Ocular complications of head injury in children

Ocular complications occurred in 28% of children with head injury. Neuro-ophthalmological lesions made up one-third of these complications, mostly involved the optic nerve, and were associated with other focal neurological signs more frequently than non-neural ocular complications. Lesions of the posterior visual pathways were rare but tended to be permanent.     

Acute head injuries in children in Ibadan,Nigeria

The city of Ibadan has a population of 3 million people and is the third largest city in Africa. In the mid-1970s, the economic boom in Nigeria was at its peak, which caused many changes in the socioeconomic scenario in the country, changes which affected the pattern of acute head injuries, especially in children. We therefore conducted a prospective study on all head injuries encountered in Nigerians treated in the Emergency Room of the University College Hospital in Ibadan between 1 July and 31 December 1974.Presented at the 11th Annual Meeting of the International Society for Pediatric Neurosurgery     

Resting energy expenditure of children attending a rehabilitation programme following head injury

Statement of purpose: Increased resting energy expenditure following head injury is well documented, but whether this increase extends into rehabilitation and whether this is affected by changes in body composition have not been studied. The aim of this study was to determine whether children attending a rehabilitation program following head injury had altered energy expenditure and body composition. Methods     

Clinical outcome after head injury in children

For at least 1 year we have done a follow-up on 178 children under the age of 18 years with head injuries treated between 1981 and 1987. The Brussel Coma Scale and the Glasgow Outcome Score were used to determine neurological deficits and patient outcome. In children with coma, there was good recovery or moderate disability in 71.4%, severe disability in 6.1%, and death in 22.5%. When all head injuries were taken into consideration, a satisfactory outcome was found in 84.3%, severe disability in 3.3%, and death in 12.4%. The outcome mainly depended on the initial coma grade, but the duration of coma or advanced age were also negative factors for outcome. In 14.8%, intracranial mass lesions showed no significant correlation with outcome. In contrast to adults, diffuse brain swelling had a satisfactory outcome in 85.1%.Presented at the 11th Meeting of the European Society for Paediatric Neurosurgery, Naples 1988     

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.     

Severe head injury in children: early prognosis and outcome

The outcome is reported in 62 children with severe head injuries following a road traffic accident. All patients were comatose for at least 6 h; all patients were graded using the Glasgow Coma Score (GCS) or the Children Coma Score (CCS). Fifty-four patients were comatose immediately after injury, 8 after a lucid interval. Thirty patients had isolated head injuries and 32 had associated injuries, either long bone fractures or rupture of an abdominal organ. Additional information concerning main brainstem reflexes, posture and respiration was included in the study. The overall mortality was 32%. The goal of the study was to identify those clinical features available soon after injury which are important indicators of treatment and outcome.Presented at the 11th Scientific Meeting of the International Society for Pediatric Neurosurgery, Gothenburg, 1983     

Early outcome prediction in severe head injury: comparison between children and adults

The prognostic value in 49 children and 56 adults of the following parameters recorded on admission was analyzed: oculocephalic and light reflexes, posturing, Glasgow Coma Scale (GCS), the need for ventilatory support, and the presence of associated injuries. All patients had been in coma for at least 6 h. The presence of intracranial hematoma and the duration of coma were recorded and the relative risk of poor outcome calculated. There was poor outcome in 51% of the children and 61% of the adults. Oculocephalic and light reflexes, posturing, GCS, need for ventilatory support, and duration of coma were significantly related to the outcome in children. Only oculocephalic and light reflexes, and posturing were significantly related to the outcome in adults. Some parameters appeared to have different prognostic value in children and in adults: the simultaneous evaluation of oculocephalic reflex and need for ventilation was the best prognostic guide in children, the light reflex was the best prognostic indicator in adults.     

Paediatric head trauma: influence of age and sex

A consecutive unselected series of 1812 children (up to 15 years old) admitted for head injuries over a period of 8.5 years was studied. The cases were divided up according to five categories of pathology: benign injury, extradural haematoma, subdural haematoma, open brain laceration and brain contusion in a broad sense. All cases of benign injury were from the Geneva area (57 000 children) and 52% of the cases of severe injury were referred from other places. To these 1812 cases were added those of 23 children who died before admission recorded by the police. In the Geneva area the mortality was 6.8/100 000 per year. Patients were divided into three age groups: I (0–3 years), II (3–9 years), and III (9–15 years); group I was further subdivided into subgroups I a (0–1 year) and I b (1–3 years). The incidence of each type of accident was calculated for each age group, separately for girls and boys. Each type of pathology was correlated, sex by sex and for different ages, with the type of accident. Overall, two boys were injured for each girl. Road accidents were responsible for 15% of head injuries in group I girls, 17% in group I boys, 43% in group II girls, 45% in group II boys, 50% in group III boys and 61% in group III girls. They were responsible for 94% of all deaths and 85% of deaths of hospitalized patients. Falling was the most frequent cause of injury. Benign injuries were more frequent in group I. Only 1 of 25 patients with extradural haematomas died, and there were only 8 patients with subdural haematomas, 4 in subgroup I a (babies aged less than 1 year).     

Traumatic subdural effusions in children following minor head injury

Aim  There is considerable disparity in literature as regards to the presentation of subdural fluid collections in children. In this report, the authors have tried to establish the clinical and radiographic criteria to define the subdural effusions (SDEs) in children following minor head injury. Methods  Twenty cases of traumatic SDEs following minor head injury were studied prospectively. The age of these children ranged from 1 month to 2 years with an average of 9 months. The duration from the onset of first symptom to presentation in our outpatient department varied from 1 month to 13 months with a mean of 4.2 months. The duration of follow-up was 6 months to 2 years with an average of 10 months. Results  Fourteen out of 20 (70%) children presented with subtle findings. Six out of 20 (30%) children presented with overt neurological signs and symptoms. Seizures were the most common mode of presentation in this group. Bilaterality and ventriculomegaly were more common in the subtle group, each with an incidence of 43%. Seven out of 20 (35%) cases required operative management of traumatic SDEs. Recurrence was seen in two of 20 (10%) cases who had been conservatively managed previously. Only one child showed conversion of traumatic subdural hygroma to chronic subdural hematoma on conservative management. Conclusion  Traumatic SDEs in children following minor head injury need to be differentiated from other causes of subdural fluid collections in children. The clinical and radiological criteria proposed by us helps to identify this subset of cases in most of the children.     

Prognostic implications of hyperglycaemia in paediatric head injury

Fifty children with head injury were evaluated in an attempt to estabilish a correlation between post-traumatic hyperglycaemia and long-term outcome. In all the patients, the blood glucose level was measured on admission and on the days following the trauma (threshold of normal value set at 150 mg/dl). Hyperglycaemia was seen more frequently in children with severe head injury than in those with mild and moderate head injury. It was present in 87.5% of the patients with a Glasgow Coma Score (GCS) ≤8 (the average blood glucose level on admission was 237.8±92 mg/dl), in 60% of the patients with a GCS of 9–12 (178±78.7 mg/dl) and only in 25% of those with a GCS of 13–15 (131.5±39 mg/dl). A close correlation was also seen between the outcome and the blood glucose level. In fact, the blood glucose on admission was higher in the patients with a poor outcome, i.e. in those having a Glasgow Outcome Score (GOS) of 2 or 3 and in those who died (GOS 1), than in the patients with a good outcome (GOS of 4 or 5). Finally, hyperglycaemia persisted beyond the first 24 h after trauma in all the children who died or who survived with a poor outcome. Hyperglycaemia, and especially its persistence over time, appears to be an important negative prognostic factor in children with head injury. Received: 14 May 1998     

Late MRI after head injury in children: relationship to clinical features and outcome

To characterize the brain pathology in relation to long-term outcome after pediatric head injury, 55 children were studied by magnetic resonance imaging (MRI) at least 3 months after sustaining moderate to severe closed head injury (CHI). Thirty-nine of the patients had abnormal signal intensity consistent with residual brain lesions, including 28 children with lesions involving the frontal lobes. The clinical features of children with frontal lesions, extrafrontal lesions, and diffuse injury were compared. The analysis disclosed that children with frontal lobe lesions were more frequently disabled than children who sustained diffuse injury. Our MRI findings indicate that residual brain lesions are more common after moderate to severe CHI in children than previously thought and that the frontal lobes are most frequently involved. Further investigation is indicated to elucidate whether distinctive cognitive and behavioral sequelae are associated with frontal lobe lesions in children.     

Recovery of educational skills following paediatric traumatic brain injury

Academic success in the classroom is often dependent upon a child's ability in the areas of literacy, such as reading and spelling, and arithmetic. Following traumatic brain injury these skills are often compromised. The present study examined the recovery of educational skills (reading accuracy, reading comprehension, spelling and arithmetic) over 24 months post-injury, in a group of children who had sustained a mild, moderate or severe TBI. Results showed that the severe TBI group exhibited greater deficits on reading comprehension and arithmetic, while the moderate and severe TBI groups performed similarly in the areas of reading accuracy and spelling. Future research is required to further investigate predictors of educational outcome post-TBI.     

Head injuries in children: a chronicle of a quarter of a century

Children aged 0–15 years hospitalized in Geneva for head trauma during the last quarter of a century are reviewed. More than half of the severely injured children were not from Geneva area. New methods of management have been introduced progressively. The cases are divided in four successive time periods and classified according to their pathology. A continuous improvement in mortality is obvious, decreasing from 29.4% to 2.2%, but climbing again to 15.2% in the last period, probably due to more severe pathologies. For the Geneva area the mortality decreased progressively from 10.4/100 000 to 3.5/100 000 annually, due to better organization and management, but also to a drop in the incidence of severe cases from 35.5–13.5/100 000 per year. A decrease in the number of traffic accidents is responsible for this. However, the number of handicapped children has not changed.     

Reduced body cell mass following severe head injury in children: implications for rehabilitation

Statement of purpose: Increased proteolysis, muscle catabolism and altered body composition have been well documented after severe head injury, but the extent of these effects in children, and whether they extend into rehabilitation, have not been studied. This study determined nutritional status and body composition, with particular reference to the body cell mass (BCM), of head injured children at entry into a rehabilitation programme, and compared body composition analysis with anthropometric nutritional assessment. Methods: Nineteen head injured children (nine males, 10 females, mean age 9:1=4:3 years range 1.2-15.1 years) were measured for height, weight and total body potassium (TBK, a measure of body cell mass) on referral to rehabilitation after the acute phase (mean 38.1 days post-injury). Data was compared with expected normative data derived from healthy age and gender matched children. Nutritional status was determined by two separate criteria based on either anthropometric or body composition methods. Results: The mean percentage of expected TBK for height was 84:4=15%, significantly below the clinically acceptable level for body cell mass (90% of expected). Using the anthropometric definition, only 1/19 was undernourished, whereas 12/19 had poor nutritional status using body composition (chi2=7:58, p=0:006). Conclusions: The data revealed a significant depletion in the metabolically active BCM in the presence of normal anthropometry, suggestive of significant muscle wasting. These findings have important pathophysiological and clinical implications in the rehabilitation of children following major head trauma.     

Features of pediatric head injury in Hong Kong

Head injury in children causes special concern in most communities. From 1989 to 1994, 2,785 children younger than 16 years old were admitted to our neurosurgical service because of head injury. Fall from a height was the major cause of head injury leading to admission in infants and children in preschool age groups, whereas traffic-related or bicycle-related accidents were more likely to be the cause of head injury for those aged 11–15 years. In all age groups there was a male preponderance. The overall mortality was 0.6%. Traffic-ralated accidents caused more severe injury and accounted for 67% of all fatalities. For patients under 6 years old, about 40% of head injuries occurred at home. Preventive measures for pediatric head injury in Hong Kong are suggested.     

Outcome in children with severe head injuries

We present a series of 56 children who suffered severe head injuries, with a Glasgow Coma Score (GCS) of less than 8. The cases were classified according to the type of morphologic lesion on computed tomography (CT) scan. Intracranial pressure (ICP) was monitored in all children in this series. A protocol that included artificial ventilation and other measures of treatment for intracranial hypertension was applied. Results were analyzed according to age, type of lesion, and ICP. The usefulness of the ICP recording and of obtaining a correct classification of lesions using the CT scan is emphasized.     

Dexamethasone therapy and cortisol excretion in severe pediatric head injury

Glucocorticoids are used in an attempt to reduce brain edema secondary to head injury. Nevertheless, their usefulness remains uncertain and contradictory. In a randomized study of 24 children with severe head injury, urinary free cortisol was measured by radioimmunoassay. Twelve patients (group 1) received dexamethasone and 12 (group 2) did not. All patients were treated with a standardized regimen. In group 1 there was complete suppression of endogenous cortisol production. In group 2 free cortisol was up to 20-fold higher than under basal conditions and reached maximum values on days 1–3. Since the excretion of cortisol in urine reflects the production rate closely and is not influenced by liver function and barbiturates, the results in group 2 show that the endogenous production of steroids is an adequate reaction to severe head injury. Exogenous glucocorticoids are thus unlikely to have any more beneficial effects than endogenous cortisol.     

Dizziness following head injury: A neuro-otological study

Dizziness is a frequent and debilitating complication of head injury and accounts for increasing numbers of medico-legal claims. A detailed neuro-otological study was carried out from the records of 100 patients with post-traumatic dizziness to explore the neuro-otological basis of their symptoms: 50 patients presenting for medico-legal purposes (group I) and 50 presenting for management of their vestibular symptoms (group II). The two groups showed a similar sex distribution, a similar range of causes of head injury and similar severity of head injury (72 minor, 24 moderate and 4 severe). Of the 100, 88 showed at least one audio-vestibular abnormality on testing. Vertigo of the benign positional paroxysmal type was the commonest vestibular diagnosis in both groups (61/100), and only 8 patients showed central vestibular abnormalities. Fifty-three patients had audiometric abnormalities attributable to the head injury, the commonest of which was a high-tone sensorineural hearing loss. There was no significant difference in the incidence of any of the abnormalities in the medico-legal group (group I) when compared with the symptom management group (group II). The results provide strong evidence for an organic basis to recurring dizziness after head injury, whether or not a claim for compensation is pending, and emphasise the need for specialist neuro-otological investigation if abnormalities are to be identified and managed correctly.     

Electroencephalography in minor head injury in children

EEG and CT scans of 280 cases of minor head injury in children under 15 years of age were studied. Abnormality on initial EEG was shown in 42.5%. Those who lost consciousness had a higher incidence of abnormality than those who did not, and it was higher between 4 and 13 years of age. The sleep state has much influence on the finding. The patients should be awake or in a light sleep stage. The most frequent abnormality was slow waves, seen predominantly in the occipital regions, and which tended to disappear more easily than the paroxysmal ones. The EEGs became or remained normal in 95%, excluding incompletely followed-up cases. There was no case of post-traumatic epilepsy in our series, but 4 cases of post-traumatic early convulsions, in which the EEGs were variable. CT scan disclosed abnormality in 6%.     

Neurobehavioral functional deficits following closed head injury in the neonatal pig

Neurobehavioral deficits in higher cortical systems have not been described previously in a large animal model of diffuse brain injury. Anesthetized 3-5 day old piglets were subjected to either mild (142 rad/s) or moderate (188 rad/s) rapid non-impact axial rotations of the head. Multiple domains of cortical function were evaluated 5 times during the 12 day post-injury period using tests of neurobehavioral function devised for piglets. There were no observed differences in neurobehavioral outcomes between mild injury pigs (N=8) and instrumented shams (N=4). Moderately injured piglets (N=7) had significantly lower interest in exploring their environment and had higher failure rates in visual-based problem solving compared to instrumented shams (N=5) on days 1 and 4 after injury. Neurobehavioral functional deficits correlated with neuropathologic damage in the neonatal pigs after inertial head injury. Injured axons detected by immunohistochemistry (beta-APP) were absent in mild injury and sham piglets, but were observed in moderately injured piglet brains. In summary, we have developed a quantitative battery of neurobehavioral functional assessments for large animals that correlate with neuropathologic axonal damage and may have wide applications in the fields of cardiac resuscitation, stroke, and hypoxic-ischemic brain injury.