Chronic posttraumatic headache in children and adolescents

Little is known about chronic posttraumatic headache (PTH) in children and adolescents. In this study we report on symptoms, clinical findings, and management of all children seen in our headache clinic who presented with recurrent headache following head injuries. A total of 23 children were identified over a period of 4 years. Twenty-one children (13 male, eight female; mean age 11.2 years, age range 3.3 to 14.9 years, median 12.1 years) fulfilled the International Headache Society's clinical criteria for the diagnosis of chronic PTH. Mean duration of headache was 13.3 months (range 2 to 60 months, median 7 months). Children were followed up for a period of 5 to 29 months (mean 12.5 months, median 9 months). Head injuries were classified as serious in four patients and minor in 17. Clinical variables were compared between children with PTH and those without a history of head injury. The headaches were migraine in five patients, tension type in 13, and mixed in three patients. Tension-type headache was significantly more common in children with chronic PTH than in those with no history of head injury, but the clinical course was comparable in the two groups.     

A prospective study of children with head injuries: IV specific cognitive deficits

Abstract

Twenty-five children with a head injury resulting in a posttraumatic amnesia of at least one week were compared with an individually matched group of 25 children with orthopedic injuries. Both groups were studied a few weeks after the accident and then again at 4 months, 1 year and 2% years after the injury. The head injury group showed a pcrsistent deficit on the WISC Performance IQ scale; the deficit on the Verbal IQ scalc was more transient. An extensive battery of neuropsychological tests was employed to identify specific deficits not shown on the WISC. On the whole, these tests shvwed a pattern of results similar to that found with the WISC, and in most cases children without deficits on the Performance IQscale ofthe WISC also did not show deficits on the battery of specific tests. However, in a few cases, tests of speed of visuo-motor o r visuo-spatial functioning picked u p deficits attributable to the head injury which occurred in children with normal scores on the WISC.     

Recommendation for an expanded classification with operational diagnostic criteria for craniocerebral trauma]

Neither nationally nor internationally is there today agreement on a classification of head injuries. The traditional system using the terms commotio/concussion, contusion and compression, as well as more functionally oriented classifications are in-adequate for present-day purposes. Furthermore, there is no conformity in evaluating the severity and duration of the posttraumatic disturbances of consciousness. None of the classifications in use today includes information on important details such as the type of head injury (closed or open), possible complications or the findings of modern neurophysiological investigation and neuroimaging procedures. The requirements which a modern classification system must meet are specified and a classification of head injuries with operational diagnostic criteria is proposed, which is intended to satisfy both clinical and scientific requirements.     

Atypical early posttraumatic syndromes (author's transl)

In a consecutive series of 1,925 head injuries, 283 patients (14.7%), could not be classified, neither in the group of simple head injuries without cerebral symptoms, nor in the group of typical concussions characterized by immediate amnesia or observed coma. We have prefered the rather neutral term of atypical early posttraumatic syndromes. In this group, apart from neurovegetative manifestations, partial disturbances of consciousness and perception, we have also classified delayed disturbances of consciousness. Special attention has been given to migraineous phenomena and to a syndrome, characteristic for children, described by Mealey. This is an intermediate group important from a medico-legal point of view because certain transient cerebral manifestations risk to be mistaken for psychological reactions. On the other hand symptoms probably of psychic origin were discussed.     

Posttraumatic visual agnosia and epilepsy as a consequence of gunshot injury to the head. Case report

Half million people in the world, each year have a gunshot injury to the head and eighty thousand of them are hospitalized. Gunshot injuries to the head have became in Poland second most frequent cause of death from head trauma, and in some countries during peace became the most frequent cause of death among patient with head injury. Glasgow Coma Scale (GCS) is a useful prognostic factor for patients with gunshot injury to the head. Injury to the eloquent regions of the brain, commotion and contusion of the brain, intracranial hematomas, subarachnoid hemorrhage, cerebro-vascular spasm, injuries to the major vessels, liquorrhea, infections, coagulopathies and epilepsy are the most important and influential factors in the clinical status of the patient with gunshot injury to the head. The operation is the preferred treatment to all patient, no matter of their clinical status at the moment of the admission. The report presents the history of treatment of a patient with gunshot injury to the head. During the treatment extremely infrequently occurring posttraumatic visual agnosia and posttraumatic epilepsy were observed. Twenty-two months after operation the patient is independent and professionally active.     

Ten-year research review of physical injuries

OBJECTIVE: To review the past 10 years of research relevant to psychiatry on injuries in children and adolescents. METHOD: A literature search of databases for "wounds and injuries, excluding head injuries," was done with Medline and PsycINFO, yielding 589 and 299 citations, respectively. Further searching identified additional studies. RESULTS: Progress is occurring in prevention, pain management, acute care, psychiatric treatment, and outcomes. The emotional and behavioral effects of injuries contribute to morbidity and mortality. Psychiatric assessment, crisis intervention, psychotherapy, psychopharmacological treatment, and interventions for families are now priorities. Research offers new interventions for pain, delirium, posttraumatic stress disorder, depression, prior maltreatment, substance abuse, disruptive behavior, and end-of-life care. High-risk subgroups are infants, adolescents, maltreated children, suicide attempters, and substance abusers. Staff training improves quality of care and reduces staff stress. CONCLUSIONS: Despite the high priority that injuries receive in pediatric research and treatment, psychiatric aspects are neglected. There is a need for assessment and for planning of psychotherapeutic, psychopharmacological, and multimodal treatments, based on severity of injury, comorbid psychopathology, bodily location(s), and prognosis. Psychiatric collaboration with emergency, trauma, and rehabilitation teams enhances medical care. Research should focus on alleviating pain, early psychiatric case identification, and treatment of children, adolescents, and their families, to prevent further injuries and reduce disability.     

Prognostic factors for life expectancy after penetrating head injury

Survival curves were made for 190 World War II veterans with penetrating head injuries, and for 106 WW II veterans with peripheral nerve injuries who matched the subjects with head injuries with respect to age at injury, years of formal education, and preinjury intelligence-test score. The results indicated that penetrating head injury coupled with posttraumatic epilepsy shortened life expectancy in subjects who survived the early postinjury period, but that head injury alone did not. Educational level was also a significant variable independent of seizures: subjects with more education survived longer than those with less education. Age at injury and the difference between preinjury and postinjury intelligence-test scores did not predict survival status.     

Sequelae of craniocerebral injuries in a neurologic patient sample--an attempt at interpreting post-traumatic headache

The sequelae of a head injury that had occurred at least six months previously, were examined in 457 patients. Neurological deficiencies, psychoorganic disturbances and disability caused by the injury correlated positively with its severity. Posttraumatic epilepsies were diagnosed approximately equally often in patients with minor head injuries and in those with more severe ones. It is probable that epilepsies have been diagnosed too often in patients with minor head injuries. Headache occurs significantly more often in patients with minor head injuries. This cannot be explained by the selection of patients alone. A hypothesis explaining the development of posttraumatic headache is presented and discussed.     

汶川地震后颅脑损伤儿童36例临床分析

目的 探讨汶川大地震后儿童颅脑损伤的临床特点.方法 收集汶川大地震后四川大学华西医院神经外科住院的36例地震致颅脑损伤儿童的临床资料(男21例,女15例;年龄3月～14岁.平均年龄8.1岁;轻型30例,中型4例,重型2例;建筑物倒塌砸伤30例,切割伤3例,逃生跌伤3例),对其伤情分类、致伤原因、治疗方法 及预后等进行回顾性分析.结果 36例颅脑损伤儿童中出院(或转院)时GOS评分为恢复良好33例,中残3例.结论 汶川大地震后建筑物倒塌砸伤为主要致伤原因,颅脑损伤儿童以轻型居多,要注意颅骨骨折的治疗,多数可恢复良好.     

Head injuries in Vietnamese refugees in Hong Kong

The Vietnamese refugee camps in Hong Kong represent a unique social situation, where as many as 55 000 people have at one time lived. The Neurosurgical Division of the Prince of Wales Hospital receives all head injured patients from two of the largest camps for management. A retrospective analysis was undertaken of all Vietnamese patients hospitalised with head injuries over a four year period from January 1990 to December 1993. Our results showed that there was a higher incidence of head injuries as compared to epidemiological studies in the USA (Marshall, 1981) and Britain (Jennett, 1981), with the highest risk group being children aged 12 years and below. The majority of head injuries were minor, with the most common cause being a fall from bed. With these findings, appropriate preventive measures were advised and steps were taken to reduce the incidence of head injuries amongst the Vietnamese children.     

Patterns of neuropsychological impairment after severe blunt head injury

A consecutive series of 100 subjects with severe blunt head injuries was followed up 6 years after trauma. Neuropsychological test performances of 82 subjects and of a noninjured control group were analyzed by two principal components analyses (PCAs). Each PCA extracted 15 factors relating to a range of cognitive impairments, as well as neuropsychological features consistent with posttraumatic personality changes. Measures identified by the PCAs were applied to 85 head-injured subjects in the series to examine the incidence of impairment in four neuropsychological areas: disorders of learning and memory, neuropsychological features consistent with posttraumatic personality change, slowness in rate of information processing, and a range of basic neuropsychological skills. Overall, impairments occurred in 70% of the series. Disorders of learning and memory were the most common type of deficit (56.5%), with disturbances in basic neuropsychological skills the least frequent (16.5%). Variability among subjects with respect to the types and combinations of neuropsychological impairments was a characteristic feature of this clinical group, but the largest proportion (one-third) demonstrated isolated impairments. The implications of the incidence and selectivity of neuropsychological impairments are discussed.     

Psychobiology of posttraumatic stress disorder in pediatric injury patients: a review of the literature

Research suggests that about a quarter to a third of children with traffic-related injuries develop posttraumatic stress disorder (PTSD). Early symptoms of PTSD have been found to predict poor mental and physical outcome in studies of medically injured children. However, these symptoms are rarely recognized by physicians who provide emergency care for these children. In addition, there is insufficient knowledge about predictors of posttraumatic stress symptoms in this specific pediatric population. Early identification of those children at particular risk is needed to target preventive interventions appropriately. After some introducing remarks on the classification and the nature of posttraumatic stress reactions, current research findings on psychological and biological correlates of PTSD in pediatric injury patients are presented. The particular focus in this paper is on the neurobiological mechanisms that influence psychological responses to extreme stress and the development of PTSD. Continued study of the psychobiology of trauma and PTSD in pediatric injury patients, both in terms of neurobiology and treatment is needed.     

Indications for brain CT scan in patients with minor head injury

OBJECTIVES: Minor head injury is the most common type of head injury. Despite of high incidence and numerous studies performed, there is much controversy about correct evaluation of these patients. The aim of this study was to find clinical signs and symptoms which help to predict the indications for brain CT scan following minor head injury. METHODS: A series of 682 consecutive patients who had been attended at two university hospitals (Alzahra and Kashani) with minor head injury (GCS=15) were prospectively enrolled in this cohort study. In all cases clinical signs and symptoms were collected and a cranial computerized tomography (CT) scan was obtained. The relationship between the occurrence of clinical findings and appearance of intracranial posttraumatic lesions on cranial CT was analyzed by chi-square tests and statistic logistic regression methods, with 95% confidence intervals. RESULTS: Of 682 patients, 46 (6.7%) presented brain injuries on CT scan. All patients with abnormal CT scans had at least one of the following factors (risk factors): posttraumatic amnesia, loss of consciousness, posttraumatic seizure, headache, vomiting, focal neurological deficit, skull fracture, coagulopathy or antecedent of treatment with anticoagulants and patient age older than 60 years. No abnormal CT scans were found among patients without any of those risk factors on admission. Vomiting, skull fracture and age greater than 60 years were risk factors significantly correlated to an abnormal cranial CT after head injury. The presence of several risk factors in a patient increased the probability of posttraumatic lesion on CT scan. CONCLUSION: Some clinical risk factors can be used as a guide to predict the probability of abnormal CT following minor head injury.     

Prognosis of brain stem lesion in children with head injury

INTRODUCTION: Traumatic brain stem lesions (tBSL) in children are thought to be a rare phenomenon. This prospective study analyzed the frequency and significance of such lesions on early magnetic resonance imaging (MRI) after severe head injury, since CT fails to demonstrate these lesions. METHODS: In 30 consecutive children comatose after head injuries, MRI was performed within 8 days of the injury. RESULTS: The incidence of tBSL was 60%. When the lesion affected the pons or caudal portions of medulla oblongata bilaterally, mortality was 100%. The presence of tBSL significantly correlated with the duration of coma and the categories of outcome, as indicated by the Glasgow Outcome Score. The frequency and the distribution of tBSL in children were similar to adults. CONCLUSION: Magnetic resonance imaging appears to be of high predictive value after severe pediatric head injuries.     

Young burned children: the course of acute stress and physiological and behavioral responses

OBJECTIVE: Symptoms of posttraumatic stress disorder (PTSD) are a focus of much research with older children, but little research has been conducted with young children, who account for about 40% of all pediatric burn injuries. This is a longitudinal study of 72 acutely burned children (12-48 months old) that assessed the course of acute posttraumatic symptoms and physiological reactivity. METHOD: Parents were interviewed shortly after their child was admitted to the hospital and 1 month after discharge. PTSD symptoms were measured with the Diagnostic Interview for Children and Adolescents (DICA) module. Nurses recorded the child's physiological data throughout the hospital stay. The child's physical and behavioral responses were assessed in a laboratory at about 1 month after discharge. RESULTS: Reduced social smiling in the children was related to PTSD symptoms, as measured by the DICA, and heart rate at 24 hours and 7 days. Reduced vocalization was related to the child's rating of pain at 24 hours. Smiling and vocalizations were also related to some DICA cluster scores but not avoidance. CONCLUSIONS: Preschool children admitted to a burn unit demonstrated PTSD symptoms and physiological reactivity. There was a relation to the frequency of smiles and vocalizations.     

重型、特重型颅脑外伤性脑梗死相关危险因素分析

目的 探讨重型、特重型颅脑外伤性脑梗死的发生机制及危险因素,为降低外伤性脑梗死的发生率和病死率提供依据.方法 对62例外伤性脑梗死患者(研究组)与680例未发生脑梗死的重型、特重型颅脑外伤患者的性别、年龄、伤情(GCS评分)、颅底骨折、脑疝、感染、手术、低血压、脱水药、活血药等因素进行调查和对照分析.结果 伤情、脑疝与否、感染与否、低血压、脱水药及活血药的使用与否等因素与外伤性脑梗死的发生密切相关(P＜0.05).结论 伤情、脑疝与否、感染与否、低血压、脱水药的过量使用等是外伤性脑梗死的常见危险因素,活血药的使用是外伤性脑梗死的保护因素.

Abstract：

Objective To explore pathogenesis and risk factors for posttraumatic cerebral infarction (PTCI) in patients with severe and extremely severe head injuries for the purpose of providing clues for reducing occurrence of PTCI and case - fatality. Methods Gender, age, Glasgow coma scale ( GCS), the presence or absence of basicranial fracture, cerebral hernia or infection, surgical modality, hypotension, and the use of diuretics and hemorheologic agents were recorded and analyzed in 62 PTCI patients ( study group)and 680 patients without PTCI (control group) following severe and extremely severe head injuries.Results GCS, the presence or absence of cerebral hernia and/or infection, hypotension, the use of diuretics and hemorheologic agents were closely correlated with the occurrence of PTCI ( P ＜ 0. 05 ).Conclusion GCS, the presence of cerebral hernia and infection, hypotension, and over - dosage of diuretics are common risk factors for PTCI, and the use of hemorheologic agents is a protective factor of PTCI in patients with severe and extremely severe head injuries.     

Vomiting in children following head injury

The criteria for hospital admission of children who have suffered a minor head injury are highly subjective. Often the presence of post-traumatic emesis becomes an influential factor, but the mechanisms that trigger emesis following minor head injuries are not known. From a prospective study of 96 consecutive children with their first mild head injury (GCS 13–15) and a retrospective study of 29 consecutive more seriously injured children (GCS 8–12), we conclude that post-traumatic emesis is more common: (1) following minor head injuries than following more severe head injuries (P<0.05); (2) in children over 2 years old; (P<0.001); (3) in children injured within an hour of a meal or snack (p<0.001). The presence of a skull fracture or the site of the impact does not influence the incidence or duration of post-traumatic emesis. Retching and vomiting generally subside within 3 h in children injured within an hour of a meal or snack. When vomiting appears in children injured more than an hour after a meal or a snack, it may be quite protracted (mean=7.5 h). Children over 2 years of age with post-traumatic emesis who are neurologically stable following a mild head injury that occurred within an hour of a meal or snack can be expected to improve quickly. Their counterparts injured more than an hour after a meal or snack are likely to remain distressed much longer and are best admitted to hospital.     

Les troubles psychotiques post-traumatiques : un modèle physiopathologique de la schizophrénie

Traumatic Brain Injury (TBI) and later serious psychopathology have long been associated in the literature. Psychotic disorder following traumatic head injury is reported to occur in 0.7 to 9% of patients who sustain a head injury. This paper summarizes the recent literature about psychotic symptoms following TBI and try to articulate these psychotic disorders to a pathophysiological model of primary schizophrenia. Psychotic disorder due to a general medical condition (TBI) indicates that the hallucinations or delusions are the direct physical consequences of the medical condition. A contrario, schizophrenia-like psychosis is a secondary schizophreniform syndrom that must be differentiated from posttraumatic schizophrenia where the head trauma is an external factor furthering the onset of a primary psychosis. A dimensional approach could although take place for understanding pathophysiology. Head injury has been reported to increase the likelihood of the development of psychosis disorder due to TBI, schizophrenia-like psychosis and posttraumatic schizophrenia. While TBI is a major public health issue, schizophrenia following TBI is relatively rare and poorly studied. The onset of schizophrenia occurs most commonly from late adolescence to mid-adulthood, in an age group where head injury is more frequent. Even if early illness features of schizophrenia might increase exposure to TBI, posttraumatic schizophrenia could be the result of a gene-environment interaction. The pathophysiology research in psychotic disorders following TBI does not distinguish schizophrenia from other psychotic syndromes but have to consider a dimensional approach of these psychotic phenomena. Family history of schizophrenia and frontal or parietal lobe deficits was more common in patients with posttraumatic psychotic symptoms. Susceptibility to schizophrenia is believed to be due to multiple genetic and interacting factors and mild childhood head injury may play a role in the development and onset of schizophrenia in families with a strong genetic predisposition. The authors suggest hypotheses aimed at furthering the understanding of the physiologic mechanisms relating traumatic brain injuries to psychotic symptoms. Psychotic disorder following TBI, schizophrenia-like psychosis and posttraumatic schizophrenia are a potential interest to clinicians and neuroscientists, as it may provide clues to understanding primary psychotic disorders such as schizophrenia. Schizophrenia is a psychotic disorder commonly attributed to the interaction of genetic vulnerability and environmental events which implies that environmental factors modulate the effects of the genotype. Schizophrenia related to TBI could also be the result of a gene-environment interaction. Schizophrenia genes may increase exposure to head trauma (through agitation or cognitive impairment), with head trauma further increasing the risk for schizophrenia. Further studies are needed to articulate the links between secondary psychotic symptoms and primary schizophrenia in a structure/function paradigm. The new imaging techniques of magnetic resonance imaging, position emission tomography and single-photon emission computed tomography could aid in this sense.     

Information–provision intervention for children and their parents following pediatric accidental injury

OBJECTIVE: This study evaluated an early intervention for children and their parents following pediatric accidental injury. METHOD: Information booklets provided to participants within 72 h of the initial trauma detailed common responses to trauma, the common time course of symptoms, and suggestions for minimizing any post-trauma distress. Following admission for traumatic injuries sustained in motor vehicle accidents, falls and sporting injuries a total of 103 children (aged 7-15) and their parents were evaluated at pre-intervention, 1 month, and 6 months post-trauma. The intervention (N = 33) was delivered to one of two hospitals, the second hospital was the control (N = 70). RESULTS: Analyses indicated that the intervention reduced child anxiety symptoms at 1-month follow-up and parental posttraumatic intrusion symptoms and overall posttraumatic symptoms at the 6-month follow-up. No other differences between the intervention and control groups were found. CONCLUSION: Overall, the information-based early intervention is simple, cost-effective method of reducing child and parent distress post-trauma.     

Posttraumatic Epilepsy Prophylaxis

Despite a large body of experimental evidence suggesting that posttraumatic epilepsy can be prevented, there is no generally accepted pharmacological regimen for posttraumatic seizure prophylaxis. This article describes a phenytoin anticonvulsant regimen specifically tailored for the patient with acute head injury and designed to provide immediate and sustained plasma concentrations of phenytoin between 10 and 20 microgram/ml. Initially, an intravenous phenytoin dose of 11 mg/kg body weight is immediately followed by an intramuscular dose of 13 mg/kg body weight. This is followed by daily intramuscular maintenance doses, usually 8.8 mg/kg body weight, until oral medication can be tolerated. Maintenance dosage adjustments, when necessary, are based on serial plasma concentrations of the drug. Eighty-four patients with severe head injuries with substantial risk of posttraumatic epilepsy were administered this regimen. Only 6% of these patients had seizures during the first year after injury (first week excluded), and this is considerably less than the rates reported elsewhere in the literature. Only one-third of these patients are known to have continued to take phenytoin after the first month, and only half of these had plasma phenytoin concentrations above the desired minimal level. The greatly reduced incidence of posttraumatic seizures in these patients, despite the low rate of long-term drug compliance, suggests that a prophylactic effect, rather than a suppressive effect, is produced.