CHAPTER 30: CHILD WITH CEREBRAL - CSF fills the entire subarachnoid

DYSFUNCTION space
- Arachnoid trabeculae a fibrous
CEREBRAL STRUCTURE AND FUNCTION
filament that provide further
• Three intimately connected & protection
functioning parts of the nervous system Brain
a. Central nervous system
b. Peripheral nervous system • Corpus callosum is the largest fiber
c. Autonomic nervous system bundle in the brain
• CNS consists of two cerebral • Basal ganglia (cerebral nuclei) serve as
hemispheres, brainstem, cerebellum, & vital sorting areas for messages
spinal cord
Cerebral Blood Flow
• PNS consists of cranial nerves and
spinal nerves • Blood supply to the brain tissue is
• ANS is compose of sympathetic and carried by the internal carotid arteries
parasympathetic • 17% of the cardiac output, supplies the
brain with 20% of body oxygen
CENTRAL NERVOUS SYSTEM
• CBF is the result of two opposing forces:
• The skull is an expansible structure in cerebral blood pressure & cerebral
the infant and young children due to vascular resistance
incomplete ossification • CBF remains constant at a cerebral
• Middle meningeal artery is a branch of blood pressure between 50 and
the external carotid artery where blood 150mmHg
is supplied to the dura matter
Blood-Brain Barrier
Brain Coverings
• Anatomic-physiologic feature of the
• Three membranes cover and protect the brain that separates the brain
brain parenchyma from the blood
• Dura matter
INCREASED INTRACRANIAL PRESSURE
- a double layer that serves as the
outer layer and the inner • The early signs and symptoms of
periosteum of the cranial bones increased ICP are often subtle, such as
- these two layers are separated by headache, vomiting, personality
the epidural space changes, irritability, and fatigue
• Falx cerebri separates the cerebral • In children whose cranial sutures have
hemispheres not closed, there will be an increase in
• Falx cerebelli separates the cerebellar head circumference
hemispheres
Clinical Manifestations of Increased ICP
• Tentorium separates the cerebellum
Infants • Macewen signs
from the occipital lobe of the cerebellum
• Drowsiness
• Arachnoid membrane
• Setting-sun sign
- delicate, avascular, weblike
Children • Forceful vomiting
structure
• Diplopia
- in between the dura and
• Lethargy
arachnoid lies the subdural area Late Signs • Cheyne-Stoke
• Pia matter respirations
- delicate, transparent membrane • Papilledema
 • Coma • Coma is a state of unconsciousness
when the patient cannot be aroused,
even with powerful stimuli
EVALUATION OF NEUROLOGIC STATUS
• The seat of consciousness of the brain
is in the reticular formation – the central
core of the brainstem
Level of Consciousness
• Assessment of LOC remains the earliest
indicator of improvement or deterioration
in neurologic status
Coma Assessment
• To produce coma, one of following must
occur
- extensive, bilateral cerebral
destruction
- lesion in the diencephalon
- destruction of the brainstem down
to the lower pons
• Glasgow Coma Scale consists of a
three-part assessment: eye opening,
verbal response, and motor response

Irreversible Coma
ALTERED STATE OF CONSCIOUSNESS
• The brain – cerebrum – has become the
• Consciousness implies awareness
tissue of most importance in determining
• Two aspects:
the time of death
- alertness
• Brain death is the total cessation of the
- cognitive power
brainstem and cortical brain function
• Unconsciousness is depressed cerebral
• Pronouncement of brain death requires
function
two conditions
 1. Complete cessation of clinical • Skull fractures result from a direct blow
evidence of brain function or injury to the skull
2. Irreversibility of condition • Types of skull fractures: linear,
comminuted, depressed, open, basilar,
NEUROLOGIC EXAMINATION
and growing
• Its purpose is to establish an accurate, • Linear fractures are a single fracture
objective baseline of neurologic function line that starts at the point of maximum
impact
Vital Signs
• Comminuted fractures consist of
• Autonomic activity is most intensively multiple associated linear fractures
disturbed in deep coma and in • Depressed fractures are those in which
brainstem lesions the bone is locally broken
• Cushing reflex causes slowing of the • Open fractures result in a
pulse and increase in blood pressure communication between the skull and
• Hyperventilation is usually the result of the scalp or the mucosa
metabolic acidosis • Basilar fractures involve the bones at
the base of the skull
HEAD INJURY
• Growing fractures result from a skull
• A pathologic process involving the scalp, fracture with an underlying tear in the
skull, meninges, or brain as a result of dura
mechanical force
Complications
Etiology
o The major complications of
• Three major causes of brain injury: falls, trauma to the head are
motor vehicle injuries, and bicycle hemorrhage, infection, edema,
injuries and herniation

CONCUSSION EPIDURAL HEMATOMA

• Most common head injury • Extradural hematoma is a hemorrhage

• It is an alteration in mental status with or into the space between the dura and the
without loss of consciousness skull
• Hallmarks: confusion and anemia • The classic clinical picture if an epidural
hemorrhage is a lucid interval
CONTUSION AND LACERATION (momentary unconsciousness)
• Terms used to describe actual bruising • Can be detected by an initial CT scan
and tearing of cerebral tissue • Cushing triad (systemic hypertension,
• Coup injury represents petechial bradycardia, and respiratory depression)
hemorrhages or localized bruising at the SUBDURAL HEMORRHAGE
site of trauma
• Contrecoup injury represents a lesion • Subdural hemorrhage is bleeding
remote from the site of trauma between the dura and the arachnoid
• Major areas of the brain susceptible are membranes
the occipital, frontal, temporal lobes • Two sources
• Shaken baby syndrome - tearing veins that bridge the
subdural space
FRACTURES - hemorrhage from the cortex of
the brain
 • Acute subdural hematoma may be
associated with contusions or
lacerations
• Chronic subdural hematoma is more
common
OTHER HEMORRHAGIC LESIONS
• Subarachnoid hemorrhage is bleeding
within the subarachnoid space
• Common risk factors for primary
intracranial hemorrhages are
arteriovenous malformations,
arteriovenous fistula, and brain tumors
CEREBRAL EDEMA
• Peaks at 24-72 hours after injury
• Cytotoxic edema is a result of direct cell
injury and is caused by intracellular
swelling
• Vasogenic edema is due to increased
permeability of capillary endothelial cells
POSTTRAUMATIC SYNDROMES
• Postconcussion syndrome is a
sequela to brain injury
• Headaches may occur within 1 week to
3 months
• Hydrocephalus is seen when there has
been subarachnoid hemorrhage or
infection
Diagnostic Evaluation
• Fundoscopic examination should be
performed to detect retinal
hemorrhages
• Underlying skull fracture should be
ruled out by CT scan
•