Skull Fractures And Traumatic Intracranial Hemorrhage

Risk Factors

CPD, or cephalopelvic disproportion; Delivery of instruments, particularly forceps and ventouse. A youngster who unintentionally falls from their bed or crib and bangs their head on a hard surface.

Skull Fracture Types

The most typical kind of skull fracture is linear. A linear skull fracture is represented as a straight line, and it usually affects the parietal bone. It is discovered that they are asymptomatic in over 95% of cases.

They are visible on a standard X-ray. There would be no need for therapy if they are asymptomatic. A tier in the dural membrane has been linked to a number of linear skull fractures. This tier can cause leptomeningeal cysts as well as hemorrhage of the brain, meninges, and CSF.

Depressed Skull Fractures

Mostly asymptomatic; produces a "ping-pong ball" depression; can affect both the frontal and parietal bones. However, there is a substantial correlation between the indentation and brain damage or hemorrhage if it is greater than 1 cm. 

The majority of depressed skull fractures only require therapy in the following situations: elevated intracranial pressure; a CT scan demonstrating the formation of CSF in the subgaleal space; a finding that the depression caused by the depressed skull fracture is greater than one centimeter; or a suspicion of CNS bleeding. 

If not, no treatment is necessary if the depressed skull fracture is asymptomatic. A depressed skull fracture requires follow-up for eight to twelve weeks, just like a linear skull fracture, to look for any leptomeningeal cyst formation.

Occipital Osteodiastasis

A rare yet deadly breech delivery complication. Describes the division of the occipital bone's squamous portion from its basal or lateral portion. It results in severe intracranial hemorrhage, cerebellar contusion, and vascular damage.

MCQ

Q.1. What is the strongest risk factor for skull fractures (especially depressed skull fracture)?

Ans. Forceps delivery followed by fetal compression.

Q.2. What are the indications for doing CT or MRI in skull fractures?

Ans. The indications include:

A CT or MRI should be performed if there are any signs of cerebral bleeding or compression. The second thing to do is if they suspect a serious skull fracture. Thirdly, if the patient has an underlying suspected coagulation disorder, there's a chance the fracture is small. For instance, a CT scan will be required to confirm a suspected depressed skull fracture measuring more than 1 centimeter. If the underlying bleeding is still substantial, an MRI or CT scan is conducted.

Traumatic Intracranial Hemorrhage

Subdural hematomas, or subdural hemorrhages in the case of term newborns, are the most common type of intracranial hemorrhage in traumatic childbirth. 

Types: Intraventricular/intracerebral hemorrhage in premature newborns 

1. SDH: Most prevalent 
2. EDH: Uncommon
3. SAH: Uncommon

When To Suspect Traumatic Intracranial Haemorrhage In The Neonate?

Acute deterioration: If within the first 72 hours the youngster exhibits acute deterioration. Irritability, changed sensorium, bradycardia, lack of doll eye movements, hypotonia or posturing, aberrant breathing, and abrupt deterioration when using a ventilator are examples of acute deteriorations.
• Convulsions
• Apnea.
• Swollen fontanelles that no longer pulse.
• Syringe CSF tap (IVH or SAH).

Risk Factors

• CPD
• Prolonged labor
• Breech presentation
• Precipitous delivery
• Use of instruments

1. Subdural Hemorrhage (SDH)

SDH is the most prevalent kind of intracranial hemorrhage in term newborns. The most prevalent kind of cerebral hemorrhage in premature infants: IVH. The posterior fossa is the most often occurring site of infratentorial SDH in neonates. The venous source primarily originates from the bridging veins; however, bleeding can occur from big sinuses. The source of the bleeding is tears in the tentorium cerebelli.

Subtypes of SDH Based on Severity and Location

Parturitional SDH

Extremely prevalent, asymptomatic, and invariably numerous.
May transpire during a typical delivery and even in the absence of risk factors. Usually take place in the fossa posterior. Therapy is not required. Originates from veins that bridge over the cerebral convexities, causing supratentorial SDH. 

If it is large, it may produce seizures; if it is little, it is asymptomatic.
Mostly in the tentorium cerebelli, but occasionally in the falx cerebelli, infractorial (Post fossa SDH) tears. If they are large, they may result in shock, posturing, an increase in intracranial pressure, and even death.
Chronic SDH. Small veins can bleed, but it happens slowly and sporadically. Although asymptomatic at first, a prolonged accumulation of fluid causes pressure symptoms, which ultimately lead to macrocephaly. The youngster will experience bulging, bossing, anemia, and even seizures. Cloherty notes that a modest co-existing SAH is typically present in most cases of big SDH.

Investigation

The USG skull is insufficient for SDH. Unless the child is hemodynamically stable or you suspect posterior fossa SDH, you should wait to perform a lumbar puncture for CSF. A brain CT scan (Plain CT/NCCT) is used for the initial inquiry. The most sensitive study is the brain MRI.

Treatment of SDH

There is no need for therapy if SDH is asymptomatic.  If the child has low PCV, administer blood transfusions, manage the child's symptoms, and seek a neurosurgical consultation. Every patient with SDH is monitored for hydrocephaly. Most SDH go away by the time a child is 4 weeks old; if SDH persists after 4 weeks or appears to be new, rule out child abuse.

2. Epidural Hemorrhage (EDH)

Rare in neonates due to the tight adherence between the skull and dura, particularly at sutures, arteriovenous malformations (AVMs) are commonly sourced from the middle meningeal artery. Over half of cases are linked to cephalohematoma and skull abnormalities. Treatment guidelines suggest that if the AVM is asymptomatic and measures 1 cm or less, no intervention is necessary. However, if symptoms are present or the size exceeds 1 cm, surgical intervention may be warranted. It is crucial to monitor the AVM closely for any signs of progression, as timely intervention can prevent potential complications.

3. Subarachnoid Hemorrhage (SAH)

Neonates rarely experience it. In those that do, venous (bridging veins) hemorrhage is the cause of bleeding. An artery is the source of SAH in adults. The leptomeningeal arteries are the main source of arterial SAH in newborns; it is rare to find arterial SAH in these cases. Most cases of SAH are asymptomatic, though seizures can occasionally happen on days 2, 3, or 4. The most sensitive test is a brain MRI. Most patients receive conservative treatment, and their hydrocephalus is monitored closely. A rare variant of SAH in term newborns is subpial hematoma.

Facial And Mandibular Fractures

Three fractures are frequently seen in facial trauma: maxilla, mandible, and lacrimal. When using instruments, especially when presenting faces, these fractures will become more frequent.

Fracture Characteristics:

Facial asymmetry, wherein one side of the face is swollen; oedema; ecchymoses; crepitus; difficulty feeding; intervention: X-ray is required; if prompt therapy is administered, the prognosis is typically favorable. A surgical intervention is required in prompt therapy.

• If treatment is postponed, many of them may experience increased respiratory discomfort or there will be a permanent asymmetry.
• If surgery is required, have it done during the first week.
• In 7 to 10 days, the maxilla and lacrimal show signs of healing. It takes the mandible 10 to 14 days to begin mending. Thus, schedule surgery for next week.

Nasal Injuries

Nasal cartilage dislocation is the most typical nasal injury. In moderate cases, it may not cause any symptoms; in severe cases, it may cause respiratory discomfort. Schedule surgery right away. Anomalous nose vs dislocation. If there is a malformed nose and no nasal deviation, compress the tip of the nose. The youngster is experiencing dislocation if there is an increasing nasal deviation and/or collapse of the external nares.

Ocular Injuries

There are two frequent types of eye injuries: subconjunctival hemorrhage and retinal hemorrhage. Increased intrathoracic pressure following a typical vaginal delivery and/or venous congestion are the causes of ocular damage. Most instances recover in less than two weeks without the need for therapy. Subconjunctival hemorrhage typically disappears in 7 to 14 days, while retinal hemorrhage often does so in 1 to 5 days.

Ear Injuries

If there are abrasions, they heal on their own and don't require therapy; this is especially noticeable with forceps delivery. If hematomas are discovered in the pinna, they have the potential to group together and cause abnormalities called cauliflower ears; act quickly to drain them. 

In 10% of cases, perichondritis is a complication following pinna laceration. Treatment: An ENT consultation and surgery are required; antibiotics should be taken first.

Sternocleidomastoid Injury

Causes a condition known as muscular or congenital torticollis. Likewise known as congenital wry neck. The injury mechanism involves the fetal compression caused by improper intrauterine placement, which results in compartment syndrome affecting the sternocleidomastoid muscle. Occasionally, the injury is also caused by the sternocleidomastoid muscle being stretched during birthing. That will cause a rupture and the production of hematomas.

Clinical attributes

It typically takes one to four weeks, though some kids may exhibit it in the first 48 hours. There is a head tilt to the same side in children, and some may also show facial asymmetry. There is a palpable lump (1-2 cm) in the sternocleidomastoid muscle on one side.

Treatment

Physiotherapy and conservative management, which involves extending the afflicted muscle. In 3 to 4 months, 80% of youngsters will recover.
Surgery is an option if it lasts longer than six months. In 10% of cases, hip joint developmental dysplasia coexists with SCM injuries.

Pharyngeal Injury

Suctioning causes a mild submucosal damage that might heal without the need for therapy. Severe damage to the pharynx, which may manifest as a hole into the pleura or mediastinum. It will happen as a result of placing an endotracheal tube or nasogastric tube; these individuals experience trouble with swelling and excessive oral secretion. 

Children may experience retropharyngeal tears occasionally. Make a water-soluble contrast research first. You will need to get a surgical opinion upon confirmation. In addition, begin IV antibiotics and discontinue oral feedings for a duration of around two weeks.

Also Read: Hearing Loss in Nicu Graduates

Hope you found this blog helpful for your NEET SS Pediatrics Neonatology Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.