Traumatic midline cerebellar contusion in 2-year-old male child—case report and review of literature

Traumatic midline cerebellar contusion in 2-year-old male child—case report and review of... Background: Cerebellar contusion accounts for 0.54% of traumatic brain injuries. They present with a variety of symptoms like ataxia, dysmetria, dysdiadokinesia, and vertigo. CT scan is the gold standard investigation for diagnosing acute cerebellar contusions. Due to the low incidence of this disease, there are no medical guidelines available for the management of cerebellar contusions. Case report: A 2-year-old child presented to the emergency department with altered level of consciousness. Computed tomography scan of the brain showed midline cerebellar contusion. He was managed conservatively with the main focus on lowering intracranial pressure. Result: Cerebellar contusion can be managed conservatively with close monitoring. However, more data is needed to study its behaviour and management. Conclusions: The patient had an excellent response to treatment and was discharged within a few days further highlighting the role of medical management in the treatment of patients with cerebellar contusions. Keywords: Cerebellar contusion, Pediatric trauma, Brain injury Background injuries (where the frontal or temporal area is targeted), Contusions are defined as any injury to the body occurring and acceleration-deceleration injuries [4]. following trauma that leads to blood vessel rupture and Cerebellar contusions present in a variety of ways. In tissue destruction. Following contusions, the area is adults, they will present with cerebellar signs like nystagmus, marked by active bleeding into the tissue [1]. This trau- dysarthria, hypotonia, ataxia, dysmetria, tremor, dysdiado- matic brain injury (TBI) is a major cause of morbidity and chokinesis, and vertigo [5]. In children, additional signs like mortality worldwide and affects up to 10 million individ- cerebellar mutism have also been seen. One study by Braga uals annually [2]. et al. studied the neuropsychological sequelae in children Tsai et al. state that only 3.3% of traumatic brain injuries with cerebellar trauma, according to the study, most involve the posterior fossa. These injuries include children with cerebellar trauma develop dyscalculia and extra-dural hematomas, sub-dural hematomas, and rarely exhibit lower visual recognition memory [6]. cerebellar contusions (which account for less than 1% of Computed tomography scan is the gold standard all head injuries) [3]. investigation for evaluating cerebellar contusions. It shows D’Avella et al. state that cerebellar contusions make up the size of the contusion, its location, the status of fourth only 0.54% of all head injuries. He categorized the type ventricles and cisterns, and any associated lesion like extra- of injuries causing cerebellar contusions into coup injuries dural or sub-dural hematomas. (where the occiput is the area of impact), countercoup Due to the rarity of traumatic intra cerebellar contusions, only case reports and case series are published detailing the presentation and the management of this disease with * Correspondence: sanaullahbashir@gmail.com the management itself remaining quite controversial. Here, Section of Neurosurgery, Department of surgery, Aga Khan University we present a case report of a male child with midline intra Hospital, Karachi, Pakistan Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Javed et al. Egyptian Journal of Neurosurgery (2019) 33:6 Page 2 of 3 Fig. 1 Midline cerebellar contusion in axial and sagittal sections with orbital fracture. Consent has been taken from the patient’s father to attach this image with case report cerebellar contusion and his subsequent medical therapy. hydrocephalus either associated with extra-dural or The management of our respective patient can help the sub-dural hemorrhages [8, 9]. greater scientific community in better understanding of The results of these treatments are diverse depending the requisite treatment for this unique phenomenon. on various factors. The most important of which is the initial Glasgow Coma score of the patients. D’Avella et al. [4] divided his patients into two groups on the basis Case report of GCS score with group 1 having score of more than 9 A 2-year-old male child presented to the emergency and other group of less than 9 at the time of admission, department of Aga Khan University Hospital with a history 95% of cases in group 1 had a favorable outcome of unwitnessed fall from height 12 h back. He presented whereas only 19% of cases in group 2 had favorable with complaints of drowsiness and altered level of outcomes. consciousness. On examination, he had a Glasgow Other determinants of patient prognosis included Coma Scale (GCS) of 10/15 and was opening eyes to pain, location of cerebellar contusion, its size, status of ven- crying on receiving painful stimuli while spontaneously tricle and associated cisterns, and presence or absence moving all four limbs. of associated lesions. Tekauchi et al. found out that Immediately, his airway was protected and cervical spine contusions present in the inner part of the cerebellum was stabilized. Computed tomography (CT) scan of the (i.e., the midline and vermis) were associated with brain showed midline cerebellar contusion with hydroce- greater mortality and morbidity [10]. phalous and linear fracture of the occipital bone (Fig. 1). Nashimoto et al. further elaborated that lesions with Immediately, the patient was admitted to special care concomitant supra-tentorial extension were associated and was monitored hourly for drop in GCS. Nasogastric with poorer prognosis and should ideally be managed tube was inserted for feeding. Hyper-osmolar therapy with surgery (i.e., sub-occipital craniotomies and clot was started to lower intracranial pressure. In few hours, evacuation) [11]. the patient started showing improvement in Glasgow Our patient showed improvement on conservative Coma score. management only. The authors feel that is primarily due Eventually, the patient was shifted to general ward and to the small size of his lesion and because his initial was kept under observation. Within few days, the patient Glasgow Coma score was not very low. The authors was discharged from the hospital with strict recommen- further speculate that the patient’s excellent response to dations of continuous follow-up. conservative treatment might also be due to his young age. A number of studies have already highlighted the Discussion positive correlation that exists between younger age group The management of cerebellar confusion remains patients and their increased recovery rates following controversial owing to its very rare incidence. However, traumatic brain injuries [12, 13]. the conservative and surgical management remains the The major strength of our study lies in the estab- main treatment modalities. lishment of conservative management as a valid and According to Buczek et al., conservative manage- alternative treatment modality for the management of ment should be initiated in fully conscious patients in cerebellar contusions especially in younger individuals. whom contusions lie superficially and are less than 3cminsize[7]. D’Avella and Pollack et al. describes Conclusions that surgical management of cerebellar contusion via Cerebellar contusions can be treated via medical man- a post occipital craniotomy is superior in comatose agement in certain instances where the age of the patient patients with larger contusions and associated is low and the Glasgow Coma Scale is high. Javed et al. Egyptian Journal of Neurosurgery (2019) 33:6 Page 3 of 3 Abbreviations 11. Nashimoto T1, Sasaki O, Nozawa T, Ando K, Kikuchi B, Watanabe M. Clinical GCS: Glasgow Coma Scale; TBI: Traumatic brain injury Study on Cerebellar Contusion:A Report on 9 Cases and Literature Review. No Shinkei Geka. 2015;43(10):901–6. 12. Flanagan SR, Hibbard MR, Gordon WA. The impact of age on traumatic Acknowledgements brain injury. Phys Med Rehabil Clin N Am. 2005;16:163–77. I would like to acknowledge Dr. Maryam Tariq for the undue support and 13. Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on cooperation. functional outcome in mild traumatic brain injury: 6-month report of a prospective multi-center trial. J Trauma. 2004;56:1042–8. Availability of data and materials Publication of patient’s data in this case report does not compromise anonymity or confidentiality or breach local data protection laws. Authors’ contributions GJ supervised, corrected, and proof read the manuscript. He was involved in the identification of the uniqueness of the case and giving care to the patient. SB was involved in examining and managing the patient. He also wrote the case summary of the patient. YuI was involved in writing of the rest of the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate I confirm that ethical approval was not required for reporting this case; informed written consent was taken from the child’s father. Consent for publication The father of the child was briefed in detail about the uniqueness of case and its management, risk, benefits, and alternate mode of treatment. Written informed consent was taken to report and publish the case. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Section of Neurosurgery, Department of surgery, Aga Khan University Hospital, Karachi, Pakistan. Dow University of Health Sciences, Karachi, Pakistan. Received: 23 October 2017 Accepted: 31 January 2018 References 1. Greve MW, Zink BJ. Pathophysiology of traumatic brain injury. Mount Sinai J Transl Personal Med. 2009;76(2):97–104. 2. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation. 2007;22(5):341–53. 3. Tsai FY, Teal JS, Itabashi HH, Huprich JE, Hieshima GB, Segall HD. Computed tomography of posterior fossa trauma. Journal of computer assisted tomography. 1980;4(3):291–305. 4. D'Avella D, Cacciola F, Angileri FF, Cardali S. Traumatic intracerebellar hemorrhagic contusions and hematomas. J Neurosurg Sci. 2001;45(1):29. 5. van Gijn J. From the Archives. Brain. 2007;130(1):4–7. https://doi.org/10.1093/ brain/awl345. 6. Braga LW, Souza LN, Najjar YJ, Dellatolas G. Magnetic resonance imaging (MRI) findings and neuropsychological sequelae in children after severe traumatic brain injury: the role of cerebellar lesion. J Child Neurol. 2007; 22(9):1084–9. 7. Buczek M, Jagodziński Z, Kopytek M, Dabrowska E. [Conservative treatment of post-traumatic intracerebellar hematoma]. Wiadomosci lekarskie (Warsaw, Poland: 1960). 1989;42(8):550–5. 8. Pollak L, Rabey JM, Gur R, Schiffer J. Indication to surgical management of cerebellar hemorrhage. Clin Neurol Neurosurg. 1998;100(2):99–103. 9. D’Avella D, Servadei F, Scerrati M, Tomei G, Brambilla G, Angileri FF, Massaro F, Cristofori L, Tartara F, Pozzati E, Delfini R. Traumatic intracerebellar hemorrhage: clinicoradiological analysis of 81 patients. Neurosurgery. 2002; 50(1):16–27. 10. Takeuchi S, Takasato Y, Masaoka H, Hayakawa T. Traumatic intra-cerebellar haematoma: study of 17 cases. Br J Neurosurg. 2011;25(1):62–7. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Egyptian Journal of Neurosurgery Springer Journals

Traumatic midline cerebellar contusion in 2-year-old male child—case report and review of literature

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Abstract

Background: Cerebellar contusion accounts for 0.54% of traumatic brain injuries. They present with a variety of symptoms like ataxia, dysmetria, dysdiadokinesia, and vertigo. CT scan is the gold standard investigation for diagnosing acute cerebellar contusions. Due to the low incidence of this disease, there are no medical guidelines available for the management of cerebellar contusions. Case report: A 2-year-old child presented to the emergency department with altered level of consciousness. Computed tomography scan of the brain showed midline cerebellar contusion. He was managed conservatively with the main focus on lowering intracranial pressure. Result: Cerebellar contusion can be managed conservatively with close monitoring. However, more data is needed to study its behaviour and management. Conclusions: The patient had an excellent response to treatment and was discharged within a few days further highlighting the role of medical management in the treatment of patients with cerebellar contusions. Keywords: Cerebellar contusion, Pediatric trauma, Brain injury Background injuries (where the frontal or temporal area is targeted), Contusions are defined as any injury to the body occurring and acceleration-deceleration injuries [4]. following trauma that leads to blood vessel rupture and Cerebellar contusions present in a variety of ways. In tissue destruction. Following contusions, the area is adults, they will present with cerebellar signs like nystagmus, marked by active bleeding into the tissue [1]. This trau- dysarthria, hypotonia, ataxia, dysmetria, tremor, dysdiado- matic brain injury (TBI) is a major cause of morbidity and chokinesis, and vertigo [5]. In children, additional signs like mortality worldwide and affects up to 10 million individ- cerebellar mutism have also been seen. One study by Braga uals annually [2]. et al. studied the neuropsychological sequelae in children Tsai et al. state that only 3.3% of traumatic brain injuries with cerebellar trauma, according to the study, most involve the posterior fossa. These injuries include children with cerebellar trauma develop dyscalculia and extra-dural hematomas, sub-dural hematomas, and rarely exhibit lower visual recognition memory [6]. cerebellar contusions (which account for less than 1% of Computed tomography scan is the gold standard all head injuries) [3]. investigation for evaluating cerebellar contusions. It shows D’Avella et al. state that cerebellar contusions make up the size of the contusion, its location, the status of fourth only 0.54% of all head injuries. He categorized the type ventricles and cisterns, and any associated lesion like extra- of injuries causing cerebellar contusions into coup injuries dural or sub-dural hematomas. (where the occiput is the area of impact), countercoup Due to the rarity of traumatic intra cerebellar contusions, only case reports and case series are published detailing the presentation and the management of this disease with * Correspondence: sanaullahbashir@gmail.com the management itself remaining quite controversial. Here, Section of Neurosurgery, Department of surgery, Aga Khan University we present a case report of a male child with midline intra Hospital, Karachi, Pakistan Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Javed et al. Egyptian Journal of Neurosurgery (2019) 33:6 Page 2 of 3 Fig. 1 Midline cerebellar contusion in axial and sagittal sections with orbital fracture. Consent has been taken from the patient’s father to attach this image with case report cerebellar contusion and his subsequent medical therapy. hydrocephalus either associated with extra-dural or The management of our respective patient can help the sub-dural hemorrhages [8, 9]. greater scientific community in better understanding of The results of these treatments are diverse depending the requisite treatment for this unique phenomenon. on various factors. The most important of which is the initial Glasgow Coma score of the patients. D’Avella et al. [4] divided his patients into two groups on the basis Case report of GCS score with group 1 having score of more than 9 A 2-year-old male child presented to the emergency and other group of less than 9 at the time of admission, department of Aga Khan University Hospital with a history 95% of cases in group 1 had a favorable outcome of unwitnessed fall from height 12 h back. He presented whereas only 19% of cases in group 2 had favorable with complaints of drowsiness and altered level of outcomes. consciousness. On examination, he had a Glasgow Other determinants of patient prognosis included Coma Scale (GCS) of 10/15 and was opening eyes to pain, location of cerebellar contusion, its size, status of ven- crying on receiving painful stimuli while spontaneously tricle and associated cisterns, and presence or absence moving all four limbs. of associated lesions. Tekauchi et al. found out that Immediately, his airway was protected and cervical spine contusions present in the inner part of the cerebellum was stabilized. Computed tomography (CT) scan of the (i.e., the midline and vermis) were associated with brain showed midline cerebellar contusion with hydroce- greater mortality and morbidity [10]. phalous and linear fracture of the occipital bone (Fig. 1). Nashimoto et al. further elaborated that lesions with Immediately, the patient was admitted to special care concomitant supra-tentorial extension were associated and was monitored hourly for drop in GCS. Nasogastric with poorer prognosis and should ideally be managed tube was inserted for feeding. Hyper-osmolar therapy with surgery (i.e., sub-occipital craniotomies and clot was started to lower intracranial pressure. In few hours, evacuation) [11]. the patient started showing improvement in Glasgow Our patient showed improvement on conservative Coma score. management only. The authors feel that is primarily due Eventually, the patient was shifted to general ward and to the small size of his lesion and because his initial was kept under observation. Within few days, the patient Glasgow Coma score was not very low. The authors was discharged from the hospital with strict recommen- further speculate that the patient’s excellent response to dations of continuous follow-up. conservative treatment might also be due to his young age. A number of studies have already highlighted the Discussion positive correlation that exists between younger age group The management of cerebellar confusion remains patients and their increased recovery rates following controversial owing to its very rare incidence. However, traumatic brain injuries [12, 13]. the conservative and surgical management remains the The major strength of our study lies in the estab- main treatment modalities. lishment of conservative management as a valid and According to Buczek et al., conservative manage- alternative treatment modality for the management of ment should be initiated in fully conscious patients in cerebellar contusions especially in younger individuals. whom contusions lie superficially and are less than 3cminsize[7]. D’Avella and Pollack et al. describes Conclusions that surgical management of cerebellar contusion via Cerebellar contusions can be treated via medical man- a post occipital craniotomy is superior in comatose agement in certain instances where the age of the patient patients with larger contusions and associated is low and the Glasgow Coma Scale is high. Javed et al. Egyptian Journal of Neurosurgery (2019) 33:6 Page 3 of 3 Abbreviations 11. Nashimoto T1, Sasaki O, Nozawa T, Ando K, Kikuchi B, Watanabe M. Clinical GCS: Glasgow Coma Scale; TBI: Traumatic brain injury Study on Cerebellar Contusion:A Report on 9 Cases and Literature Review. No Shinkei Geka. 2015;43(10):901–6. 12. Flanagan SR, Hibbard MR, Gordon WA. The impact of age on traumatic Acknowledgements brain injury. Phys Med Rehabil Clin N Am. 2005;16:163–77. I would like to acknowledge Dr. Maryam Tariq for the undue support and 13. Mosenthal AC, Livingston DH, Lavery RF, et al. The effect of age on cooperation. functional outcome in mild traumatic brain injury: 6-month report of a prospective multi-center trial. J Trauma. 2004;56:1042–8. Availability of data and materials Publication of patient’s data in this case report does not compromise anonymity or confidentiality or breach local data protection laws. Authors’ contributions GJ supervised, corrected, and proof read the manuscript. He was involved in the identification of the uniqueness of the case and giving care to the patient. SB was involved in examining and managing the patient. He also wrote the case summary of the patient. YuI was involved in writing of the rest of the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate I confirm that ethical approval was not required for reporting this case; informed written consent was taken from the child’s father. Consent for publication The father of the child was briefed in detail about the uniqueness of case and its management, risk, benefits, and alternate mode of treatment. Written informed consent was taken to report and publish the case. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Section of Neurosurgery, Department of surgery, Aga Khan University Hospital, Karachi, Pakistan. Dow University of Health Sciences, Karachi, Pakistan. Received: 23 October 2017 Accepted: 31 January 2018 References 1. Greve MW, Zink BJ. Pathophysiology of traumatic brain injury. Mount Sinai J Transl Personal Med. 2009;76(2):97–104. 2. Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation. 2007;22(5):341–53. 3. Tsai FY, Teal JS, Itabashi HH, Huprich JE, Hieshima GB, Segall HD. Computed tomography of posterior fossa trauma. Journal of computer assisted tomography. 1980;4(3):291–305. 4. D'Avella D, Cacciola F, Angileri FF, Cardali S. Traumatic intracerebellar hemorrhagic contusions and hematomas. J Neurosurg Sci. 2001;45(1):29. 5. van Gijn J. From the Archives. Brain. 2007;130(1):4–7. https://doi.org/10.1093/ brain/awl345. 6. Braga LW, Souza LN, Najjar YJ, Dellatolas G. Magnetic resonance imaging (MRI) findings and neuropsychological sequelae in children after severe traumatic brain injury: the role of cerebellar lesion. J Child Neurol. 2007; 22(9):1084–9. 7. Buczek M, Jagodziński Z, Kopytek M, Dabrowska E. [Conservative treatment of post-traumatic intracerebellar hematoma]. Wiadomosci lekarskie (Warsaw, Poland: 1960). 1989;42(8):550–5. 8. Pollak L, Rabey JM, Gur R, Schiffer J. Indication to surgical management of cerebellar hemorrhage. Clin Neurol Neurosurg. 1998;100(2):99–103. 9. D’Avella D, Servadei F, Scerrati M, Tomei G, Brambilla G, Angileri FF, Massaro F, Cristofori L, Tartara F, Pozzati E, Delfini R. Traumatic intracerebellar hemorrhage: clinicoradiological analysis of 81 patients. Neurosurgery. 2002; 50(1):16–27. 10. Takeuchi S, Takasato Y, Masaoka H, Hayakawa T. Traumatic intra-cerebellar haematoma: study of 17 cases. Br J Neurosurg. 2011;25(1):62–7.

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Egyptian Journal of NeurosurgerySpringer Journals

Published: Jun 1, 2018

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