Outcomes following childhood head injury: a population study

Memory deficits

This chapter begins with a discussion about the common characteristics of people with memory deficits resulting from brain injury followed by a description of a typical patient referred for memory rehabilitation. We then address some general principles to help people with memory deficits. These principles include ways of improving encoding, storage, and retrieval. The next section addresses more specific strategies to help people (a) cope without a memory through environmental modifications, (b) learn more efficiently (particularly through errorless learning strategies), and (c) compensate for their problems through external memory aids. A memory aids resource center is described. The impact of memory impairment on emotions is considered. A summary of the main components of a memory rehabilitation program is provided. The overall conclusion is that rehabilitation can help people to compensate for, bypass, or reduce their everyday problems and thus survive more efficiently in their own most appropriate environments.

Taking Care of Children After Traumatic Brain Injury

Purpose: The purpose of this article is to inform speech-language pathologists in the schools about issues related to the care of children with traumatic brain injury.

Method: Literature review of characteristics, outcomes and issues related to the needs serving children.

Results: Due to acquired changes in cognition, children with traumatic brain injury have unique needs in a school setting.

Conclusions: Speech-Language Pathologists in the school can take a leadership role with taking care of children after a traumatic brain injury and coordination of medical and educational information.

Is a diagnosis of "mild traumatic brain injury" a category mistake?

BACKGROUND

Efforts to produce definitions and diagnostic standards for mild traumatic brain injury (TBI) have a long and complex history. The diagnosis of TBI must be considered in the larger context of neuropsychiatric diagnosis. A major reconceptualization of diagnosis is now underway in which the classical syndrome conceptualization is being discarded. We address the question, what are the implications of this revision of thinking in the specific context of TBI?

METHODS

A recent literature on logical structures for neuropsychiatric disorders was reviewed. The symptom pattern of TBI was identified, and a literature survey determined the frequency of these symptom patterns in other disorders and in healthy control populations.

RESULTS

The frequency of symptom endorsement in populations without a history of TBI can be equal to endorsement frequencies in populations with a history of mild TBI. In some studies, the frequency of symptom endorsement in healthy controls having no history of head injury actually exceeded the endorsement rates in a comparison group with a history mild TBI.

CONCLUSION

The heterogeneity of this clinical population and their clinical presentations, the absence of a unitary etiology of postinjury deficits, and the complex idiosyncratic time course of the appearance of these deficits argue against the valid implementation of the classical model of diagnosis. In addition, the accepted criteria of diagnostic utility are not satisfied. TBI is not a disease; it is an event. More precisely, TBI is an event or a sequence of events that can, in some instances, lead to a diagnosable neurological or psychiatric disorder.

Use of the King's Outcome Scale for Childhood Head Injury in the evaluation of outcome in childhood traumatic brain injury

OBJECTIVE

To examine the inter-rater reliability of The King's Outcome Scale for Childhood Head Injury (KOSCHI) with clinicians of varying experience in paediatric traumatic brain injury (TBI); and to examine change in outcome during long-term follow-up of children following traumatic brain injury (TBI) using KOSCHI.

METHOD

Retrospective assessment of detailed clinic reports of 97 children followed-up by a tertiary specialist paediatric brain injury service. Investigators were blinded to each other's scores.

RESULTS

Inter-rater reliability was substantial (weighted kappa 0.71) and similar for investigators of varying experience. KOSCHI outcome was strongly associated with markers of injury severity (p = 0.028). In longitudinal follow-up, KOSCHI score worsened in 7 (23%) children who were injured under 8 years but in no older children (p = 0.02).

CONCLUSION

KOSCHI has high inter-rater reliability for investigators of different experience. Long-term KOSCHI outcome is associated with injury severity. Some young children may develop worse disability over time.

Paediatric head injury admissions over a 10-year period in a regional neurosurgical unit

Traumatic brain injury is a leading cause of death and disability in childhood. A retrospective study of all paediatric head injuries admitted to the neurosurgical unit for the West of Scotland over a 10-year period was performed to assess the impact of the National Institute for Health and Clinical Excellence head injury guidelines on the admission rate and to determine the associated risk factors, causes, severity and outcomes of these injuries. There were 564 admissions between 1998 and 2007. The median age at presentation was nine years and two months. There was no change in the admission rate, injury mechanism or severity of head injury admitted over the period studied. A relationship was observed between the Scottish Index of Multiple Deprivation Score and the incidence of head injury ( P = 0.05). Alcohol was reported as a causative factor in only a small number of cases, and moderate to severe head injuries were more commonly identified as a result of road traffic accidents.

Impact of elevated ICP on outcome after paediatric traumatic brain injury requiring intensive care

INTRODUCTION

Traumatic brain injury is an important cause of morbidity and mortality in children and adolescents. Moderate to severe brain injuries account for approximately 20 % of all brain injuries, and nearly 50 % of the patients experience neuropsychological sequelae due to the injury. The purposes of this study are, firstly, to describe intensive care management of children with a severe brain injury and, secondly, to study the impact of elevated intracranial pressure on outcome.

METHODS

A retrospective review of medical records was done.

RESULTS

Sixty children were admitted for intensive care during the study period. Seventy-three percent of all children received neurosurgical interventions, 26 children received an intracranial pressure-monitoring device and 14 of those had an elevated intracranial pressure (ICP) >20 mmHg requiring ICP-targeted therapies. Eighty-eight percent of all children reported cognitive impairment at follow-up. No significant correlation was found between the King's Outcome Scale for Childhood Head Injury outcome groups and whether or not the children have had a neurosurgical intervention or were treated with ICP-targeted medical therapies.

CONCLUSION

Children receiving rehabilitation after a brain injury during childhood make a moderate to good recovery. No significant correlation was found between outcome and whether or not the child had been treated for elevated intracranial pressure.

Environmental risk and protective factors of adolescents' and youths' mental health: differences between parents' appraisal and self-reports

PURPOSE

We investigated the effect of parents' mental health, life events, and home life (among other factors) on adolescents'/youths' mental health, whether such an effect varies when several variables are assessed jointly, and also whether the informant source of the mental health problem modifies the estimations.

METHODS

We studied a representative sample of 454 Spanish adolescents/youths studied longitudinally (2 assessments, 3 years apart). We considered factors associated with adolescents'/youths' mental health (conduct, emotional, and hyperactivity scores [SDQ]): risk factors (parents' mental health and life events) and mediators (social and financial support). Structural equation modeling was applied. We constructed two models: (a) with parents' SDQ responses and (b) with self-reported SDQ responses (in a subsample of N = 260).

RESULTS

Model fit was adequate for parents' appraisal. Parents' mental health (p < 0.05) and undesirable life events (p < 0.05) were the most important risk factors. The same model showed poorer fit when self-reported measures were used. Home life exerted a stronger protective effect on adolescents'/youths' mental health when reported by adolescents/youths. The negative effect of parents' mental health was significantly protected by home life in emotional [-0.14 (0.07)] and hyperactivity scores [-0.2 (0.08)].

CONCLUSIONS

Even in the presence of other factors, parents' mental health has an important effect on adolescents'/youths' mental health. Good levels of home life are protective, especially when adolescents'/youths' mental health is self-reported.

Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations

Aim:

To determine factors associated with poor outcome in children suffering traumatic head injury (HI).

Materials and Methods:

A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians.

Results:

There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41).

Conclusions:

A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.

Mild traumatic brain injury in children

Head injury occurs frequently in childhood and results in approximately 500,000 emergency department visits and over $1 billion in costs annually. Nearly 75% of these children are ultimately diagnosed with mild traumatic brain injury (MTBI), a misnomer because many will have radiographically identified intracranial injuries and long-term consequences. Identification of the brain at risk and prevention of secondary injury is associated with the largest reduction in head trauma morbidity and mortality. This article reviews the current literature to discuss the initial evaluation, management, and long-term outcomes in children sustaining MTBI.

Impact of recent life events on the health related quality of life of adolescents and youths: the role of gender and life events typologies in a follow-up study

Background

Most studies on the effect of life events (LEs) have been carried out in convenience samples which cannot be considered representative of the general population. In addition, recent studies have observed that gender differences in the health related quality of life (HRQoL) impact of LEs might be lower than believed. We assessed the relationship between LEs and HRQoL in a representative sample of Spanish adolescents/youths, focusing on gender differences.

Methods

Participants (n = 840) completed the KIDSCREEN-27 to measure HRQoL at baseline and again after 3 years (n = 454). Follow-up assessment included the Coddington Life Events Scales (CLES) to measure LEs experiences in the previous 12 months. Respondents were categorized according to the amount of stress suffered. We calculated both the number of LEs and the Life Change Unit (LCU) score, a summary of the amount of stress inherent to the event and the time elapsed since occurrence. LEs were classified as desirable or undesirable, and family-related or extra-family. Effect sizes were calculated to evaluate changes in HRQoL. To assess the impact of LEs typologies, multiple linear regression models were constructed to evaluate their effect on HRQoL.

Results

Girls reported a mean 5.7 LEs corresponding to 141 LCUs, and boys 5.3 and 129, respectively. The largest impact of LEs on HRQoL was observed in the group of boys that reported to have lived more stress (third tertil of LCUs distribution). The linear association between LEs and HRQoL tended to be stronger among boys than girls, but the difference was not statistically significant. The effect on HRQoL was deemed important when undesirable events had been experienced. To have an important impact on HRQoL, 200 LCUs due to undesirable events were necessary in boys. In girls, slightly higher scores were necessary for a similar impact.

Conclusions

A moderate association was found between recent LEs and HRQoL, mainly among those who experienced several undesirable events that correspond to at least 200 LCUs. No gender differences were found in this association. Results may be useful for identifying adolescents with particular health risks, regardless of gender.

Progenitor cell therapy for traumatic brain injury: effect of serum osmolarity on cell viability and cytokine production

INTRODUCTION

The potential translation of mesenchymal stem cell (MSC) therapy into a multimodal protocol for traumatic brain injury requires evaluation of viability and cytokine production in a hyperosmolar environment. Optimization of MSC therapy requires delivery to the target area without significant loss of cellular function or viability. No model evaluating the potential efficacy of MSC therapy at varying osmolarities currently exists.

METHODS

Rat MSCs were characterized with flow cytometric immunophenotyping. MSCs (passage 3) were placed in culture with multipotent adult progenitor cell media at varying osmolarities (250, 270, 290, 310, 330, 350 and 370 mOsm) potentially found with hypertonic saline infusion. After culture for 24 h, cellular viability was measured using flow cytometry (n = 6). Next, brain tissue supernatant was harvested from both normal rat brains and injured brains 6 h after cortical injury. Subsequently, MSCs were placed in culture with multipotent adult progenitor cell media +/- 20% normal brain or injured brain supernatant (at the aforementioned osmolarities) and allowed to remain in culture for 24 h (n = 11). At this point, media supernatant cytokine levels were measured using a multiplex cytokine assay system.

RESULTS

MSCs showed no clinically significant difference in viability at 24 h. MSCs cultured with 20% injured brain supernatant showed an decrease in proinflammatory cytokine production (IL-1alpha and IL-1beta) with increasing osmolarity. No difference in anti-inflammatory cytokine production (IL-4 and IL-10) was observed.

CONCLUSION

Progenitor cell therapy for traumatic brain injury may require survival and activity in a hyperosmolar environment. Culture of MSCs in such conditions shows no clinically significant effect on cell viability. In addition, MSC efficacy could potentially be enhanced via a decrease in proinflammatory cytokine production. Overall, a multimodal traumatic brain injury treatment protocol based upon MSC infusion and hypertonic saline therapy would not negatively affect progenitor cell efficacy and could be considered for multicenter clinical trials.

Deep white matter volume loss and social reintegration after traumatic brain injury in children

OBJECTIVE

To explore whether children judged by their parents as showing an "excellent" or "complete" social reintegration after pediatric traumatic brain injury have less white matter volume (WMV) loss and better neuropsychological test scores than children who do not achieve this same level of reintegration.

SETTING

Primary-care hospital/medical center.

PARTICIPANTS

Twenty-eight children with post-acute traumatic brain injury evaluated as outpatients.

MEASURES

Parental ratings of overall social reintegration, neuropsychological test performance, and voxel-based morphometry analysis of brain WMV loss.

RESULTS

In addition to showing worse neuropsychological test performance, children judged not to make a complete or excellent social reintegration had greater WMV loss, particularly within the corpus callosum. WMV loss in the corpus callosum correlated with the child's Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV) Full Scale IQ (rho = .677, P = .000) and parental ratings of level of social integration (rho = .415, P = .028). Admitting Glasgow Coma Scale scores, mother's level of education, WISC-IV Processing Speed Index scores, and WMV loss in the region of the corpus callosum significantly contributed to parental ratings of a child's level of social reintegration.

CONCLUSIONS

Preliminary findings suggested that diffuse WMV loss, particularly in deep brain regions (eg, corpus callosum), may relate to the child's long-term psychosocial outcome as viewed from the parents' perspective.

Neurodevelopmental outcomes of pediatric traumatic brain injury

Pediatric traumatic brain injury is a major cause for concern when considering both the number of children sustaining injuries and the large number of children incurring life-long difficulties that impact on quality of life. Research is continuing to investigate outcomes and predictors of recovery in both cognitive and behavioral domains. Findings have contributed to better identification of children at high risk for neurobehavioral difficulties. The challenge is to now develop intervention programs to prevent or lessen the impact of such difficulties.

Brief report: The KIDSCREEN follow-up study on Health-related Quality of Life (HRQoL) in Spanish children and adolescents. Pilot test and representativeness

The Spanish KIDSCREEN follow-up study reassessed the Spanish baseline sample (n=840) of the European KIDSCREEN study 3 years later (2006). The aims of this paper were to describe the KIDSCREEN follow-up study and the pilot test, and to analyze participation rates and representativeness. Instruments included the KIDSCREEN-52 HRQoL measure and a set of scales including the possible explanatory variables. Focus groups and individual interviews were carried out in a pilot test. Participants were compared with non-participants at baseline, and also with Eurostat census data. Twenty-two out of 24 subjects were interviewed in the pilot test. Fifteen items needed to be modified after the pilot test. Participation rate reached 54% (n=454). Participants (mean age=12.71 years old) were on average 6 months younger than non-participants (p=0.03), and from more educated families. KIDSCREEN follow-up instrumentation seems adequate for collecting factors with potential influence on HRQoL. Follow-up respondents' representativeness seems to be acceptable.

Modern approaches to pediatric brain injury therapy

Each year, pediatric traumatic brain injury (TBI) accounts for 435,000 emergency department visits, 37,000 hospital admissions, and approximately 2,500 deaths in the United States. TBI results in immediate injury from direct mechanical force and shear. Secondary injury results from the release of biochemical or inflammatory factors that alter the loco-regional milieu in the acute, subacute, and delayed intervals after a mechanical insult. Preliminary preclinical and clinical research is underway to evaluate the benefit from progenitor cell therapeutics, hypertonic saline infusion, and controlled hypothermia. However, all phase III clinical trials investigating pharmacologic monotherapy for TBI have shown no benefit. A recent National Institutes of Health consensus statement recommends research into multimodality treatments for TBI. This article will review the complex pathophysiology of TBI as well as the possible therapeutic mechanisms of progenitor cell transplantation, hypertonic saline infusion, and controlled hypothermia for possible utilization in multimodality clinical trials.

Saint or sinner? Teacher perceptions of a child with traumatic brain injury

PURPOSE

To examine influences on classroom performance and behaviour following traumatic brain injury (TBI).

METHODS

A case-study of one child who suffered a moderate TBI, with frontal brain damage, aged 8, followed up at ages 12 and 13 years. Parents and child were interviewed to establish pre- and post-injury behaviour and functioning. All 19 teachers who taught the child reported on classroom performance, behaviour and educational achievement in each of their subjects. The child completed a comprehensive neuropsychological assessment battery including the Weschler Intelligence Scale for Children (WISC-III(UK)), Children's Memory Scale (CMS) and Vineland Adaptive Behaviour Scales (VABS).

RESULTS

This child demonstrated above-average intelligence and good attention/concentration on the CMS. However, he was unable to focus or maintain attention in most classroom situations. His behaviour was erratic and disruptive in class and at home. At 5-year follow-up, his behaviour had deteriorated in both home and school situations, particularly in less structured environments.

CONCLUSIONS

Teachers of more structured subjects (maths and science) perceived the child as excitable but performing at average or above-average levels, whereas teachers of less structured subjects (art, drama, music) perceived him to be 'attention-seeking' and very disruptive in class. The influences of environmental factors are discussed.

Fitting back in: Adolescents returning to school after severe acquired brain injury

PURPOSE

To explore the experiences of Australian adolescents with severe acquired brain injury (ABI) and their families as the adolescent returned to school. In particular, to understand the influence of services and support on the school return.

METHOD

In-depth interviews conducted over a two-year period with families who had an adolescent with a recent severe ABI (mean age 15 years, 11 months) analysed using a grounded theory approach.

RESULTS

Two critical phases for adolescents returning to school post ABI were identified: organizing the school return and being back at school. Experience in these phases was influenced by length of school absence, extent of noticeable and hidden problems and school response to the students' return post injury. The central concept characterizing experience was the challenge of fitting back in. Some adolescents fitted back in adequately and continued school participation. Those that did not fit in tried again by revisiting the organizing phase, re-evaluated their school experience and either continued or left school.

CONCLUSIONS

Adolescents with ABI faced the challenge of fitting back in when they returned to school. This was either facilitated or hindered by the extent and quality of organization, communication and support from parents, schoolteachers and the rehabilitation team.

Concussive symptoms in emergency department patients diagnosed with minor head injury

BACKGROUND

Evidence-based protocols exist for Emergency Department (ED) patients diagnosed with minor head injury. These protocols focus on the need for acute intervention or in-hospital management. The frequency and nature of concussive symptoms experienced by patients discharged from the ED are not well understood.

OBJECTIVES

To examine the prevalence and nature of concussive symptoms, up to 1 month post-presentation, among ED patients diagnosed with minor head injury.

METHODS

Eligible and consenting patients presenting to Kingston EDs with minor head injury (n = 94) were recruited for study. The Rivermead Post-Concussion Symptoms Questionnaire was administered at baseline and at 1 month post-injury to assess concussive symptoms. This analysis focused upon acute and ongoing symptoms.

RESULTS

Proportions of patients reporting concussive symptoms were 68/94 (72%) at baseline and 59/94 (63%) at follow-up. Seventeen percent of patients (18/102) were investigated with computed tomography scanning during their ED encounter. The prevalence of somatic symptoms declined between baseline and follow-up, whereas some cognitive and emotional symptoms persisted.

CONCLUSION

The majority of patients who present to the ED with minor head injuries suffer from concussive symptoms that do not resolve quickly. This information should be incorporated into discharge planning for these patients.

Hitting a moving target: Basic mechanisms of recovery from acquired developmental brain injury

Acquired brain injuries represent a major cause of disability in the pediatric population. Understanding responses to developmental acquired brain injuries requires knowledge of the neurobiology of normal development, age-at-injury effects and experience-dependent neuroplasticity. In the developing brain, full recovery cannot be considered as a return to the premorbid baseline, since ongoing maturation means that cerebral functioning in normal individuals will continue to advance. Thus, the recovering immature brain has to 'hit a moving target' to achieve full functional recovery, defined as parity with age-matched uninjured peers. This review will discuss the consequences of developmental injuries such as focal lesions, diffuse hypoxia and traumatic brain injury (TBI). Underlying cellular and physiological mechanisms relevant to age-at-injury effects will be described in considerable detail, including but not limited to alterations in neurotransmission, connectivity/network functioning, the extracellular matrix, response to oxidative stress and changes in cerebral metabolism. Finally, mechanisms of experience-dependent plasticity will be reviewed in conjunction with their effects on neural repair and recovery.

The King's Outcome Scale for Childhood Head Injury and injury severity and outcome measures in children with traumatic brain injury

The aim of this study was to relate discharge King's Outcome Scale for Childhood Head Injury (KOSCHI) category to injury severity and detailed outcome measures obtained in the first year post-traumatic brain injury (TBI). We used a prospective cohort study. Eighty-one children with TBI were studied: 29 had severe, 15 moderate, and 37 mild TBI. The male:female ratio was 1.8:1. The mean age was 11 years 10 months (SD 3.6, range 5-16y). Discharge KOSCHI categories were good (n=34), moderate (n=39), severe (n=6), and unclassifiable (n=2). KOSCHI category correlated strongly with admission Glasgow Coma Score, length of hospital stay, and post-traumatic amnesia. It also correlated significantly with Verbal IQ and Performance IQ (Wechsler); measures of attention; health status (Health Utilities Index [HUI]); health-related quality of life (Pediatric Quality of Life Inventory [PedsQL]); depressive symptoms (Birleson Depression Scale) assessed within 3 months postTBI; and with Verbal IQ, selective attention (map mission), and HUI and PedsQL domains assessed at least 6 months post-TBI discharge. KOSCHI did not correlate with behaviour or executive function. We conclude that the KOSCHI scored at hospital discharge correlates with severity of injury and some cognitive, health status, and HRQL outcomes early after TBI. It is not helpful at predicting later difficulties, or behavioural and emotional problems.

Outcome and predictors of functional recovery 5 years following pediatric traumatic brain injury (TBI)

OBJECTIVES

The aim was to examine functional outcomes following traumatic brain injury (TBI) during early childhood, to investigate impairments up to 5 years postinjury and identify predictors of outcome.

METHODS

The study compared three groups of children (mild = 11, moderate = 22, severe = 15), aged 2.0-6.11 years at injury, to a healthy control group (n = 17). Using a prospective, longitudinal design, adaptive abilities, behavior, and family functioning were investigated acutely, 6, 30 months and 5 years postinjury, with educational progress investigated at 30 months and 5 years postinjury.

RESULTS

A strong association was suggested between injury severity and outcomes across all domains. Further, 5-year outcomes in adaptive and behavioral domains were best predicted by preinjury levels of child function, and educational performance by injury severity.

CONCLUSION

Children who sustain a severe TBI in early childhood are at greatest risk of long-term impairment in day-to-day skills in the long-term postinjury.

Management of mild head injury in the pediatric patient

SUMMARY MHI is a common disorder in t he pediatric population. While most children recover uneventfully, a small percentage has persistence of symptoms and long-term sequelae. Determining the optimal timing for return to play can be difficult, but adherence to guidelines may reduce the risk of compounding the injury.

A survey of information given to head-injured patients on direct discharge from emergency departments in Scotland

AIM

To survey the information provided to head-injured patients on discharge from emergency departments (EDs) in Scotland.

METHODS

EDs throughout Scotland were asked to supply a copy of their head injury advice pamphlet for analysis. Each pamphlet was assessed against a template and an Excel spreadsheet was created.

RESULTS

All 30 (100%) Scottish EDs responded. The frequency with which specific features appeared varied widely, with most pamphlets concentrating on emergency features, with less emphasis on postconcussion symptoms.

CONCLUSIONS

Head injury discharge advice should be standardised throughout EDs, with more emphasis given to postconcussion features.

Pediatric injuries: prevention to resolution

Despite improved education and prevention initiatives, trauma remains the leading cause of death in children. A variety of preventative measures have been developed to decrease the morbidity and mortality, and the financial burden on the health care system. This article discusses injury prevention strategies, issues in prehospital care, and key points of initial resuscitation. In addition, the major injury patterns are described with attention paid to the diagnosis and management of patients with multiple traumatic injuries.

The validity of post-concussion syndrome in children: a controlled historical cohort study

The aim of this controlled historical cohort study was to assess the validity of post-concussion syndrome in children. We identified 301 children aged 4-15 years who had sustained an isolated brain concussion, and another group of 301 children who sustained any other mild body injury excluding the head. Parents from both groups filled in standardized questionnaires containing questions about the health condition of the children: headache, neck pain, dizziness, malaise, fatigability, exercise or noise intolerance, irritability, weepiness, sadness, anxiety, nocturnal enuresis, tics, sleep disorders, memory or learning difficulties, hyperactivity, seizures, attention disorder, buzzing in the ears, subjective parental concerns about the child's health condition, and parental concerns about their child having a brain disorder. The severity of the complaints was rated on the Visual Analogue Scale. After the final exclusion, 102 pairs strictly matched by sex, age, and the date of trauma were analyzed. The differences of parental complaints about the health condition of their children between case and control groups were statistically insignificant for all symptoms, except parental concerns about their child having brain damage which were significantly higher in the case group. The likelihood of parental concerns about the possibility of their child having brain damage was 2.7 times higher in the case group. Headache, learning difficulties, and sleep disorders were significant variables predicting the concerns. These results question the validity of the post-concussion syndrome in children.

A prospective, population-based, follow-up study of mild traumatic brain injury in children

OBJECTIVE

Outline the annual incidence of mild traumatic brain injury in children, aged 0-17 years, using the American Congress of Rehabilitation Medicine classification and record the presence of new symptoms up to six months after injury.

SETTINGS AND METHODS

The study population comprised all the children in the age group of 0-17 years (a total of 40,984) in an administrative district in south-western Sweden. All the individuals registered in the Brain Injury Register, during the periods 1 January to 30 June 1999 and 1 April to 30 September 2000, fulfilling the inclusion criteria defined by American Congress of Rehabilitation Medicine, were included. New symptoms occurring three to six months after the injury were recorded using a mailed 21-item questionnaire.

RESULTS

192 children fulfilled the criteria, yielding an annual incidence of 468/100,000 (95% CI 402-535/100,000). Boys accounted for 57 per cent and fall injuries accounted for 61 per cent of the external causes. New symptoms were reported by 24 per cent of those who answered the questionnaire.

CONCLUSION

This study revealed that the annual incidence of mild traumatic brain injury in children was almost as high as that among adults in the same area and population.

Survey of the management of children with minor head injuries in Sweden

BACKGROUND

This study investigates current management practice of children with MHI in Swedish hospitals to define present need for management guidelines for children.

METHODS

A cross-sectional mail survey including 51 hospitals treating children with MHI outlines management routines concerning clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up.

RESULTS

Twenty-seven per cent of the hospitals have established written criteria for referral and management of children with MHI. Eighty-eight per cent use the Swedish Reaction Level Scale for assessing the level of consciousness. Eight per cent use the paediatric Glasgow Coma Scale. Routine computerised tomography is performed in 18% of the hospitals, 12% perform skull radiography and/or radiography of the cervical spine as routine. Eighty-four per cent have established criteria for early discharge without hospitalisation.

CONCLUSION

The management of children with MHI varies in Swedish hospitals. There is a need for standardised protocols for detection of intracranial complications and guidelines for the management of MHI in children.

[Functional status, scholastic placement after rehabilitation and follow-up of children with traumatic brain injury: a retrospective study of 48 patients]

OBJECTIVE

To evaluate the follow-up of children with traumatic brain injury (TBI).

POPULATION AND METHODS

A retrospective study during 4.5 years of 48 children with TBI. We measured GOS during admission and after rehabilitation and where children were placed after hospitalisation.

RESULTS

Most patients were males; the mean age was 9.4 years (range 14 months to 16.5 years). The rehabilitation length was 11.4 months. Most children (77%) had a good functional outcome. For 23%, placement was in establishments for severely handicapped people, for 35.4%, an environment with specific support, and for 37.5%, an environment without specific support. After 2 years, 43.7% of infants were lost to follow up.

CONCLUSION

Rehabilitation and functional results have improved for children with TBI, but some improvements must be made.

Concussive head injury in children and adolescents related to sports and other leisure physical activities

OBJECTIVE

To compare the characteristics of children and adolescents with concussive head injury (CHI) sustained during organised sports or other leisure physical activity.

METHODS

This was a case series study reviewing the medical records retrospectively over a four year period of children 6-16 years presenting to the emergency department with a CHI after participating in sport and/or recreation activity.

RESULTS

There were 592 cases of sport and recreation related concussion over the study period (2000-2003). Most of the patients (n = 424, 71.6%) were male, with half (n = 304, 51.4%) being older than 10 years of age. A total of 152 (25.7%) cases of CHI were related to playing sports. Most cases (71.2%) were mild concussion. The cause of injury was a fall (n = 322, 54.4%) or a collision. Nearly a quarter of the children (n = 143, 24.2%) were admitted to hospital, with imaging performed in 134 (22.7%). Most children were treated appropriately and no adverse events were reported.

CONCLUSIONS

A severe CHI in a child is six times more likely to have resulted from organised sport than from other leisure physical activities. Outcomes for CHI in children is excellent, although their management places a considerable burden on emergency services. The need for activity restriction and the benefits of this in reducing long term cognitive effects of CHI are uncertain.

Pediatric minor closed head injury

Many studies have found conflicting evidence over the use of clinical indicators to predict intracranial injury in pediatric mild head injury. Although altered mental status, loss of consciousness, and abnormal neurologic examination have all been found to be more prevalent among head-injured children, studies have observed inconsistent results over their specificity and predictive value. Children older than 2 years have been evaluated, managed, and studied differently than those less than 2 years old. Evidence strongly supports a lower threshold to perform a CT scan in younger children because they have a higher risk of significant brain injury after blunt head trauma.

Persistence of Cognitive Deficits Following Paediatric Head Injury Without Professional Rehabilitation in Rural East Coast Malaysia

OBJECTIVE

To use data from a prospective, longitudinal study to determine whether psychomotor functions improve spontaneously during the first year following paediatric traumatic brain injury without modern rehabilitation facilities in a rural area of Malaysia.

METHODS

Thirty-six paediatric patients who were referred for neurosurgical management for mild to severe head injuries were studied over a period of 2 years. No patients had orthopaedic or surgical trauma. Assessment of patients occurred at 3, 6 and 12 months, and patients were subjected to the Bender Gestalt Test, Weschler Intelligence Scale for Children--Revised and subtests from the Weschler Preschool and Primary Scale of Intelligence. None of the patients received professional rehabilitation due to a lack of facilities; only traditional treatment was given during this period.

RESULTS

There were no significant changes in any of the parameters, except for integration error, after a period of 1 year. Cognitive function improved in 30% of patients after 1 year of follow-up. Despite an increased relationship of the caregiver to the patient in the first year of trauma, there was no general improvement when compared to the Western literature.

CONCLUSION

A lack of modern resources in the community, a low general practitioner to patient ratio, and no inpatient or outpatient rehabilitation services do not lead to spontaneous improvement in the psychomotor condition of our patients despite good interfamily support. These are important findings for the future restructuring of the psychological service in Malaysia.

Neuropsychiatric consequences of traumatic brain injury: a review of recent findings

PURPOSE OF REVIEW

Behavioral and psychiatric disturbances are the more frequent consequences of traumatic brain injury and major determinants of the quality of life of patients. This review was designed to familiarize the reader with the more recent work published in this field.

RECENT FINDINGS

We have now a more consistent view of the epidemiology of post-traumatic brain injury psychiatric disorders both in adult and pediatric populations. Mood disorders, anxiety disorders and substance use disorders are the more prevalent psychiatric diagnoses among traumatic brain injury patients. The phenomenological characteristics and clinical correlates of major depression, post-traumatic stress disorder, alcohol use disorders, and post-traumatic brain injury attention deficit hyperactivity disorder have been studied in more detail. Newer structural, metabolic and functional neuroimaging techniques help to clarify the pathogenesis of these disorders. In turn, this knowledge may lead to the implementation of more efficient therapeutic interventions. Unfortunately, controlled treatment studies have been the exception in the field, and treatment decisions usually lack adequate empirical support.

SUMMARY

Recent advances in the basic neuroscience of traumatic brain injury as well as in behavioral genetics, social science and neuroimaging techniques should contribute to a better understanding of the pathophysiology of the psychiatric disorders occurring after the injury. There is a great need for randomized, double-blind, placebo-controlled trials to establish the most effective treatments for these disorders.

Admission to hospital following head injury in England: incidence and socio-economic associations

Background

Head injury in England is common. Evidence suggests that socio-economic factors may cause variation in incidence, and this variation may affect planning for services to meet the needs of those who have sustained a head injury.

Methods

Socio-economic data were obtained from the UK Office for National Statistics and merged with Hospital Episodes Statistics obtained from the Department of Health. All patients admitted for head injury with ICD-10 codes S00.0–S09.9 during 2001–2 and 2002–3 were included and collated at the level of the extant Health Authorities (HA) for 2002, and Primary Care Trust (PCT) for 2003. Incidence was determined, and cluster analysis and multiple regression analysis were used to look at patterns and associations.

Results

112,718 patients were admitted during 2001–2 giving a hospitalised incidence rate for England of 229 per 100,000. This rate varied across the English HA's ranging from 91–419 per 100,000. The rate remained unchanged for 2002–3 with a similar magnitude of variation across PCT's. Three clusters of HA's were identified from the 2001–2 data; those typical of London, those of the Shire counties, and those of Other Urban authorities. Socio-economic factors were found to account for a high proportion of the variance in incidence for 2001–2. The same pattern emerged for 2002–3 at the PCT level. The use of public transport for travel to work is associated with a decreased incidence and lifestyle indicators, such as the numbers of young unemployed, increase the incidence.

Conclusion

Head injury incidence in England varies by a factor of 4.6 across HA's and PCT's. Planning head injury related services at the local level thus needs to be based on local incidence figures rather than regional or national estimates. Socio-economic factors are shown to be associated with admission, including travel to work patterns and lifestyle indicators, which suggests that incidence is amenable to policy initiatives at the macro level as well as preventive programmes targeted at key groups.