Tectorial Membrane Injury: Frequently Overlooked in Pediatric Traumatic Head Injury

Abstract

SUMMARY:REHs and tectorial membrane injuries are rare complications of pediatric head and neck injuries. We aim to describe the neuroimaging findings in pediatric REHs, to summarize the mechanism of injury, and to correlate the imaging findings with the clinical presentation. We retrospectively evaluated CT and/or MR imaging studies of 10 children with traumatic REH. Most patients were involved in MVAs. The tectorial membrane was injured in 70% of patients, and REHs were medium to large in 80%. None of the patients had a focal spinal cord or brain stem injury, craniocervical junction dislocation, or vertebral fractures. Tectorial membrane disruption was diagnosed in most patients without craniocervical junctionϪrelated symptoms. Tectorial membrane lesions and REHs were seen in young children who sustained high-speed head and neck injuries. Clinical symptoms may be minimal or misleading. The radiologist should be aware of these injuries in children. MR imaging appears to be more sensitive than CT.ABBREVIATIONS: DAI ϭ diffuse axonal injury; GCS ϭ Glasgow Coma Scale; MVA ϭ motor vehicle accident; REH ϭ retroclival epidural hematoma; STIR ϭ short T1 inversion recovery R EH and tectorial membrane injuries are rare complications of traumatic head-neck injuries. Only 1.2%-12.9% of all posterior fossa epidural hematomas are located in the retroclival epidural space.1-5 REHs have only been reported in a few children and even more rarely in the adult population. 6,7 Most pediatric traumatic REHs are seen in children involved in MVAs.8 Tectorial membrane disruption has been reported to be 1 of the most important factors resulting in the formation of a REH. None of the previous reports, however, have systematically studied the simultaneous occurrence of REH and tectorial membrane injuries in children. 6 Conventional radiography and CT are typically used in acute trauma to exclude injury to the brain or cervical spine. Conventional radiography and CT may, however, not always detect craniocervical junction injuries adequately or may underestimate the degree and extent of injury. MR imaging is the technique of choice for the detailed assessment of craniocervical junction injuries. MR imaging also allows the evaluation of the lower brain stem and cervical spinal cord with higher sensitivity and specificity. 6,9 The goals of our report are the following: 1) to describe the CT and MR imaging features in children with confirmed traumatic REH, 2) to specifically assess the frequency of simultaneous REH and tectorial membrane injury, and 3) to correlate the imaging findings with the clinical presentation. Materials and MethodsTen children with confirmed REH by CT and/or MR imaging were included in the study. All children had experienced an acute significant head and neck injury and were seen at the Johns Hopkins Hospital between June 2006 and July 2010. The age and sex of all patients were recorded. The electronic patient records were reviewed for the following: 1) the mechanism of trauma (eg, fall, MVA), and 2) clinical signs on th...

Trauma imaging of the cranio-cervical junction: Diagnosis

“…Tectorial membrane injury is manifest by discontinuity of the normal T2 hypo-intense signal of the ligament, increase of the T2 signal intensity or if the intact membrane is elevated by a REH. 2 Complete assessment of the CCJ ligaments must include those listed in Fig 1. Review of the literature indicates that this entity is under-diagnosed. Suspicion by the treating clinician and equally by the reporting radiologist is crucial.…”

Retroclival collections associated with abusive head trauma in children

“…Retroclival hematomas were first described by Orrison et al [2] in 1986 and have been subsequently noted in occasional case reports [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] and small series [20][21][22][23]. Most retroclival epidural and subdural hematomas occur in children, and these collections are almost always reported in the context of accidental trauma, particularly motor vehicle accidents [19,[24][25][26][27].…”

“…Children with retroclival epidural hematomas occurring in the setting of accidental trauma often present with neurological deficits ranging from lower cranial nerve paresis to tetraplegia and loss of spontaneous respiration [21][22][23]28]. Children with retroclival subdural hematomas arising from accidental injury may present with hemiparesis and respiratory arrest but children can also be asymptomatic [27,30,32].…”

“…Furthermore, retroclival epidural hematomas were not easily detected on head CT, and all isolated retroclival epidural collections were identified on MRI only. This is of potential clinical significance because retroclival epidural hematomas seen in accidentally injured children are usually associated with craniocervical junction injuries [4,21,28].…”

Application of Normative Occipital Condyle-C1 Interval Measurements to Detect Atlanto-Occipital Injury in Children

“…[8][9][10] However, studies in children, who are much more susceptible to atlanto-occipital injury than adults, 11,12 suggest a more essential role of MR imaging in the correct diagnosis of otherwise occult injuries at the craniocervical junction. 13,14 In 1 study of subjects younger than 18 years of age, Junewick et al 13 showed that 30/45 subjects with normal CT findings at the craniocervical junction had abnormal findings on MR imaging. Seventeen of these patients, most younger than 8 years of age, had findings that met the criteria for "significant craniocervical junction injury," though the need for surgical management was not investigated in this study.…”