What is the treatment for a 7-year-old with a skull fracture and subarachnoid hemorrhage?

Treatment of Skull Fracture with Subarachnoid Hemorrhage in a 7-Year-Old Child

For a 7-year-old child with skull fracture and subarachnoid hemorrhage, immediate computed tomography (CT) without contrast is the first-line imaging followed by neurosurgical consultation, with close neurological monitoring and supportive care as the mainstay of treatment. 1

Initial Assessment and Imaging

• CT scan without contrast is the preferred initial imaging modality for suspected skull fracture and intracranial injury in children 1

  • Use dedicated pediatric protocols with parameters tailored to patient size
  • Multiplanar and 3D reconstructions increase sensitivity for fractures

• MRI may be used in non-emergency settings for further evaluation 1

  • More sensitive for small-volume extra-axial hemorrhage
  • Can provide additional diagnostic information in about 25% of patients compared to CT 2
  • Not recommended for routine acute evaluation due to longer acquisition time and possible need for sedation

Acute Management

1. Neurosurgical consultation is mandatory for all children with confirmed skull fracture and subarachnoid hemorrhage 2, 1

2. Admission for observation is advised since the child:

   • Is under age 7
   • Has a skull fracture with associated intracranial injury (subarachnoid hemorrhage) 1

3. Neurological monitoring:

   • Regular neurological assessments (GCS, pupillary responses, motor function)
   • Monitor for signs of increased intracranial pressure
   • Watch for delayed cerebral ischemia which can occur after subarachnoid hemorrhage 2

4. Medication management:

   • Nimodipine should be initiated early to prevent delayed cerebral ischemia and improve functional outcomes 2, 3
     • Pediatric dosing should be adjusted based on weight (standard adult dose is 60 mg every 4 hours for 21 days) 3
   • Analgesics for pain management as needed
   • Avoid medications that may affect level of consciousness or mask neurological deterioration

5. Airway management:

   • Ensure patent airway and adequate oxygenation
   • If intubation is required, control ventilation with end-tidal CO2 monitoring 2
   • Maintain normocapnia to avoid cerebral vasoconstriction 2

Surgical Considerations

• Most pediatric skull fractures can be managed conservatively 4
• Surgical intervention may be required for:
  • Progressive neurological deterioration
  • Significant mass effect
  • Depressed skull fractures with brain compression (thickness >5 mm, displacement of midline >5 mm) 2
  • Acute hydrocephalus requiring CSF drainage 2

Monitoring and Follow-up

• Inpatient monitoring for at least 24-48 hours to observe for neurological deterioration 5
• Follow-up imaging is recommended to assess for resolution of hemorrhage or development of complications 2
• Rehabilitation assessment should be performed before discharge to identify any physical, cognitive, or behavioral deficits 2

Prognosis

Recent evidence indicates that children with isolated subarachnoid hemorrhage and GCS of 15 generally have good outcomes with conservative management 5. A 2021 study showed that in pediatric patients with head injuries and GCS scores of 15, those with isolated subarachnoid hemorrhage did not show clinical deterioration 5.

Important Considerations

• Evaluate for non-accidental trauma, especially when the mechanism of injury is unclear or inconsistent with the injury pattern 1
• Children under 2 years of age are at higher risk for clinically important brain injuries even after minor head trauma, but a 7-year-old with normal neurological status has a better prognosis 1
• Avoid hypocapnia during mechanical ventilation if required, as it can induce cerebral vasoconstriction and increase risk of brain ischemia 2

The management approach should be guided by the child's neurological status, with close monitoring for any signs of deterioration that would necessitate more aggressive intervention.