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194 Craniocerebral and Spinal Trauma
Posttraumatic seizures Prevention
Seizures that occur in the first 7 days of injury are termed early post- The greatest majority of paediatric head injuries are preventable. The
traumatic seizures, and those that occur after 1 week are late post- mortality and morbidity from motor vehicle accidents could be reduced
traumatic seizures. The incidence of early posttraumatic seizures is by 50% with proper use of child restraints and responsible driving.
1–5%. It can precipitate adverse events as the result of an elevation Enforcement of legislation for observation of speed limits, use of seat-
of intracranial pressure, alteration in blood pressure, and changes in belts and restraints, and wearing motorcycle helmets are said to have
oxygenation. The estimated incidence of late posttraumatic seizure is worked well in the developed world. Parental attitudes and sibling
10–13% within 2 years after head injury. The risk of seizure is higher behavior influence a child’s attitude immensely.
in patients with acute intracranial haematoma, open depressed skull Children playing by the roadside, street hawking, and engaging in
fractures, parenchymal injury, seizures within the first 24 hours of activities such as tree climbing to obtain a means of livelihood should
injury, GCS <10, penetrating brain injury, history of significant alcohol be discouraged. Legislation should be enacted and enforced to contain
abuse, and cortical haemorrhagic contusion on CT scan. Treatment with child abuse.
anticonvulsants is started early. IV phenobarbitone (5–10 mg/kg in 3 Spinal Cord Injury
divided doses) or IV phenytoin (15 mg/kg loading dose; at a rate of 1-3
mg/kg per minute is given to control convulsion, and continued orally Introduction
for 18-24 months). Spinal cord injuries remain one of the most devastating of all surviv-
Fat embolism able trauma. Paediatric spinal cord injury is relatively uncommon,
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Fat embolism may occur especially in the presence of multiple inju- accounting for 5–7% of all spinal injuries. The peculiar developing
ries. Symptoms include drowsiness, confusion, epilepsy, and irritabil- anatomy and biomechanics of the child’s spine make the management
ity. Dyspnoea, tachypnoea, and tachycardia may also occur. Petechial of spinal cord injury in children distinct. A good number of affected
haemorrhage over the base of the neck and upper chest appears after children will need supportive care for life. The availability of only a
48–72 hours. Treatment is by measures aimed at protecting the brain few specialised centres in Africa compounds the problem of adequate
from anoxia (i.e., proper care of the airway, tracheostomy, and oxygen care for these children.
therapy). Epidemiology
Paediatric spinal injuries peak from June to September in the West
Posttraumatic (concussion) syndrome
This syndrome is a collection of symptoms that is considered as a due to extracurricular activities during the summer holidays. About
sequel of a mild head injury. It can also be seen in patients recovering 1–13% of spinal cord injuries occur in children 1–15 years of age,
from severe head injury. The symptoms include headache, dizziness, with 60–75% occurring in older children aged 10–15 years. The male-
lightheadedness, visual disturbances, and anosmia, as well as memory to-female ratio in paediatric spinal cord injury varies with age, being
impairment, loss of intellectual ability, depression, anxiety, disruption 1.1–1.3:1 for ages 0–9 years, to 2.3–2.5:1 for ages 15–17 years. Most
of sleep/wake cycles, photophobia, and personality changes. The treat- spinal cord injuries occur in the cervical spine (42%), thoracic (31%),
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ment of the condition is supportive. Recovery follows a variable course. and lumbar (27%). In children younger than 9 years of age, 67% of
the cervical spine injuries occur between the occiput and C2 due to the
Carotico-cavernous fistula higher level of the fulcrum for maximal flexion.
This fistula is between the intracavernous part of the internal carotid Aetiology
artery and the cavernous sinus. The patient complains of noise in the The cause of spinal cord injuries varies with age. Pedestrian-vehicle
head and has pulsating exophthalmos, which is usually unilateral. accidents and falls account for 75% of the injuries in the 0–9 year
A continuous to-and-fro murmur is synchronous with the pulse and age range. Motor vehicle accidents account for about 40%, and in
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audible on auscultation of the eyeball. This murmur is abolished by the 15–17 year age group, motor vehicle accidents account for more
compression of the carotid artery in the neck.
than 70%. Other causes include sporting activities and motorcycle and
Posttraumatic headache bicycle accidents, which tend to occur in the older child.
Posttraumatic headache is a common complaint. It may be caused by Pathophysiology
intracranial haemorrhage, increased intracranial pressure, skull frac- The mechanisms of spinal cord injury in children are similar to those
tures, CSF leaks, and infections. Treatment of the primary cause is seen in adults. They include hyperflexion, rotation, hyperextension,
essential; analgesics and bed rest are supportive.
axial loading, flexion rotation and shearing forces. The initial injury,
Posttraumatic aneurysm either concussive or compressive, leads to immediate death of neural
Posttraumatic aneurysms comprise less than 1% of intracranial aneu- cell bodies in the local central grey matter. Subsequently, secondary
rysms. Most are false aneurysms. They commonly arise from closed damage occurs, initiated by the release of inflammatory mediators
head injury and penetrating trauma. They present with delayed intra- such as glutamate and free oxygen radicals. Oedema and spinal cord
cranial haemorrhage. The patient may present with recurrent epistaxis, infarction result. Apoptotic changes in neurons and glial cells are now
progressive cranial nerve palsy, or severe headache. A CT scan shows evident.
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intracerebral and subarrhacnoid haemorrhage. Angiography can dem- Paediatric spinal traumas commonly cause ligamentous injury and
onstrate the site of the aneurysm. Although cases of spontaneous reso- facet capsule rupture. In the cervical region, there could be avulsion
lution have been reported, direct treatment is usually recommended by and epiphyseal separation of basal synchondrosis of the odontoid into
clipping, coiling, or trapping. the body of C2. There could be a split in the cartilaginous end plate,
Posttraumatic hypopituitarism particularly of the growing zone. Fractures of the vertebral bodies and
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Posttraumatic hypopituitarism follows penetrating trauma or closed disc herniation are uncommon in children.
head injury with or without a basilar skull fracture. The patient may Epidural, intradural, or intramedullary haematomas also occur
have deficiency of the growth hormone, gonadotropin, corticotrophin, following trauma.
or reduced TSH. Some patients will develop diabetes insipidus.