The brain is a constantly evolving organism

28. MHT: Concussion There is a growing trend toward neuropsychologic testing in the evaluation of concussion in athletes There is a growing trend toward neuropsychologic testing in the evaluation of concussion in athletes There are many different types of exams: several are commercially available There are many different types of exams: several are commercially available Knowing a baseline is crucial Knowing a baseline is crucial The primary goal is to prevent the return to competition before the brain has healed The primary goal is to prevent the return to competition before the brain has healed More research is needed in this field, especially in children and adolescents More research is needed in this field, especially in children and adolescents

29. MHT: Concussion New Radiologic Modalities in Concussion New Radiologic Modalities in Concussion The CT scan is rarely a useful tool The CT scan is rarely a useful tool Promising Modalities include Promising Modalities include 1) Functional MRI 1) Functional MRI 2) Spect Scanning 2) Spect Scanning

31. MHT: Cases A 17yo male presents because he needs a note to return to baseball; he had a concussion one week prior. A 17yo male presents because he needs a note to return to baseball; he had a concussion one week prior. PE remarkable for PE remarkable for 1) An alert oriented patient 1) An alert oriented patient 2) Normal neurological exam 2) Normal neurological exam

32. Current Guidelines Any player with signs or symptoms of a concussion should not be allowed return to the game or practice. Any player with signs or symptoms of a concussion should not be allowed return to the game or practice. Emphasis is on physical and cognitive rest until symptoms completely resolve: in simple concussions this will be in about a week. Emphasis is on physical and cognitive rest until symptoms completely resolve: in simple concussions this will be in about a week.

33. Concussion: Return to Play Once asymptomatic patients advance through a graduated level of activity: Once asymptomatic patients advance through a graduated level of activity: 1: light aerobic activity 2: sport specific exercise 3: noncontact training 4: contact training

34. Concussion: complex There is no consensus on management There is no consensus on management Role of neuropsychiatric testing? Role of neuropsychiatric testing? Long-term sequela are probably patient specific Long-term sequela are probably patient specific

35. Concussion What happened to the 17 year old: Hes done with contact sports What happened to the 17 year old: Hes done with contact sports There is no consensus on when to quit after repeated concussions There is no consensus on when to quit after repeated concussions

36. Concussion Advantage of new data: greater understanding of concussion. Advantage of new data: greater understanding of concussion. Disadvantages of new data: Disadvantages of new data: Unnecessary sports restrictions Unnecessary sports restrictions Pre-existing condition in young people? Pre-existing condition in young people?