Primary brainstem injury in children

Introduction to primary brain stem injury in children Primary brain injury (primarybrain-steminjury) refers to brain stem injury caused by external force in children's head, which can be divided into primary brain stem injury and secondary brain injury. basic knowledge The proportion of illness: 0.001% Susceptible people: children Mode of infection: non-infectious Complications: Stress ulcers

Causes of primary brain stem injury in children

(1) Causes of the disease

The main reason is caused by falling, impact, newborns caused by birth injury, can be divided into primary brain stem injury and secondary brain injury, pressure loss caused by brain displacement or cerebral palsy, diffuse brain swelling and so on.

(two) pathogenesis

Directly caused by external force, the brain tissue is displaced to cause the brain stem to hit the hard skull base slope or the free edge of the cerebellum; or the torsion of the brain stem itself caused by the rotating shear stress, the injury caused by the traction, the child's skull is directly When the violence is violent, the deformity of the skull is large, which can cause a strong shock wave in the cerebrospinal fluid in the cerebral ventricle, causing hydraulic impact injury around the midbrain aqueduct or the bottom of the fourth ventricle. It is also an important cause of primary brain stem injury. Most of the brain stem injury is located in the covered or central part of the brainstem of the brain, and there are different degrees of contusion and laceration with focal hemorrhage and edema. In the later stage, the ischemic infarction may occur due to blood supply disorder, and softening and necrosis appear. There may be glial cell hyperplasia, and diffuse axonal injury is also a type of primary brain stem injury. It is a contusion of diffuse axonal cord caused by shear stress when the head is subjected to accelerated external rotation. Pathological changes Mainly located in the central part of the brain, namely the corpus callosum, the cerebral peduncle, the brainstem and the upper part of the cerebellum, manifested as contusion of white matter conduction bundle, hemorrhage and edema.

Microscopic changes often manifest in three forms due to the patient's survival period:

1. Patients who survived for a short period of time: manifested as axonal disintegration, axoplasmic spillage, followed by a large number of axonal retraction spheres distributed along the white matter conduction bundle.

2. Patients who survived for several weeks in the mid-term: manifested as infiltration of "small-string" microglia distributed along the white matter bundle.

3. Patients who survived for several months in the state of plant survival: manifested as the "Waller" degeneration of the long stem bundle and the proliferation of colloid.

Primary brain stem injury prevention in children

Pay attention to perinatal health care, prevent premature birth, dystocia; improve delivery technology, prevent neonatal brain injury; care for children of all ages to prevent brain trauma.

Complications of primary brain stem injury in children Complications, stress ulcers

There may be central hyperthermia, gastrointestinal stress ulcers, intractable hiccups, paralysis of the limbs, midbrain injury, and brain rigidity.

Symptoms of primary brain stem injury in children Common symptoms Go to the brain, tonic, hyperthermia, vital signs, change of consciousness disorder, coma, angular bow, antihypertension, blood pressure, loss of light response, pupil abnormality

A large number of important cranial nerve nuclei accumulate in the brainstem, reticular structure and movement, and sensory nerve conduction bundles are the center of life. A series of clinical symptoms and signs that threaten the lives of children can occur.

1. Consciousness disorder: Most children enter a continuous coma after injury, and the degree of coma is deep. The lighter may respond to strong painful stimuli. All the physiological reflexes disappear, the limbs are soft and paralyzed, and the state of sudden death is caused by The brainstem reticular uplift system is damaged.

2. Changes in vital signs: There are respiratory rhythm regulation centers and long suction centers in the pons. After the brain stem is damaged, respiratory rhythm irregularities may occur, and Chen Shi breathing or sobbing-like breathing may occur. Exhaled or inspiratory neurons in the reticular area of the medulla oblongata may experience apnea, slow breathing and shallower respiratory dysfunction after the injury, and the ventrolateral medulla of the medulla oblonga (rVLM) regulates cardiovascular activity in the brain. The key center plays an important role in maintaining normal blood pressure and heart rate. When this area is contused, there may be a drop in blood pressure, arrhythmia or cardiac arrest. When the brain stem injury causes autonomic nerve central disorder, central hyperthermia may occur. Digestive tract stress ulcer, intractable hiccup.

3. Changes in eye movement and pupil: In the oculomotor nucleus of the midbrain, the nucleus or the lateral center of the pons, there may be eye separation, binocular gaze and co-movement, and horizontal movement of the head. Disappeared; the pupil can be changed from small to small on both sides, or extremely reduced into a needle shape, or it can be loosely fixed or the two sides are not equal, the shape of the pupil can be irregular, and the light reflection is more likely to disappear.

4. Pyramid bundle sign: Due to the damage of the pyramidal bundle in the brain stem, the limbs may be paralyzed, the muscle tension is increased, the tendon reflex is active, the shallow reflex disappears, and one or both pathological signs may be positive, when the primary brain stem injury In severe cases, all physiological reflexes disappear and muscle tension is relaxed.

5. Destruction of the brain is an important sign of midbrain injury. The level of the vestibular nucleus of the midbrain has a center that promotes the contraction of the extensor muscle. The red nucleus of the midbrain and the surrounding reticular structure are the centers of the extensor contraction inhibition. Transverse injury can occur to the brain tonic, manifested as increased muscle tone, paroxysmal limbs over-extension, head tilted back angulation, external stimulation can be induced, the severe persistent persistent rigidity.

Examination of primary brain stem injury in children

Continuous monitoring of intracranial pressure can help identify primary and secondary brain stem injury, the former mostly normal intracranial pressure, the latter mostly manifested as increased intracranial pressure.

1. Brainstem auditory evoked potentials: It can accurately reflect the plane and extent of brain stem injury, and it is often manifested as abnormal or disappearance of auditory waves above the damage plane; it also contributes to the judgment of prognosis, and it has been reported that deep coma after trauma In children, if the auditory evoked potential is abnormally found, 69% of the children can recover, 31% of the children will die, and the auditory evoked potential will not respond at all, and 100% of the children will die.

2. CT: visible small brain-shaped irregular high-density hemorrhagic foci around the cover or the aqueduct, surrounded by low-density edema, swelling of the brain stem, and occlusion of the brain pool.

3. MRI: This test is rarely performed in the acute phase. It can be expressed as a short-T1 and long-T2 high-signal hemorrhagic change in the brainstem. It is superior to CT in the brainstem and is late (months or even years). The brain stem can be thinned due to diffuse axonal degeneration.

4. Detection of brainstem physiological or pathological reflex: The appearance of pathological palmar reflex indicates the damage of the brainstem cortex-cortical area plane; the disappearance of the ciliary ridge reflex and the palmar reflex indicates that the lesion has extended to the diencephalic plane; Loss of rim muscle reflex and corneal mandibular reflex appear as inter-brain-middle-brain level involvement; pupillary disappearance of light reflex and corneal mandibular reflex suggest lesions extend to midbrain level; loss of corneal reflex and masticatory muscle reflex is pons level The performance of the damage; the reflex of the eye and the disappearance of all the above reflections are signs of damage to the medulla.

Diagnosis and diagnosis of primary brain stem injury in children

After craniocerebral trauma, it is plunged into continuous deep coma, eyeball separation, pupil size change; vital signs disorder; degenerative brain attack, angular arch reversal; limb muscle tension increased, pathological signs positive; if CT excludes intracranial hematoma, If the lumbar puncture pressure is not high, the diagnosis of primary brain stem injury can be established.

It is differentiated from intracranial hemorrhagic disease and can be identified by brain CT examination.

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