Functional MRI of working memory in paediatric head injury

A case study examining the recovery of a 9 year old boy who sustained a severe head injury is reported. The subject sustained damage to the left parietal-occipital and right frontal-parietal regions. Structural and functional imaging and cognitive data were collected at the time of injury and 1 year post-injury. Cognitive assessment revealed improvement over time. Functional imaging at the time of injury revealed minimal activation in the right posterior temporal region. Imaging 1 year post-injury revealed increased activation in the right pre-frontal cortex, bilateral pre-motor cortex and bilateral posterior parietal cortex. This activation pattern is consistent with the performance of unaffected individuals on working memory tasks. These findings differ from those in the adult literature and suggest an alternative pattern of recovery of function in children.     

Computerized tomography and prognosis in paediatric head injury

Summary The authors have analysed the computerized tomography (CT) findings and their correlation with the clinical state, early and late outcome in children and adolescents with head injuries (HI). This study represents clinical and CT data of 82 consecutive HI patients under 18 years of age. Among them 51 (62%) were boys and 31 (38%) girls. The application of CT to the evaluation of the morphologic manifestations of HI in children has shown some differences in forms and mechanisms of injury and in outcome compared to adults. In the paediatric HI the most frequent finding was diffuse brain swelling with CT evidence of ventricular and cisternal compression or obliteration. Prognostically the most unfavourable findings were shearing injury, intracerebral and subdural haematomas combined with brain swelling and parenchymal damage. According to the Lidcombe impairment scale, outcome from severe paediatric HI was determined in the 3rd and 6th months, one year and 2 years after the injury. The outcome two years after severe HI varied to a great extent and was better in children than in adults. Although there was long-term disruption of the patient's quality of life, our data show that as there are no predictors of individual outcomes in child HI, no child should be excluded from early and long-term rehabilitation.     

Long‐term disability in the local population 2 years after mild head injury: Prospective cohort study

Introduction: More than 4000 patients with mild head injury are managed in public hospitals in Hong Kong every year. It is a common belief that mild head injuries do not result in long‐term disabilities. We aim to: (i) investigate the disability after mild head injury using objective assessment tools; and (ii) analyse risk factors that contribute to these disability. Methods: Patients with a Glasgow Coma Score of 13–15 admitted between January and March 2002 were recruited for study. Their long‐term clinical outcome (2 years after initial injury) was prospectively documented with the Glasgow outcome scale – extended (GOSE). Glasgow outcome scale – extended is the primary outcome measure. A GOSE score less than 7 was considered failure to restore to previous working capacity. Results: One hundred and sixty‐two patients were recruited, of which 101 were successfully contacted. Two years after injury, 28.7% of the patients scored less than 7 (failure to restore working capacity). Injury on duty was shown to be a significant risk factor for predicting long‐term disability (P = 0.03). Radiological abnormality was not a significant predictor in long‐term disabilities. Conclusion: Incidence of long‐term disability after mild head injury is common among the local working population in Hong Kong and should not be overlooked. Further research is needed to quantify the disability and to identify possible risk factors.     

Severe head injury in a paediatric population.

Forty eight, patients under fourteen years of age, with severe head injury, who were admitted to the Children's Hospital, over a a period of 4 years were studied. During the same period 2500 children with head injury admitted, an incidence 2% approx. The low mortality and the good prognosis of these children is pointed out. The literature is also reviewed and a few conceptions regarding treatment, age of the patients in various series and intracranial haematomas were reconsidered. Extradural and subdural haematomas are excluded from this particular study.     

Neuropsychological function 23 years after mild traumatic brain injury: a comparison of outcome after paediatric and adult head injuries

Primary objective: To the authors' knowledge no study comparing very long-term neuropsychological outcome after mild paediatric and adult traumatic brain injury (TBI) has been published. The primary objective of this study was to compare neuropsychological outcome 23 years after mainly mild paediatric and adult TBI.

Research design: The study was a neuropsychological follow-up 23 years after a prospective head injury study conducted at a Norwegian public hospital.

Methods and procedures: One hundred and nineteen patients were assessed with a comprehensive neuropsychological test battery. Of these, 45 were paediatric TBI and 74 were adult TBI.

Main outcomes and results: Both the paediatric and adult groups obtained scores in the normal range. In the paediatric group significant relationships were found between head injury severity and current neuropsychological function. The most important predictors of poor outcome were length of post-traumatic amnesia (PTA) and a combination of PTA and EEG pathology within 24 hours of injury. No influence of pre- and post-injury risk factors on current neuropsychological function was evident.

Conclusions: The findings indicate that children sustaining complicated mild TBI may be more vulnerable to development of chronic mild neuropsychological dysfunction than adults sustaining similar head injuries.     

Hypothermia and severe head injury

Two patients who were deeply unconscious (GCS = 4) following head injuries, sustained whilst intoxicated with alcohol, became hypothermic due to cold exposure. Despite negative prognostic factors both underwent craniotomy and evacuation of large acute subdural haematoma. After intensive postoperative management and rehabilitation both have made satisfactory recoveries. The contribution of hypothermia to their unpredicted favourable outcome is discussed, and the importance of recording temperature in head-injured patients is emphasized.     

Transorbital penetrating head injury with a hunting arrow: Case report

The development of more complex and diverse hunting weapons may result in an increase of uncommon forms of penetrating injury to the brain. We present a case of non-fatal transorbital arrow injury to the brain. High velocity projectile injuries merit certain management adaptations from gunshot or low velocity stab wounds. This case highlights the necessity for anterograde removal of the arrow in the direction of its line of trajectory. Early assessment of the patient with cerebral angiography to identify surgically correctable vascular injury is recommended.     

Paediatric head injury: incidence, aetiology and management

Trauma is the commonest cause of hospital admission in children. Head injuries are present in 75% of children with trauma and 70% of all traumatic deaths are due to the head injury. The mechanism of brain injury is examined, resulting from the effects of the primary insult and secondary ischaemic damage. Therapeutic interventions will be discussed with specific emphasis on outcome studies. However, institution of adequate oxygen delivery and haemodynamic stability in the child at the earliest moment remains the most important aspect of the management plan.     

Severe head injury among children: computed tomography evaluation as a prognostic factor

Background

The value of neuroimaging in predicting unfavorable events in the outcome of pediatric patients has not been established. Our objectives were to determine clinical characteristics and outcome of severely head-injured children admitted to the pediatric intensive care unit (PICU) of a pediatric third-level university hospital and to evaluate the use of neuroimaging as a prognostic factor of morbimortality in these patients.

Methods

We performed a 9-year retrospective review. We included all patients with severe head injury admitted to the pediatric intensive care unit of our hospital from January 1995 to December 2003 requiring invasive intracranial pressure monitoring. Clinical summaries and imaging studies were reviewed.

Results

Data for 156 pediatric patients, aged 1 to 18 years, were collected. We reclassified neuroimaging patterns into 2 groups: those with few imaging findings and those with important lesions. These 2 groups were significantly correlated with initial Glasgow Coma Scale (P < .05). We classified patients into favorable evolution, moderate disability, and unfavorable evolution. Poorer evolution correlated with poorer initial neuroimaging patterns, and these differences were statistically significant (P < .05).

Conclusions

In our group of patients, initial Glasgow Coma Scale was related with the initial neuroimaging pattern, and this relation was statistically significant. Findings in the first and second neuroimaging were useful as prognostic factors in our series.     

Dysphagia with head injury

This retrospective study was conducted: (1) to establish the incidence of dysphagia with head injury, (2) to demonstrate the capabilities of videofluorography (VFG) in identifying the common areas of swallowing dysfunction, and (3) to demonstrate the dysphagia management advantages of the VFG. Nine patients (30%) were found to have significant swallowing problems among 30 patients admitted to the Head Injury Program, Erie County Medical Center, Buffalo, NY in 9 months. These nine patients represent 4-5% of all head-injured patients admitted. The most common swallowing problems demonstrated by videofluorography barium swallow were prolonged oral transit and delayed swallowing reflex; each occurring in 87-5% of eight cases. The study revealed a high correlation between swallowing dysfunction and prolonged hospitalization. Serial VFGs document improved swallowing function, and indicate when relatively safe cessation of nasogastric tube feedings can be achieved. This may permit shorter hospitalization.     

Post-traumatic growth after head injury: a long-term follow-up

Primary objective: To investigate the time course of any positive psychological changes after traumatic brain injury (TBI) by comparing questionnaire responses in two groups of TBI survivors, early, 1-3 years post-injury and late, 10-12 years post-injury.

Research design: A cross-sectional, between-group design.

Method and Procedure: TBI survivors were selected from the Reading Head Injury out-patient records by date of registration, early survivors from 2002-2004 and late survivors from 1993-1996 and sent a battery of postal questionnaires. These included The Post-traumatic Growth Inventory, The Life Satisfaction Checklist and The Hospital Anxiety and Depression Scale. Individuals were also given the opportunity to answer questions about their perception of their condition and to provide free text responses to reflect best and worst advice received, to describe positive and negative changes in themselves and to identify their most useful coping strategies.

Results: 61 'early' and 65 'late' people were contacted with study details and 52 consented to the study, receiving questionnaires which provided 23 'early' and 25 'late' responses. There was a significantly greater degree of post-traumatic growth, as measured on 'The Post-traumatic Growth Inventory', reported by the later group (*p = 0.000), but no other significant differences between the groups in terms of all the other variables. Both groups reported greater life satisfaction pre-injury.

Conclusion: Measures of Post-traumatic Growth (Relating to Others, Personal Strength, New Possibilities, Appreciation of Life and Spirituality) appear to increase over time after head injury. This is a positive message that clinicians should note and reinforce and could help to shape future adjustment.     

Post-traumatic epilepsy following head injury

The occurrence of post-traumatic epilepsy (PTE) was studied in 164 consecutive closed head injury patients, each of whom had been unconscious and amnestic for at least one hour. The overall incidence of PTE was found to be 25%, significantly higher than previously reported. Analysis of data revealed PTE was not related to the presence or absence of a hematoma, but rather to the duration of the coma. The incidence of PTE was found to be 35% among patients comatose for three weeks or more.     

CHILDREN OR YOUNG ADULTS? A POPULATION‐BASED STUDY ON ADOLESCENT HEAD INJURY

BACKGROUND: The aim was to study the epidemiology of significant adolescent head injury in a statewide population. METHODS: A retrospective review of all significant adolescent (12-19 years old) head injuries over a period of 3 years was undertaken and compared with those of children (0-11 years old) and young adults (20-29 years old). RESULTS: The incidence of significant adolescent head injury was 19.2 per 100,000 adolescents per year. This compared to the incidence in children of 12.9 per 100,000 and in young adult of 14.7 per 100,000. Of all significant adolescent head injuries, 63.9% are managed at adult trauma centres. Demographics, pathology, neurosurgical management, length of intensive care unit stay, ventilated hours and length of hospital stay were similar to those of young adults and significantly different from those of children. Prehospital predictors of mortality were similar across all groups. Adolescent discharge destinations were similar to those of young adults and significantly different from those of children. CONCLUSIONS: The study emphasizes the incidence of and mortality from adolescent head injury. The pattern of adolescent head injury is different from that of children and supports current practice of treatment of a majority of adolescents in adult trauma centres. These differences have implications on planning for injury prevention and trauma management.     

Effect of cerebrolysin on moderate and severe head injury: Preliminary result of a cohort study

Introduction: Cerebrolysin is a compound with neurotropic activities and has a beneficial effect in the treatment of mild and moderate Alzheimer's disease. The present study investigated whether the addition of cerebrolysin to the initial treatment regimen in patients with moderate and severe head injury would improve their functional outcome. Method and Results: At 6 months, 42% of the rehabilitated patients achieved good recovery without significant cognitive deficit. The study group was compared with the historical cohort of patients eligible for active rehabilitation. Despite a younger population of the historical cohort, the functional outcome was not significantly different from the study group. No significant side‐effects requiring cessation of cerebrolysin was noted. Conclusion: Use of cerebrolysin as a part of the initial management of moderate and severe head injuries was safe and well‐tolerated. The result suggests that cerebrolysin is beneficial to the functional outcome in these patients, especially in elderly patients.