The neurological outcome of non-accidental head injury

Purpose: The literature regarding the outcome of non-accidental head injury (NAHI) is scarce and lacks specific detail even though it is generally considered to be poor. The purpose of this study is to review the literature to date and report the neurological outcome of these children in detail.

Methods: A cross-sectional and prospective study of children admitted to hospital with NAHI in Scotland.

Results: Twenty-five children were enrolled and 68% of children were neurologically abnormal at an average follow-up of 59 months. A wide range of abnormalities and outcomes was seen. Speech and language difficulties were present in 64% including autistic spectrum disorder. Cranial nerve abnormalities were present in 20%. Visual deficits and epilepsy compounded learning difficulties in 25% of survivors. Consent for follow-up was more likely to be obtained where the perpetrator was known.

Conclusions: The spectrum and degree of severity of neurological abnormalities in survivors of NAHI is extremely variable, with the majority of these children being moderate or severely abnormal. These children require the support of a multi-disciplinary team in the community. Further study regarding the process of follow-up, where complex medicolegal issues exist, are needed in order to facilitate maximum neurological development.     

The heterogeneity of social outcome following head injury.

This study compares nine different measures of social outcome applied to 56 patients seen 0 to 4 years after head injury. Social outcome was found to be heterogeneous: correlations between the measures and a principal components analysis both indicated that time off work (as a percentage of time since injury) was independent of most other measures of social performance. In the group studied, the best measures of non-work social performance were the Katz Adjustment Scales form 2 (socially expected activity) and Bond's Social Scale, which both showed good agreement between subject and informant ratings. If a single outcome measure is desired (to include work and non-work social performance), the most suitable measure was found to be the Glasgow Outcome Scale, original and extended versions.     

重型颅脑损伤后高血糖与预后的关系

目的探讨重度脑损伤后高血糖反应及与预后的关系。方法对165例重型颅脑损伤患者(GCS≤8分)入院后24 h内测定的空腹血糖值进行回顾性分析,比较高血糖组(血糖值> 6.11 mmol/L)与正常血糖组的GOS良好率和死亡率,同时比较高血糖组中不同GCS的血糖水平。结果高血糖组GOS良好率(21.7 %)低于正常血糖组(35.6 %),而死亡率(43.5 %)高于正常血糖组(26 %);高血糖组中GCS 3~5分组血糖值(12.37±2.27)mmol/L明显高于GCS 6 ~ 8分组(9.0±2.0)mmol/L。以上数据经统计学处理,差异均有显著性(P<0.05)。结论重型颅脑损伤病人早期因应激反应或损伤下丘脑、脑干等因素易出现血糖升高,伤情越重,血糖越高,且严重影响预后,过高血糖是导致伤者死亡的重要因素之一。     

Hyperkinésie volitionnelle following head injury]

A 13-year-old girl was struck by a car while riding her bicycle. She was comatose on her arrival at the hospital. Neurological examination revealed no focal sign except for right oculo-motor palsy. She became alert 15 days after the head injury when she first experienced a coarse tremor-like movement on the right arm. Neurological examination showed persistent oculo-motor palsy on the right side, decreased sensation of pain and touch on the left. There was no pyramidal deficit. Her gait and speech were normal and joint sensation was intact. A coarse tremor of the right arm was induced by volitional movements especially such as maintaining the arm in certain posture. It was not present at rest. Trajectory of finger-to-nose test was fairly well. However, the tremor became worse when the patient kept her finger near the target. Occasionally myoclonic-jerk and movement oppositionniste were mixed. Superficial EMG recordings of the tremor revealed 4 c/s rhythmic reciprocal grouping discharges, alternating flexor and extensor muscles. From these features, the abnormal movement should better be called tremor type of hyperkinésie volitionnelle (HV). The HV subsided spontaneously 4 months later. MRI of T2-weighted image showed high-intensity areas corresponding anatomically to the caudal part of right red nucleus and the right superior cerebellar peduncle just before its decussation. It is widely believed that lesions in cerebellar outflow pathway (i.e. dentate, red nucleus and thalamus) can cause HV.(ABSTRACT TRUNCATED AT 250 WORDS)     

A comparison between electroencephalography and somatosensory evoked potentials for outcome prediction following severe head injury.

The value of somatosensory evoked potentials (SEPs) for the prediction of outcome following severe head injury (HI) is established. The role of the electroencephalogram (EEG) in this setting is uncertain. In this comparative study, SEPs and EEGs were recorded within 3 days of severe HI in 90 patients, and the results related to outcome at 6 months. Patients with an isoelectric EEG or an EEG with repeated isoelectric intervals died. Reactivity of the EEG to external stimulation tended to be associated with favorable outcome. Grading of the EEGs on the basis of frequency composition otherwise provided no prognostic information. The presence of SEP scalp potentials bilaterally predicted favorable outcome, particularly if the central conduction times were normal. Conversely, the absence of one of both scalp potentials was associated with unfavorable outcome. EEGs thus provided useful prognostic information in only a minority of patients. By comparison, SEPs allowed prediction of both favorable and unfavorable outcomes in a much larger number of patients, and were therefore prognostically superior.     

头部创伤后延迟性神经症状恶化：可能是创伤性轴索损伤

We report a patient who presented with neurological deterioration 26 days after a motor vehicle accident. A 25-year-old man crashed a car onto farmland from a height of approximately 3 meters. Neurological deterioration including ataxia and visual disturbance became apparent 26 days after the accident. Brain magnetic resonance imaging did not reveal any abnormality, but brain single photon emission computed tomography showed mild hypoperfusion in the left frontotemporal lobe. An ophthalmic examination revealed no specific abnormality, but visual-evoked potentials revealed prolonged latencies in both eyes. We propose that this neurological deterioration might have resulted from traumatic axonal injury. As such, future studies should examine preventive strategies against delayed deterioration in patients with head trauma.     

Predicting neurological outcome following cardiac arrest

Because a large number of patients will suffer cardiac arrest each year, physicians must place attention on improving care for patients in the post-resuscitative setting. Part of this effort requires setting realistic goals based on patients' potential for recovery. Recovery from cardiac arrest often depends on the extent of anoxic brain injury, and for this reason primary teams consult neurologists to offer insight into potential for awakening from post-arrest coma. In doing so, neurologists inform a decision with legal, social and ethical implications. Though inapplicable without preparation at the time of cardiac arrest, the four principles of medical ethics have a direct impact on decision making during the post-resuscitative period. A review of the literature reveals that physical examination, electrophysiology, radiology, and biochemical markers can prove useful in estimating a patient's chances for neurological recovery from cardiac arrest. These factors most reliably predict poor outcome, but do so with high specificity. However, the role of the neurology consultant must change to include guidance on strategies of neuroprotection. Aggressive efforts directed towards neuroprotection may change predictions for outcomes after cardiac arrest in the future.     

Pathophysiology, treatment and outcome following severe head injury in children.

The pathophysiology and outcome following severe head injury in 85 children are presented. The commonest initial CT diagnosis was of acute brain swelling. This swelling was associated with an increased white matter density on the CT scan which decreased to normal concomitant with recovery and increased ventricular size. CBF measurements in 6 of these patients revealed an increased blood flow despite a decreased CMRO2 and clinical coma. This CT pattern of diffuse swelling is believed to be due to acute cerebrovascular congestion and hyperemia and not to edema. Because of this, all children were treated with endotracheal intubation and controlled hyperventilation as part of the initial management. Mass lesions were uncommon, 20%. ICP was monitored in 40 children. The ICP rose above 20 Torr despite therapy in 80% of children with decerebrate or flaccid coma and in only 20% of children with spontaneous motor function. The ICP was at its highest between the second and fifth day. Aggressive therapy to control the ICP, with barbiturates if necessary, was successful in 80% of the patients. The overall results were useful recovery in 87.5% of the children, 3.5% were left vegetative or severely disabled and 9% died.     

The relation between intracranial pressure and outcome in non-accidental head injury

The aim of this retrospective study was to ascertain whether physiological derangement and potential secondary brain insult from raised intracranial pressure (ICP) or reduced cerebral perfusion pressure (CPP) in non-accidental head injury (NAHI) influences outcome. Any child who had a diagnosis of NAHI and had ICP monitoring or measurements during the acute illness was entered in the study. Seventeen children with an average age 5.1 months (range 1 to 20 months) were identified. Details of the acute encephalopathy, lowest mean arterial blood pressure (MAP), mean of maximum ICP measured, lowest CPP, and neurodevelopmental outcome at follow up were obtained from the hospital case notes. Seshia's (1994) outcome classification scale was used. The lowest CPP was very significantly related to outcome (P=0.0047, tau=-0.544). Mean of maximum ICP did not correlate with outcome. The lowest MAP was significantly related to outcome (P=0.039). It was concluded that the degree of secondary brain insult from reduced CPP influences outcome.     

Impact of early intervention on outcome following mild head injury in adults

BACKGROUND: The impact of mild head injury is variable and determinants of outcome remain poorly understood. Results of previous intervention studies have been mixed. OBJECTIVES: To evaluate the impact on outcome of the provision of information, measured in terms of reported symptoms, cognitive performance, and psychological adjustment three months postinjury. METHODS: 202 adults with mild head injury were studied: 79 were assigned to an intervention group and were assessed one week and three months after injury; 123 were assigned to a non-intervention control group and were seen at three months only. Participants completed measures of preinjury psychological adjustment, concurrent life stresses, post-concussion symptoms, and tests of attention, speed of information processing, and memory. Subjects seen at one week were given an information booklet outlining the symptoms associated with mild head injury and suggested coping strategies. Those seen only at three months after injury did not receive this booklet. RESULTS: Patients in the intervention group who were seen at one week and given the information booklet reported fewer symptoms overall and were significantly less stressed at three months after the injury. CONCLUSIONS: The provision of an information booklet reduces anxiety and reporting of ongoing problems.     

Mania following head injury

ABSTRACT— A case of mania following head injury in an individual with a genetic predisposition to schizophrenia is reported. It is argued that the head injury is probably causative in his case and suggested that head injury should be considered as one of the aetiological factors in secondary mania.     

Relationship between verbal memory and language performance after blunt head injury

The relationship between verbal memory and language functions after head injury was investigated using the California Verbal Learning Test (CVLT) and selected subtests of the Multilingual Aphasia Examination (MAE). Multiple stepwise regression analyses indicated that visual object naming showed the strongest relationship to various verbal memory indices, accounting for significant variance in (1) correct responses for learning trials, (2) intrusion errors during learning trials, (3) intrusion errors after the short delay, (4) percent of original learning recalled during cued recall after the long delay, (5) intrusion errors after the long delay, and (6) false positive recognition errors on the recognition trial. Auditory-verbal comprehension (Token Test) also accounts for significant variance in correct responses during learning trials. Indexing delayed recall performance to original learning provides a measure that is not influenced by language functions. Although initial injury severity (i.e. posttraumatic amnesia length) is related to CVLT indices, this variable does not explain all the common variance between CVLT and MAE measures. Implications for assessment and research are discussed.     

Relationship between WAIS-R subtests and language measures after blunt head injury

Abstract

The relationship between language performance (Multilingual Aphasia Exam: MAE) and WAIS-R subtests was examined in 79 head-injured patients using multiple stepwise regression analyses. As expected, WAIS-R Verbal subtests are more highly correlated with basic language skills than are WAIS-R Performance subtests. The Verbal subtests demonstrated significant relationships with the Visual Naming, Controlled Oral Word Association, and Sentence Repetition subtests of the MAE. Most Verbal subtests were more strongly correlated with MAE Visual Naming; however, Digit Span and Arithmetic were more strongly related to MAE Sentence Repetition. WAIS-R Performance subtests also correlated with MAE subtests, primarily the Token Test and Controlled Oral Word Association. In general, premorbid education was not a significant factor in these correlations. Although severity of injury did not impact correlations between language measures and Verbal subtests, it was a factor in the correlations with some Performance subtests. Results argue that WAIS-R profiles of head-injured persons can be interpreted most accurately when knowledge of more basic language skills is available.     

Intracranial blood flow velocity after head injury: relationship to severity of injury, time, neurological status and outcome.

Middle cerebral artery (MCA) blood flow velocity was measured daily by transcranial Doppler ultrasonography in 121 patients with severe (50), moderate (16) and minor (55) head injury during their hospital stay, and the results compared with findings in control subjects. Admission MCA velocity was significantly lower after severe 35.8 (31.9-39.7) cm/s, mean (95% confidence limits), moderate 45.5 (40.0-51.0) cm/s and minor 51.7 (47.9-55.5) cm/s head injury when compared with normal controls 60.1 (56.9-63.3) cm/s. Initial mean velocity in severe head injury was significantly lower than in moderate and minor injury. At discharge, MCA velocity in severe injury remained below normal 46.2 (43.2-49.0) cm/s, whereas, in moderate and minor injury flow velocity had returned to normal. Correlation (r = 0.46, p less than 0.01) was found between MCA velocity and Glasgow Coma Score (GCS) on admission but not on discharge. Persistently low flow velocity was found in all 10 patients who died within 72 hours (early deaths). An admission MCA velocity of less than 28 cm/s correctly predicted 80% of the early deaths. Patients who made a good recovery or had only moderate disability at six months showed a significant increase in velocity from admission 36.2 (31.5-41.2) cm/s to discharge 47.8 (43.7-51.9) cm/s in contrast to those who were severely disabled, in whom velocity generally remained low.     

The relationship between sponsorship and rehabilitation outcome following spinal cord injury

The effect of sources of support on rehabilitation outcomes of 866 patients treated at the University of Alabama at Birmingham Spinal Cord Injury Care System since 1973 was assessed using multiple linear and logistic regression. System admission was delayed for Medicaid beneficiaries, while patients who were responsible for at least a portion of their incurred charges were admitted sooner than other patients. Increased lengths of stay were noted among vocational rehabilitation clients and patients with either Workers' Compensation or private insurance coverage. Patients with Workers' Compensation also had significantly higher average hospital charges. Medicaid patients were more likely to be rehospitalised after discharge from rehabilitation. Vocational rehabilitation clients averaged fewer days in nursing homes after injury while Medicaid and Medicare patients experienced longer stays in nursing homes. We conclude that source of support has a significant impact on numerous measures of outcome.     

Paroxysmal choreoathetosis following head injury

A 33-year-old man developed paroxysmal choreoathetosis following a severe head injury. Phenobarbital therapy was promptly effective. The family history as well as physical examinations and laboratory studies were unremarkable.     

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.     

中间高血糖与急性脑血管病的关系

目的 探讨中间高血糖与急性脑血管病的关系.方法 以365例急性脑血管病住院患者为研究对象,检测其空腹血糖、随机血糖和血脂.非糖尿病患者于发病一周后进行葡萄糖耐量试验(OGTT).按糖代谢状况分为正常糖耐量组、中间高血糖组[包括空腹血糖受损(IFG),糖耐量受损(IGT),IFG合并IGT]及糖尿病组三组,比较各组间动脉粥样硬化危险因素发生率、疾病严重程度及B超发现颈动脉粥样硬化的差异.结果 本组资料中IFG、IGT及IFG合并lGT的发生率分别为1.37%、24.66%和3.01%.糖尿病组与正常糖耐量组高血压发病率差异有统计学意义(P=0.007),而正常糖耐量组与中间高血糖组、糖尿病组与中间高血糖组比较,高血压发病率差异无统计学意义(P>0.05).各组间吸烟率、饮酒率、血脂异常率、疾病严重程度及B超发现动脉粥样硬化率差异无统计学意义(P>0.05).结论 中间高血糖是急性脑血管病患者普遍存在的问题,其与动脉粥样硬化其他危险因索共同作用导致发病.