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  • The most common cause of head injury in children is falls. More severe injuries are likely caused by motor vehicle collisions, bicycle collisions, and assaults, including child abuse.
  • Children with skull fractures are more likely to have an associated intracranial injury. However, intracranial injury may occur in the absence of skull fracture.
  • Children with severe injuries, including those with altered mental status, focal neurologic deficits, or penetrating injuries, should undergo emergent computed tomography (CT) of the head and prompt neurosurgical consultation.
  • Infants and children younger than 2 years may have subtle presentations despite clinically significant intracranial injury.
  • Children with minor head injury and no loss of consciousness or brief loss of consciousness may be observed without CT of the head.
  • Prevention of hypoxia, ischemia, and increased intracranial pressure is essential for children with severe head injuries.
  • Although children have a greater likelihood of survival and recovery from brain injury than adults, they may be more vulnerable to long-term cognitive and behavioral dysfunction.


Traumatic brain injury is a significant cause of pediatric morbidity and mortality in the United States. More than 7000 children die each year as a result of traumatic brain injury, while another 60 000 are hospitalized, and an additional 500 000 seek care in emergency department.1 Among children who die from trauma, 90% have an associated brain injury.2 Pediatric brain injury leads to major morbidity from physical disability, seizures, and developmental delay. The most common cause of head injury in children is falls; however, severe injuries are more likely caused by motor vehicle collisions (with the child as occupant or pedestrian), bicycle collisions, and assaults, including child abuse particularly in the youngest children.1,3 Boys are injured twice as commonly as girls.2


Primary brain injury occurs as a result of direct mechanical damage inflicted during the traumatic event. Secondary injuries occur from metabolic events such as hypoxia, ischemia, or increased intracranial pressure. The prognosis for recovery depends on the severity of the injuries. Anatomic features, specific injuries, and intracranial pressure physiology are important components in the pathophysiology of pediatric brain injury.




The scalp is the outermost structure of the head and adjacent to the galea, which is a tendinous sheath connecting the frontalis and occipitalis muscles (Fig. 29–1). Beneath the galea is the subgaleal compartment where large hematomas may form in this space. The pericranium lies just below, tightly adhering to the skull. The outer and inner tables of the skull are separated by the diploic space. The thin, fibrous dura is next, and it contains few blood vessels compared to the underlying leptomeninges, the arachnoid, and pia. Small veins bridge the subdural space and drain into the dural sinuses. Dural attachments partially compartmentalize the brain. In the midline, the falx cerebri divides the right and left hemispheres of the brain. The tentorium divides the anterior and middle fossa from the posterior fossa, with an opening ...

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