elevated ICP. A subarachnoid hemorrhage is associated with a poor outcome
in severe TBI as there is associated cerebral vasospasm. Techniques such as
angiography and transcranial Doppler imaging can be utilized to identify
vasospasm. Calcium channel blockers and neurointerventional techniques are
not well studied in children and not commonly used.
Figure 3: Subarachnoid hemorrhage
Skull fractures are commonly associated with head trauma in 2 - 21% of
children.^9 CT is the diagnostic study of choice for skull fractures, which will
allow concomitant diagnosis of underlying brain parenchymal injury. The four
major types of skull fractures are linear, depressed, diastatic and those at the
skull base. Linear skull fractures are the most common and should be followed
for epidural hematoma. Skull fractures depressed deeper than surrounding
inner table (> 1cm) may require operative management. Deeper depressions
are associated with greater risk of dural tear as well as cortical laceration and
therefore worse prognosis [10].^ Skull base fractures are uncommon in children.
Clinical signs of skull base fractures include raccoon’s eyes (periorbital
ecchymosis) and battle’s sign (mastoid ecchymosis) [11].^ (Figure 4)