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.     

Rhythmic coma in children

We describe a syndrome of rhythmic coma in children that consists of an invariant, nonreactive, diffuse cortical activity of a specific frequency, such as alpha, beta, spindle, or theta, recorded from a comatose child. We report 11 cases of children who were found to be in rhythmic coma during their acute illnesses. Their ages ranged from 2 to 15 years, and their diagnoses included encephalitis, head trauma, seizures, near drowning, brain tumors, stroke, and metabolic derangements. The specific frequency of the electroencephalographic pattern, ie, alpha, beta, spindle, or theta, did not influence the outcome. The clinical outcome appeared to depend on the primary disease process rather than the electroencephalographic finding. The prognosis of alpha-frequency rhythmic coma as well as of rhythmic coma in general was better in children than in adults. The pathophysiology in children may be similar, ie, the interruption of reticulothalamocortical pathways by metabolic or structural abnormalities, but the expression of this deafferentation may be more varied in the developing brain. Thus, we propose the term rhythmic coma as a unified concept for alpha, beta, spindle, and theta coma in children.     

Comparison of tic characteristics between children and adults

There are limited data about clinical characteristics of tics in adults. We performed a video and chart retrospective longitudinal review of patients diagnosed with tics from a tertiary referral medical center to compare tic characteristics between adults and children. Tic severity in 40 children and 31 adults was assessed using the modified Rush videotape rating scale and the Yale global tic severity scale (YGTSS). Baseline tic severity scores were similar in adults when compared with children (P = 0.11). In follow‐up visits, compared to baseline total YGTSS scores were significantly reduced in both children (P < 0.003) and adults (P < 0.0009), but children were less frequently treated with medications for tics (P = 0.004) when compared with adults. Tic phenomenology and severity were similar between children and adults, but pharmacological tic management was different, perhaps reflecting a practice trend to avoid medications in children. © 2008 Movement Disorder Society     

Which EEG patterns in coma are nonconvulsive status epilepticus?

Nonconvulsive status epilepticus (NCSE) is common in patients with coma with a prevalence between 5% and 48%. Patients in deep coma may exhibit epileptiform EEG patterns, such as generalized periodic spikes, and there is an ongoing debate about the relationship of these patterns and NCSE. The purposes of this review are (i) to discuss the various EEG patterns found in coma, its fluctuations, and transitions and (ii) to propose modified criteria for NCSE in coma.Classical coma patterns such as diffuse polymorphic delta activity, spindle coma, alpha/theta coma, low output voltage, or burst suppression do not reflect NCSE. Any ictal patterns with a typical spatiotemporal evolution or epileptiform discharges faster than 2.5 Hz in a comatose patient reflect nonconvulsive seizures or NCSE and should be treated. Generalized periodic diacharges or lateralized periodic discharges (GPDs/LPDs) with a frequency of less than 2.5 Hz or rhythmic discharges (RDs) faster than 0.5 Hz are the borderland of NCSE in coma. In these cases, at least one of the additional criteria is needed to diagnose NCSE (a) subtle clinical ictal phenomena, (b) typical spatiotemporal evolution, or (c) response to antiepileptic drug treatment. There is currently no consensus about how long these patterns must be present to qualify for NCSE, and the distinction from nonconvulsive seizures in patients with critical illness or in comatose patients seems arbitrary.The Salzburg Consensus Criteria for NCSE [1] have been modified according to the Standardized Terminology of the American Clinical Neurophysiology Society [2] and validated in three different cohorts, with a sensitivity of 97.2%, a specificity of 95.9%, and a diagnostic accuracy of 96.3% in patients with clinical signs of NCSE. Their diagnostic utility in different cohorts with patients in deep coma has to be studied in the future.This article is part of a Special Issue entitled “Status Epilepticus”.     

Cerebellar haematomas caused by angiomas in children

Spontaneous cerebellar haematomas in previously well children are most often caused by haemorrhage from small angiomas. Eight such cases in children 12 years of age or younger have been reported previously. Their clinical course was usually not as acute as the course most commonly seen in adults, and four of the children survived after evacuation of the haematoma. Two additional cases are presented. Both children were admitted in a comatose state, but survived after surgical intervention. Cerebellar haematomas in children seem to have a better prognosis than in adults and should be considered in the evaluation of children with subarachnoid haemorrhage or the rapid onset of coma. Even if admitted in extremis, recovery is possible after prompt diagnosis and surgical evacuation of the haematoma.     

Herpetic encephalitis: prognostic elements in adults and children (49 cases)

In 49 cases (26 children, 23 adults) of proven Herpes simplex encephalitis, the authors studied the influence of age, disturbances of consciousness, time of diagnosis and therapy on patients' outcome, as well as the prognostic value of EEG data. Mortality was low in late childhood and young adulthood in spite of the constancy and depth of coma; it was very high in newborns and adults over 40 years of age and it was always correlated with the severeness of initial consciousness disturbances. The onset of periodic complexes (in 65% of the children and 78% of adults on the first EEG) does not systematically imply a poor outcome. Correlations between these EEG patterns and bioptic or surgical data tend to prove that these periodic complexes are already present in a prenecrotic state. Reversibility may be complete. On the other hand, the association between a contralateral focus or diffusion of initial abnormalities and an early coma imply a poor prognosis (12 deaths and 2 major sequellae in 14 cases). The importance of early presumptive diagnosis and therapeutical onset is stressed. The only cases of complete recovery are found among young adults treated early (surgery for older cases) thanks to an initial typical EEG. In young children, first clinical symptoms are often not evocative. Great importance should be attached to the onset of partial seizures and interictal loss of consciousness in a feverish child (24 out of 26 cases). Antiviral therapy should be started as soon as a Herpes simplex encephalitis is suspected, since the new antiviral drugs have a relatively low toxicity and do not interfere with the immunological diagnosis.     

Rates of apparently abnormal MMPI-2 profiles in the normal population

MMPI-2 standardization data were re-sampled using Monte Carlo simulations to estimate the base rate of apparently abnormal scores expected by chance in the normal population when multiple scales are interpreted. 36.8% of normal adults are likely to obtain a score that would otherwise be considered clinically significant at 65T on one or more of the 10 Clinical scales. The normal incidence of at least one apparently abnormal score was 38.3% on the Content and 55.1% on the Supplementary scales. When the Clinical, Supplementary, and Content scales and subscales are interpreted together, at least three seemingly meaningful scores will be found in 47.4% of perfectly normal individuals, and five or more scales that appear to be clinically significant can be expected in 30.1% of cases that are actually unremarkable. These results imply that the number of MMPI-2 scales that can be meaningfully interpreted in clinical practice is limited, and that high T-scores are necessary for an adequate level of confidence even when interpretation is appropriately limited to the Clinical scales.     

Predictive value of electrophysiology in children with hypoxic coma

Assessment of prognosis of children in hypoxic coma is difficult. The value of clinical evaluation is often limited. The usefulness of electrophysiologic tests has been documented mostly in adults and neonates and in cases of traumatic coma. We reviewed retrospectively 39 consecutive children with nontraumatic hypoxic coma to assess the prognostic value of EEG, visual, and auditory evoked potentials. Correlation between electrophysiology and neurologic outcome after mean follow-up period of 30 months was significant (r(s) = 0.6, P < 0.001). In contrast there was no correlation between Pediatric Risk of Mortality score (PRISM) and outcome (r(s) = -0.42, P = 0.8). Combining magnetic resonance imaging with electrophysiology further enhanced their prognostic value (r(s) = 0.69, P < 0.001). Neuroimaging was highly sensitive but less specific, and electrophysiologic tests were highly specific but less sensitive. We conclude that early electrophysiology can contribute to predicting outcome in pediatric hypoxic coma.     

A reappraisal of rhythmic coma patterns in children

OBJECTIVE: This study was designed to determine the prevalence of rhythmic coma patterns in comatose children and to ascertain the prognostic significance of reactive rhythmic coma patterns. METHODS: We retrospectively analyzed and classified electroencephalogram (EEGs) in comatose children between two months and 18 years of age during the period 1996 - 2003 according to modified Young's classification. Outcome at one-year was scored according to the Paediatric Cerebral and Overall Performance Category Scale. Outcomes were compared using Fisher's exact test and Mann-Whitney test. RESULTS: Analysis of 63 electroencephalogram (EEG) records in 38 patients showed rhythmic patterns in 19 records (30.2%; 9 alpha, 4 spindle, 4 theta and 2 beta coma patterns, total number of children = 14). Aetiology and outcome of alpha coma patterns and other rhythmic coma patterns were similar. In five children, one type of rhythmic pattern changed to another. Records with reactive rhythmic coma 66.7% (6/9), were associated with favourable outcome. Sixty percent of the records (6/10 records in seven children) with non-reactive pattern were associated with unfavourable outcome. This clinically significant difference did not reach statistical significance (lower Paediatric Cerebral and Overall Performance Category Scale score p= 0.14; favourable outcome p=0. 19). CONCLUSION: Rhythmic coma patterns in comatose children are not uncommon. Aetiology, reactivity and outcome of individual patterns are similar and thus make the rhythmic coma patterns distinct EEG signatures in comatose children. There was a clinically significant better outcome with reactive rhythmic coma patterns.     

ASSESSMENT OF POST-TRAUMATIC AMNESIA IN YOUNG CHILDREN

To assess the duration of post-traumatic amnesia (PTA) in children, a new procedure is described, derived from a method described previously for adults. The procedure was tested on 70 healthy children between 3.5 and 10 years of age, then applied in a longitudinal prospective study of 54 children with brain damage resulting from closed head-injury. The procedure consistently measured PTA in children of various ages. The duration of PTA was found to be as good a prognostic indicator for the occurrence of long-term residual sequelae as is duration of coma.     

Rates of Apparently Abnormal MMPI-2 Profiles in the Normal Population

MMPI-2 standardization data were re-sampled using Monte Carlo simulations to estimate the base rate of apparently abnormal scores expected by chance in the normal population when multiple scales are interpreted. 36.8% of normal adults are likely to obtain a score that would otherwise be considered clinically significant at 65T on one or more of the 10 Clinical scales. The normal incidence of at least one apparently abnormal score was 38.3% on the Content and 55.1% on the Supplementary scales. When the Clinical, Supplementary, and Content scales and subscales are interpreted together, at least three seemingly meaningful scores will be found in 47.4% of perfectly normal individuals, and five or more scales that appear to be clinically significant can be expected in 30.1% of cases that are actually unremarkable. These results imply that the number of MMPI-2 scales that can be meaningfully interpreted in clinical practice is limited, and that high T-scores are necessary for an adequate level of confidence even when interpretation is appropriately limited to the Clinical scales.     

A comparison of measures for assessing the level and nature of intelligence in verbal children and adults with autism spectrum disorder

Previous work has suggested that the Raven's Progressive Matrices (RPM) are better suited for capturing the nature of intelligence for individuals with autism spectrum disorder (ASD) than the Wechsler scales. The RPM measures ‘fluid intelligence’, an area for which it has been argued that persons with ASD have a relative strength. Given that measures of intelligence are used for establishing clinical diagnoses, for making educational decisions, and for group-matching in research studies, continued examination of this contention is warranted. In the current study, verbal children with ASD performed moderately better on the RPM than on the Wechsler scales; children without ASD received higher percentile scores on the Wechsler than on the RPM. Adults with and without ASD received higher percentile scores on the Wechsler than the RPM. Results suggest that the RPM and Wechsler scales measure different aspects of cognitive abilities in verbal individuals with ASD. For the verbal children and adults with ASD in the current study, the RPM and Wechsler scales have unique contributions that must be considered in context when establishing a baseline of cognitive function. The results of this investigation highlight the importance of thoughtfully selecting appropriate measures of intelligence consistent with clinical, educational, and research purposes, especially for verbal children and adults with ASD.     

A comparison of clinical and radiological findings in adults and children with Japanese encephalitis

BACKGROUND: Japanese encephalitis (JE) is the most common human endemic encephalitis, prevalent mainly in Southeast Asia. It affects both adults and children in different areas, but there is no comparative study of their clinical features and outcomes. OBJECTIVE: To evaluate clinical and radiological features in adults and children with JE. METHODS: Patients with serologically or virologically confirmed JE who were treated during the past 10 years were included in this study. All patients underwent a detailed neurological examination, computed tomography, or magnetic resonance imaging. The presence of movement disorders, anterior horn cell involvement, and electroencephalographic changes was noted. After 6 months, each patient's outcome was defined as poor, partial, or complete recovery. The clinical and radiological findings for both adults and children were compared using chi2 tests. RESULTS: The results are based on 30 children and 37 adults. Seizure was present in 23 adults (62.2%) and in 17 children (56.7%). Three children had associated neurocysticercosis, and all of them had partial seizures. The occurrence of focal neurological deficit, anterior horn cell involvement, and parkinsonian features was not significantly different between adults and children. Dystonia was more common in children, occurring in 20 (66.7%) compared with 7 adults (18.9%). Six adults died, but none of the children did; however, the 6-month outcome was better for surviving adults compared with the children. Computed tomography and magnetic resonance imaging findings were not significantly different between the 2 groups. CONCLUSIONS: Children with JE are more likely to have dystonia and a poor outcome at 6 months compared with adults. The difference in clinical findings and outcome in children and adults with JE may be owing to immunological factors, maturation of the central nervous system, and neuronal plasticity.     

基于卒中登记的缺血性卒中亚型分布及危险因素分析

目的 了解徐州地区缺血性卒中OCSP临床分型及M-TOAST病因分型及其相关危险因素,为该地区缺血性卒中的治疗及预防提供参考依据.方法 运用卒中注册软件,采用前瞻性单中心登记方法,登记566例缺血性卒中患者的临床资料,研究缺血性卒中的亚型分布,并以卒中登记中96例出血性卒中患者为对照,研究缺血性卒中的相关危险因素.结果 566例缺血性卒中患者中,脑梗死505例,TIA61例.部分前循环是最多见的缺血性卒中亚型,共243 例（48.12%）.脑梗死病因学分型M-TOAST分型中,动脉粥样硬化性血栓形成（AT）最多,共248例（49.11%）.高血压、吸烟、饮酒、高同型半胱氨酸是缺血性卒中最常见的危险因素.相对于出血性卒中,与缺血性卒中关系更为密切的是房颤、高同型半胱氨酸（OR=3.854,2.922）.结论 本研究中缺血性卒中OCSP分型中部分前循环梗死最多见,其病因学分型动脉粥样硬化性血栓形成 （AT）最多.相对出血性卒中,与缺血性卒中密切相关的是房颤、高同型半胱氨酸.     

儿童烟雾病与成人烟雾病79例临床及影像学分析

目的 分析并总结儿童烟雾病与成人烟雾病的临床及影像表现的差异.方法 对回顾性分析79例烟雾病患者的临床资料,儿童30例,成人49例,对其临床症状和影像特征进行对照研究.结果 儿童组首次发病以缺血性脑血管病表现为主,显著高于成人组（P＜0.05）,成人组首次发病以出血性脑血管病表现为主,显著高于儿童组（P＜0.05）.结论 儿童烟雾病与成人烟雾病的临床症状和影像表现具有差异,临床接诊应区别对待.     

Enjeux actuels de l’évaluation psychologique dans la clinique de l’enfant et de l’adolescent : vers une approche intégrée de la psychopathologie

This article will discuss different theoretical approaches and methods of data collection in view of the psychological assessment of children and adolescents. There are generally two different approaches; one being the single case study using a subjective method and the second consisting of clinical interviews and psychological tests using the objective method. In our opinion, psychological assessments should rely on two main axes. The first should be based on an updated knowledge of psychopathology, integrating new models and scientific findings with the methodology of Evidence Based Medicine (EBM). The second axis should be concerned with the psychological assessment combining subjective and objective methods. For example, the use of standardized tools such as scales or projective tests is essential to understand the interaction between multiple clinical variables influencing child psychopathology as well as to understand family and social interactions. The diversity of risk factors (e.g. family, personality, social, biological factors, etc.), implicated in mental illness shows the multi-dimensional aspects of psychopathology. Different theoretical approaches have been developed to study psycho-pathological mechanisms (neuro-psychology, psychoanalysis, biological psychiatry approaches, etc.). Therefore an integrative approach of psychopathology using different models and factors is needed to understand psychiatric disorders. A thorough psychological assessment is essential to the comprehension of mental illness in children and adolescents and is the first step to tailor treatments to individual needs. In order to answer these objectives, psychological assessments must be multi-modal, multi-disciplinary and multi-source: - Multi-disciplinary: For a better clinical assessment, psychologists and psychiatrists will need information from other professionals such as speech therapists, psychomotor therapists, neurologists… - Multi-modal: This aspect is crucial in clinical assessment. It characterizes all tools that clinicians will use in their assessment practice: Psychological tests, clinical interviews or clinical scales. - Multi-source: A comprehensive assessment of child and adolescent psychopathology includes assessments of different informants and sources (family, teachers…). These different approaches will be discussed in the perspective of the actual stakes of psychological assessment in children and adolescents. Developing integrative assessment approaches seems to be a promising field for the future in mental health services, allowing the tailoring of specific therapeutics for each child.     

Aspects of sleep disorders in children and adolescents

Sleep disorders in children and adolescents is a topic that has been, and remains, neglected in both public health education and professional training. Although much knowledge has been accumulated in recent times, it has been poorly disseminated and, therefore, relatively little is put into practice. Only some general issues can be discussed in this article. The aspects chosen relate mainly to clinical practice, but they also have relevance for research. They concern various differences between sleep disorders in children and those in adults, the occurrence of such disorders in young people, their effects on psychological and physical development, the essential (but often ignored) distinction between sleep problems and their underlying causes (ie, sleep disorders), types of sleep disturbance encountered at different ages during development, and the differential diagnosis of certain parasomnias that are at particular risk of being confused with each other.     

Prediction of outcome in non-traumatic coma in childhood

The data in 104 comatose children were analysed, neonates and those with head injury being excluded. The median age was 30 months, with a range of one month to 17 years. 50% were normal, 32% died and the remainder had handicaps ranging from mild to severe. A number of individual clinical variables related with outcome. Stepwise multivariate discriminate analysis individually classified 75% of 102 cases correctly into one of 5 outcome groups, using clinical information obtained at the time of initial assessment within 12 hours of the onset of coma; 67% of 66 cases could be classified correctly on the basis of information available at 24 hours after the onset of coma. There were, respectively, 8% and 3% serious misclassification errors for the 2 time periods. Our data suggest that the stepwise procedure may be a useful method for the early prediction of outcome in comatose children. Classification errors may be minimized by enlarging the data base, by using alternate statistical methods and by taking into account information from investigative variables, the most promising of which seems to be multimodality evoked potentials.     

Prolonged direct catheter thrombolysis of cerebral venous sinus thrombosis in children: a case series

Cerebral venous sinus thrombosis is a rare condition with potentially devastating neurologic outcome--death and severe disability are common in advanced cases. In adults, protocols for mechanical clot disruption and direct thrombolysis are established; no guidance exists for children. We present our experience of 6 children with cerebral venous sinus thrombosis and ominous clinical progression. We found that effective thrombolysis required substantially longer infusion, more rounds of mechanical disruption, and higher doses of thrombolytics than are commonly practiced. Despite pervasive thrombosis, prethrombolysis hemorrhage, coma, and other predictors of death and disability, our patients survived and 4 of 6 had no functional deficits. One patient had moderate, and one had severe deficits. We report these cases to illustrate that hemorrhage may not be a contraindication to thrombolysis for cerebral venous sinus thrombosis, that prolonged infusion may be required to restore perfusion, and that good neurologic outcomes can be achieved despite dire clinical presentations and extensive sinus thrombosis.