Bitemporal compression injury to the head.

Most cranio-cerebral injuries seen in the emergency department are caused by acceleration-deceleration or a direct impact mechanism. Compression or crush injury to the head is less commonly seen. A crush injury occurs when a body part is subjected a degree of force or pressure, usually after being trapped between two heavy objects or hard surfaces. We describe here a case of accidental bitemporal and facial compression injury in a young lady.

INTRODUCTION

Traumatic brain injuries (TBI) occur when sudden trauma damages the brain and disrupts its normal function. It can cause significant disability and mortality and represents a public health concern in both developed and developing countries. Besides the physical effects, TBI can also have profound and lasting psychological, cognitive, emotional and social outcomes. Males are about twice as likely to sustain TBI compared to females, and adults older than 70 years account for the highest TBI-related hospitalization rates.[12]

TBI may be divided into primary and secondary injuries. The former is induced by mechanical force and occurs at the time or moment of injury. Secondary injuries are mechanically induced and may be delayed from the moment of impact or it could represent superimposed injuries on the brain which is already affected by mechanical injury.[1-3]

Most cranio-cerebral injuries seen in the emergency department (ED) are caused by acceleration-deceleration or a direct impact mechanism. Compression or crush injury to the head is less commonly seen. A crush injury occurs when a body part is subjected a degree of force or pressure, usually after being trapped between two heavy objects or hard surfaces. The bilateral application of static forces on the head can occur in any region, however it often occurs the bitemporal region.[4-6] This is a case report highlighting one such injury.

CASE REPORT

WQ, a 20 year lady, was sent to the ED by ambulance paramedics. She was going up the escalator at a shopping mall, when she accidentally rested her head on its side arm rail. Without realizing it, the escalator ascended and the arm rail came close against an overhead concrete beam. WQ was unable to move her head away on time and it was thus trapped between the two hard surfaces (i.e., the concrete beam superiorly and the arm rail of the escalator inferiorly). Her head was trapped for approximately 10 seconds before the emergency button was activated to stop the escalator.

On arrival she was conscious, alert and orientated to time, place and person. Her vital signs were stable and there were no neurological deficits. The cranial nerves assessment was normal. Both pupils were equal and reactive to light but there were subconjunctival hemorrhages seen in both eyes. There was also an area of erythematous, fresh demarcation bruise on her right cheek, presumably the contact area with the arm rail. There were petechiael hemorrhages seen over both periorbital and maxillary areas. Her tympanic membranes were intact, with no otorrhagia or epistaxis. She had a mild headache with neck pain at presentation.

Her full blood count, urea and electrolytes as well as cervical spine X-ray were normal. She underwent a computerized axial tomography scan of the brainwhich showed normal results. There were no fractures, hemorrhages or pneumocephalus. In consultation with the neurosurgeon, she was observed for a period of 12 hours with neurological monitoring. She remained well and her neck pain and headache had subsided when she was discharged. A follow up appointment with the neurosurgeon at one week showed her to be well and without any symptoms.

DISCUSSION

This case illustrates an example of a short transient bitemporal compression injury to the head/face. The injuries sustained in this case were minor. In compression head injuries, the energy tends to be transmitted to the foramina and hiati of the middle cranial fossa, thus resulting in multiple injuries to the cranial nerves, sympathetic nerves as well as blood vessels. The bilateral critical pressure applied to the skull produces a fracture that often runs in the same direction as the applied force. The fracture line usually joins another one, originating on the opposite side and traverses the dorsum and selar floor or the spheno-occipital synchondrous. The tympanic membrane has been found to be involved in about 50% of cases.[7-11]

In more serious compression injuries, the following have been reported.[8-11]

Stretching of the cranial nerves at the base of the skull, sometimes associated with a fracture in the area as well;

Diabetes insipidus (the injury to the skull can result in pituitary stalk transaction which causes infarction of parts of the pars distalis. This can result in the failure of the hypothalamic hormones to reach the adenohypophysis. The intrinsic inability of cellular response of the gland can lead to panhypopituitarism associated with Diabetes Insipidus);

Intra- and pre-retinal hemorrhage, and

Intracranial hemorrhage.

The prognosis in patient WQ is excellent, with no neurological deficits. The likelihood of long term sequelae is also very low. In children who survive the acute phase, the prognosis has been documented to be good as well. In cases associated with multiple trauma of other systemic areas of the body, the prognosis is variable.[51012]

Motor vehicle accidents are generally the main cause of TBI. The enforcement of adequate training, compulsory helmets laws, use of child car seats for those below 4 years of age, repeated public education and campaigns and technological improvement in seat belts as well as airbags, have been implemented over the years to help manage the morbidity and mortality associates with TBI. The next most common cause of TBI, in most countries, is fall-related head injury.

The healthcare professional managing TBI patients include emergency physicians, neurologist, neurosurgeons, intensive care specialists, psychologist, psychiatrist and rehabilitative care physicians must continue to work together and ensure TBI research and knowledge sharing make advances. Without such support and collaboration, progress will be slow and TBI will remain as a silent epidemic.