Prognosis in children with head injury: an analysis of 340 patients

BACKGROUND: The outcome in children with head injury is distinctive because of the different biophysical properties of the child's skull and brain, and their reaction to injury. METHODS: In this retrospective study of three hundred and forty children with head injury, managed from January 1993 to December 1998, at NIMHANS, the factors influencing outcome were analyzed. RESULTS: On admission there were 40 children in GCS 3-5, 55 children in GCS 6-8, 96 in GCS 9-12 and 152 children in GCS 13-15. Eleven patients were under 2 years of age, 53 were between 3-5 years, 140 were between 6-10 years and 156 were between 11-15 years of age. The prognosis in various intracranial pathologies due to head injury was evaluated and outcome assessed at discharge. There were 95 children with EDH and 8.4% had poor outcome (vegetative state or death). There were 85 patients with contusion and poor outcome was noted in 18.8%. One hundred patients had diffuse cerebral oedema on CT scan and outcome was poor in 25% of these patients. The clinical features associated with poor prognosis were, absence of ocular movements (50%), abnormal pupillary size and reaction (49%) and age less than 2 years (27%).     

Adult stem cell therapy for acute brain injury in children

Adult stem cell therapy has been proposed for brain injury in young children. While there have been no clinical trials in the US, the therapy is widely advertised and anecdotally reported in multiple internet sources, leading families to seek the treatment in uncontrolled circumstances. The purpose of this review is to present a discussion of the various types of stem cell preparations, with emphasis on adult stem cells, the scientific basis of their development, and the available experimental evidence for their utility in childhood brain injury. We will also provide background information on the biologic events occurring in injured immature brain, as they relate to the transplantation of stem cells. We will then review our own data from neonatal rodent studies with experimental hypoxic-ischemic brain injury. We have shown that early intracerebral administration promotes improved behavioral outcome in the animals, the formation of new neurons, and the preservation of intrinsic cells. New experiments demonstrate the equality of intracerebral and intravenous transplantation in acute neonatal hypoxic-ischemic injury in rodent. We will speculate on the possible clinical uses of adult stem cells. Our current impression is that the cells have the greatest potential for success when administered soon after an injury. What needs to be done to further the field? The different types of cell preparations should be tested against each other in experimental situations. A suitable model of chronic brain injury should be utilized for evaluating the benefit of the cells for this purpose. Long term safety of the cells should be confirmed in animal models. Finally, multicenter clinical trials should be conducted in highly controlled protocols.     

Early post-traumatic seizures in children with head injury

Post-traumatic seizures (PTS) can be a serious complication of head injury, because they can cause secondary brain damage through increased metabolic requirements, raised intracranial pressure, cerebral hypoxia, and/or excessive release of neurotransmitters. In children, early PTS are more frequent than late ones. In this retrospective study we conducted an epidemiological analysis and tried to identify potential risk factors for the onset of early PTS in children hospitalized for head injury in our Paediatric Intensive Care Unit. The severity of injury was assessed using the Glasgow Coma Scale (GCS), while the outcome of traumatized children was defined using the Glasgow Outcome Score (GOS). Early PTS were diagnosed in 15 out of the 125 children hospitalized (12%). Most of the children (73.3%), developed seizures within 24 h of the trauma (immediate PTS). Among the risk factors, a very important role was played by the severity of the injury; in fact, the incidence of early PTS among patients with GCS≤8 was ten times greater than that among children with GCS 13–15. Other risk factors that significantly influenced the onset of early PTS, were age (60% of children with early PTS were less than 3 years old) and severe cerebral edema. Overall, children with early PTS had a worse outcome than the other patients. In fact, 53% had a GOS of ≤3 compared to 19.1% of those without early PTS (P<001). In particular, considering children with severe head injury, 80% of those with early PTS had a GOS of ≤ 3, compared to 41% of those without early PTS (P<0.05). In conclusion, PTS can be a serious complication of head injury in children, because they can worsen secondary brain damage. Appropriate management of head-trauma patients must include suitable and immediate prophylaxis with anti-epileptic drugs. Received: 27 April 2000 Revised: 7 June 2000     

Long-term sequelae of brain damage from closed head injury in children and adolescents

A study was made of the sequelae of brain damage in young patients. Seventy patients between 4 and 18 years, admitted under the diagnosis “diffuse brain contusion”, have been followed at least two years after head injury. The degree of function impairment in the fields of motor skills, cognition and behaviour was recorded. It was found that many patients with neurologically little or no function loss, nevertheless after the accident did suffer from psychosocial problems in the realm of family life, school or profession. Based on these findings, the authors recommend a consequent and systematic follow up of patients if they have been in coma for more than 1 hour, the objective being the early assessment of such dysfunctions, followed by adequate assistence.     

Brain lesion correlates of fatigue in individuals with traumatic brain injury

ABSTRACT

The purpose of this study was to investigate the neurological correlates of both subjective fatigue as well as objective fatigability in individuals with traumatic brain injury (TBI). The study has a cross-sectional design. Participants (N?=?53) with TBI (77% male, mean age at injury 38 years, mean time since injury 1.8 years) underwent a structural magnetic resonance imaging (MRI) scan and completed the Fatigue Severity Scale (FSS), while a subsample (N?=?36) was also tested with a vigilance task. While subjective fatigue (FSS) was not related to measures of brain lesions, multilevel analyses showed that a change in the participants’ decision time was significantly predicted by grey matter (GM) lesions in the right frontal lobe. The time-dependent development of the participants’ error rate was predicted by total brain white matter (WM) lesion volumes, as well as right temporal GM and WM lesion volumes. These findings could be explained by decreased functional connectivity of attentional networks, which results in accelerated exhaustion during cognitive task performance. The disparate nature of objectively measurable fatigability on the one hand and the subjective experience of fatigue on the other needs further investigation.     

神经干细胞在创伤性脑损伤灶周边的成活和迁移*

背景：成年人中枢神经系统再生困难,颅脑损伤后,损伤灶周边区域神经细胞的存活数量直接影响患者的预后。如何有效地使移植入创伤性脑损伤灶周边的神经干细胞存活分化,是目前神经修复再生研究的重点。 目的：探讨神经干细胞移植入大鼠创伤性脑损伤灶周边的成活、迁移和分化情况。 方法：利用无血清培养技术,加入表皮生长因子、碱性成纤维生长因子诱导刺激大鼠胚胎源性前脑神经干细胞生长增殖,并在体外进行克隆培养,移植前行BrdU标记,采用免疫组化和免疫荧光法检测其增殖特性和多向分化潜能,并观察其移植到Fenney’s落体脑损伤模型鼠脑皮质内的成活和迁移情况。 结果与结论：免疫组化及免疫荧光检测结果显示克隆细胞球呈nestin和BrdU阳性,分化后呈NSE,GFAP,MAP-2阳性。免疫组化及荧光双标检测结果显示移植后7,14 d损伤灶周边散在BrdU阳性细胞,并且GFAP阳性细胞增多。提示前脑神经干细胞在体外培养中能够增殖,并分化为神经元和神经胶质细胞,移植后能够在创伤性脑损伤灶周边存活和迁移,形态上显示出与脑组织整合的特点。     

Cerebral blood flow and brain stem lesion

Summary In 11 necropsy cases with prolonged states of unresponsiveness (apallic syndrome) of various origin (8 cases following closed head injuries, one patient with postmeningitic phlebothrombosis and 2 postanoxic encephalopathies) the decrease of cerebral blood flow (CBF) was correlated to the extent and pattern of the anatomical lesions. Arranging the patients according to the severity and pattern of brain stem damage and according to the CBF values a Spearman rank correlation resulted in a highly significant relationship between these two parameters. By contrast, the extent of damage to the telencephalon and basal ganglia did not correlate to the CBF reduction in these cases. One patient with extensive neocortical destruction without damage to the brain stem had moderately decreased CBF.The data indicate that CBF reduction may result from both extensive destruction of the cerebral pallium and from states in which the cerebral cortex is out of function due to damage at lower levels. The importance of the reticular formation in the brain stem for the function and perfusion of the cerebral cortex is stressed.

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Zusammenfassung An 11 Autopsiefällen mit protrahierten Bewußtseinsstörungen (apallisches Syndrom) verschiedener Genese (8 Zustände nach gedecktem Schädel-Hirn-Trauma, 1 Patient mit postmeningitischer Sinusthrombose und 2 post-anoxische Encephalopathien) wurde die Reduktion der Hirndurchblutung (HDB) mit der Ausdehnung und Lokalisation der anatomischen Hirnschäden korreliert. Unter Anordnung der Patienten jeweils nach der Schwere und Ausdehnung der Hirnstammläsionen sowie nach den HDB-Werten wurde eine Rang-Korrelation nach Spearman durchgeführt, die eine hochsignifikante Korrelation zwischen diesen beiden Parametern ergab. Hingegen zeigten diese Fälle keine Beziehungen zwischen Schwere bzw. Ausdehnung der Läsionen in Telencephalon und Stammganglien und der HDB-Reduktion. Ein Patient mit ausgedehnter postanoxischer Zerstörung des Neocortex ohne Hirnstammläsionen bot eine mäßiggradige HDB-Reduktion.Die erhobenen Befunde weisen darauf hin, daß eine Reduktion der Hirndurchblutung sowohl durch ausgedehnte Schädigung des Hirnmantels als auch durch Funktionsausfall der Großhirnrinde infolge von Schädigungen auf tieferen Ebenen bedingt sein kann. Die Bedeutung der Formatio reticularis des Hirnstammes für die Funktion und Durchblutung der Hirnrinde wird hervorgehoben.

     

Management and classification of children with head injury

Background Traumatic brain injury is the most common cause of morbidity and mortality during childhood.Aim This study was conducted to describe the primary management and classification of children admitted to the emergency department for head trauma.Series All children (0–15 years) with a history of head injury who were admitted to the outpatient emergency department at a single paediatric trauma centre in the Stockholm region during 1 month were included.Results There were 242 children (137 girls and 105 boys; mean age 5.3±4.4 years) who fulfilled the inclusion criteria. Based on the Scandinavian Head Injury Classification, 73% were classified as minimal, 17% mild and 2% moderate head injury. This classification seemed to be more accurately reflective than the ICD-10-based classification in the management of the children with head trauma.     

Brain stem lesions after head injury

There is little knowledge on the morphology of the brain stem in survivors of head injury, as CT fails to shown brain stem lesions, and neuropathological data is only available from autopsies. As magnetic resonance imaging (MRI) sheds new light on morphological lesions of the brain, the authors investigated 100 patients with a severe head injury. MRI was performed in a prospective study within the first seven days after head injury while the patients were still in coma and on ventilation. Relating the location of the lesions as depicted by MRI with the initial CT scan and outcome, death appeared to be closely linked to the phenomenon of bilateral pontine lesions. The extent of supratentorial lesions had no bearing on survival at all in the absence of brain stem lesions. Altogether the brain stem was affected in 52%. Obviously the occurrence of bilateral upper pontine lesions is of highest predictive value for a fatal outcome. Severe destruction of supratentorial white matter as demonstrated by MRI is not related to increased mortality, as long as the brain stem is spared.     

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.     

老年人重型颅脑外伤预后分析(附73例报道)

目的分析老年重型颅脑外伤患者的临床资料，总结影响老年人重型颅脑外伤预后的因素。方法回顾性分析73例急性重型颅脑外伤老年患者的临床资料，比较生存组及死亡组中各种因素的构成比，确定其对预后的影响。统计方法使用t检验、X^2检验及Logistic回归分析。结果本组生存30例，其中恢复良好5例，轻中残9例，重残13例，植物生存3例；死亡43例，死亡率为58．9％。结论老年重型颅脑外伤（TBI）患者死亡率高，预后差。年龄是影响预后的独立因素；GCS评分、瞳孔对光反射、原发性昏迷时间等指标是判断预后的重要因素。     

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.     

Brainstem lesions in children with perinatal brain injury

Several distributive patterns of hypoxic-ischemic cerebral injury have been recognized in asphyxiated newborns. Lesions of the brainstem have been rarely noted on magnetic resonance images in previous reports because they are difficult to detect. In this study, we demonstrate subtle but definite uniform symmetric brainstem lesions in children with perinatal brain injury. The areas of abnormal intensity were judged to comprise the central tegmental tract. The clinical manifestations in our patients were less severe than those previously described in patients with brainstem lesions. Two patients had difficulty of eye movement, but otherwise had no significant symptoms of brainstem cranial nerve nuclei involvement. All patients had lesions of white matter or cortex. Therefore, the abnormality in the dorsal brainstem revealed by magnetic resonance images is possibly as a result of secondary degeneration of the neurons that send axons into that tract.     

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%.     

Traumatic brain injury in children

We investigated the prognosis of 42 children with traumatic brain injuries. The main etiology was a traffic accident in 46 cases, especially during walking and bicycling, and child abuse in 7 cases. Eighteen cases of acute subdural hematoma 18 cases distributed at all ages, 9 cases of diffuse axonal injury mainly during school age, 4 cases of chronic subdural hematoma under 2 years. These were all caused by child abuse. Fifteen cases showed a good prognosis with independent activities of daily living (ADL). The main type of injury was diffuse axonal injury in this group. Twelve cases showed a bad prognosis with completely dependent ADL. The bad prognostic factors were chronic subdural hematoma caused by child abuse, consciousness loss with Glasgow Coma Scale less than 8 or lasting more than 2 weeks. After rehabilitation in our hospital, 37 cases returned to school: an ordinary class in 20 cases, a special class in an ordinary school in 5 cases and a special class in 12 cases. About half of the cases returned to an ordinary class, although with problems such as learning difficulty, danger and bullying.