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.

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.

[Own experience with the treatment of intracranial aneurysms using "Perneczky" - Zeppelin clips]. / Wlasne doswiadczenia w leczeniu tetniaków mózgu przy zastosowaniu zacisków naczyniowych typu "Perneczky" Zeppelin.

The basic design and the mechanism of clip application have not changed for many years. However in cases of aneurysms located deeply inside brain structure, in narrow spaces, multiple aneurysms or those which require applying of several clips the surgeon may have problems with visual control of the position of the clamping arms on the neck of aneurysm, nearby blood vessels and nerve structures. The above mentioned problems motivated prof. Axel Perneczky to construct a new model of clip with an applying and a removing holder whose mechanism is based on the principle of inverted--spring. Between February and August 1998 in the Neurosurgical Clinic in Katowice, 12 Perneczky's clips were applied in 9 patients. Intraoperative complications were not observed in any of the cases. In two cases of aneurysms located on the bifurcation of the basilar artery, application of two clips enabled precise intraoperative control of clip position.

[Head injuries in pediatric age]. / Urazy czaszkowo-mózgowe wieku dzieciecego.

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.

The prognostic value of some clinical and diagnostic factors in traumatic intracranial haematoma.

In order to carry out the analysis of predictive values of some clinical and diagnostic features, 146 patients of the Neurosurgical Clinic of the Silesian School of Medicine, were examined in 1980-1986. All the patients were in coma when admitted while CT findings showed traumatic intracranial haematomas. The examination included neurological diagnosis and CT examination. The analysis of statistical discrimination let us specify the probability of predicting death or survival of every patient. On the basis of 10 prognostic factors applied, the compatibility of prognosis and the real outcome for patients who survived was 78.2% and for those who died 91.2%.

[Results of toothlessness treatment by calottic method in the Cracow modification. Clinical studies]. / Wyniki leczenia bezzebia metoda kalotowa w modyfikacji krakowskiej. Badania kliniczne.

The purpose of the paper was to control the new method of teeth positioning in complete dentures based on the modification of callottic method in clinical practice. Clinical studies depended on occlusion and articulation estimation, examination of denture statics, control of occlusion height and registration of the patients' subjective experiences. They concerned 81 toothless patients divided into 2 groups according to the specific classification and wearing complete dentures in which the teeth had been positioned according to the modified method and Gysi-Fischer' method. In the groups of patients under examination that had teeth positioned according to the modified method significantly better results of the values estimated than in comparative groups have been achieved. It has been found that using the modified method smooth OA surface of artifical teeth is obtained without necessity of its correction satisfactory denture statics is obtained and rehabilitation of mastication function and adaptation to the dentures take place in a short period of time.

[Results of the surgical treatment of intracranial aneurysm]. / Wyniki leczenia operacyjnego tetniaków sródczaszkowych.

In the years 1976-1984 in the Department of Neurosurgery, Silesian Medical Academy in Katowice 196 patients were treated surgically for intracranial aneurysms. In the patients with aneurysms in the anterior part of the circulus arteriosus Yasargil's craniotomy was done. In some cases of aneurysms of the posterior cranial fossa suboccipital craniotomy was performed. In 181 cases the aneurysm was isolated by clipping it, in 4 cases it was trapped and in 11 wrapped. Good results were obtained in 60% of cases and bad in 15.9%. Death from extracranial causes occurred in 3 cases. The results of surgical treatment depended on the condition of the patient estimated by the Botterell scale, age, situation of the aneurysm and number of subarachnoid haemorrhages, duration of operation and experience in qualification of patients for surgery and on surgical technique.

[Surgical treatment of a giant aneurysm of the middle cerebral artery]. / Chirurgiczne leczenie olbrzymich tetniaków tetnicy srodkowej mózgu.

Four patients with giant aneurysms of the middle cerebral artery over 2.5 cm in diameter were treated surgically. The aneurysms were excised during operations carried out under hypotension achieved with sodium nitroprusside, with administration of large amounts of mannitol and with arrest of blood flow in the middle cerebral artery for 3-10 minutes. Two patients had reoperations for postoperative complications. After the operation the patient who was initially in grade III of Botterell's scale died, and three other patients were in a good condition after one years with moderate paresis of the upper extremity.

[Homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) levels in the cerebrospinal fluid from the lateral ventricle of patients with brain tumors]. / Stezenie kwasu homowanilinowego (HVA) oraz kwasu 5-hydroksyindolooctowego (5-HIAA) w plynie mózgowo-rdzeniowym pochodzacym z komory bocznej mózgu u chorych z guzami mózgu.

In patients with supratentorial tumours and posterior fossa tumours or in the third ventricle the concentrations of HVA and 5-HIAA were determined in the cerebrospinal fluid from the lateral ventricle. A significantly greater concentration of HVA and 5-HIAA was found in the patients with considerable hydrocephalus caused by occlusion of the third ventricle, aqueduct or fourth ventricle as compared with the cases of supratentorial tumours and with cases of moderate hydrocephalus and partial block of fluid outflow caused by third ventricle tumorous or posterior fossa tumours.

[Subarachnoid hemorrhage in acoustic neuroma]. / Krwawienia podpajeczynówkowe w przebiegu nerwiaka nerwu sluchowego.

A 32-year-old patient is reported with two subarachnoid bleedings occurring at an interval of 5 years. The cause of bleeding was a richly vascularized neurinoma of the acoustic nerve with focal necrosis. Operation was successful.

[Biogenic amines and their metabolites in brain tumor tissue]. / Zachowanie sie amin biogennych i ich metabolitów w tkankach nowotworów mózgu.

The concentrations of noradrenaline, 5-hydroxytryptamine, dopamine, 5-hydroxyindoleacetic acid and homovanillic acid were determined in the tissue of gliomas, meningiomas and neurinomas of the brain obtained during operations. Significantly higher levels of noradrenaline and 5-hydroxyindoleacetic acid were found in gliomas than in non-malignant tumours.

[Spontaneous resorption of an epidural hematoma. Description of 2 cases]. / Samoistna resorpcja krwiaka nadtwardówkowego. Opis dwóch przypadków.

Two patients with subacute epidural haematomas without shifted ventricular system are described in whom the diagnosis was made by computer tomography 8 and 9 days after trauma. Both patients were treated successfully checking the progress with computer tomography and using agents reducing brain oedema.

[Brain glioma complicated by subdural hematoma]. / Powiklanie glejaka mózgu krwiakiem podtwardówkowym.

A case is reported in which chronic subdural haematoma developed in association with a glioma of the left temporal lobe. The stroke-like onset of symptoms one month before surgical intervention, encapsulated liquid subdural haematoma, necrotic cerebral cortex over the tumour and easily bleeding peripheral parts of the tumour suggested a primary haemorrhage into the peripheral part of the tumour followed by penetration of the haematoma into the subdural space.

Possible significance of juvenile oral venous angioma as marker of intracerebral vascular lesion.

This 10-year-old child suffered a hemorrhage into the right parietal lobe, the result of a ruptured arteriovenous angioma. From birth, the boy had a venous angioma of the mucous membrane of the cheek, lower lip, and hypoglossal area on the right side. The coexistence of these two vascular defects is most unusual, and venous angioma in early life may suggest the presence of cerebral angioma.

[Traumatic aneurysm of the cortical branch of the middle cerebral artery]. / Tetniak pourazowy w obrebie galezi korowej tetnicy srodkowej mózgu.

A 22-year-old patient is described in whom sudden deterioration developed on the 9th day after severe craniocerebral trauma. Left common carotid angiography demonstrated an aneurysm on a cortical branch of the middle cerebral artery and subdural haematoma. During the operation the aneurysm was excluded from the circulation.

[Intracranial hemorrhages in patients with renal polycystic degeneration]. / Krwotoki sródczaszkowe u chorych z torbielowatoscia nerek.

A female patient is described in whom symptoms of cholecystitis developed after operation for intracranial aneurysm. Enlarged polycystic kidney was recognized erroneously as gallbladder and this error led to laparotomy. In another case meningocerebral haemorrhage developed in a hypertensive patient with polycystic kidney degeneration.

[Post-traumatic hematoma of the posterior cranial fossa in a 4-year-old boy with hemophilia A]. / Pourazowy krwiak tylnego dolu czaszkowego u czteroletniego chlopca z hemofilia A.

A case of a rare post-traumatic complication of haemophilia A is reported. Similarly as other authors an atypical clinical course and growing internal hydrocephalus were observed in the present case. Haemorrhagic diathesis prolonged only the period of healing of the surgical wound.

[Homovanillic (HVA) and 5-hydroxyindoleacetic (5-HIAA) acid concentration in the cerebrospinal fluid of patients with supratentorial tumors and symptoms of intracranial hypertension (preliminary report)]. / Stezenie kwasu homowanilinowego (HVA) i kwasu 5-hydroksyindolooctowego (5-HIAA) w plynie mózgowo-rdzeniowym u chorych z guzami nadnamiotowymi i objawami nadcisnienia sródczaszkowego. Doniesienie wstepne.

In 14 patients with supratentorial tumours and symptoms of intracranial hypertension the concentrations of HVA and 5-HIAA were determined in cerebrospinal fluid obtained by lumbar tap. Significantly raised levels of both these metabolites were demonstrated in the cerebrospinal fluid in these patients in relation to controls. The cause of this rise could be excessive production of serotonin or dopamine, increased turnover of these amines or impaired absorption of 5-HIAA and HVA by the choroid plexus of the fourth ventricle.