Sustained Head Trauma Research Articles

The Yield of Lumbar Puncture to Exclude Nosocomial Meningitis as Aetiology for Mental Status Changes in the Medical Intensive Care Unit

We aimed to evaluate the diagnostic value of lumbar puncture in excluding nosocomial meningitis as the cause of mental status changes in medical intensive care unit patients. We retrospectively reviewed the records of all patients admitted to the medical intensive care unit at our institution over a four-year period who had a lumbar puncture performed during their stay. Patients with central nervous system devices were excluded. During the study period 63 lumbar punctures were performed, 31 to exclude nosocomial meningitis. Of these 31 patients, 25 (80.6%) received antimicrobials during hospitalization before performance of lumbar puncture. In one patient with human immunodeficiency virus (HIV) infection, Gram stain demonstrated yeast; in the remainder, Gram stain was negative. Cultures were negative for pathogenic bacteria in all 30 of these patients (overall yield: 0%, 95% CI: 0-10.0%). Five patients (16.1%) had a cerebrospinal fluid leucocytosis (>10 leukocytes/mm3); of these, all had received prior antibiotics, two had positive cryptococcal antigen results, and three had central nervous system infection suspected clinically without an evident alternative diagnosis. In no non-HIV subject did lumbar puncture alter management. Lumbar puncture performed in the medical intensive care unit to exclude nosocomial meningitis as the cause of mental status changes has a low yield and rarely changes management. These findings should not be generalized to patients who have sustained head trauma, have undergone neurosurgical procedures, or may be immunosuppressed.

The impact of mild developmental learning difficulties on neuropsychological recovery from head trauma

Objectives: To investigate the prevalence of mild developmental learning difficulties (MDLD) in a group of patients who had sustained head trauma, to determine the impact on cognitive and neurobehavioural recovery.Methods: A case-control design comprised 136 consecutive cases (55 MDLD; 81 control). Information regarding a history of MDLD was obtained during clinical interview, with neurobehavioural problems recorded using a checklist. Neuropsychological assessment and questionnaire measures of anxiety and depression were completed.Results: Between group cognitive differences were only found on Digit Symbol (p < 0.01) and Trails B (p < 0.05) tests. The MDLD group reported a higher incidence of impulsive aggression and mood swings (both p < 0.01). Adjustment problems in the MDLD group were inferred from higher anxiety and depression ratings (both p < 0.05).Conclusions: The MDLD group did not appear to display a more generalized deficit in cognitive functions. However, neurobehavioural problems, plus the incidence and degree of affective changes, suggest greater psychological vulnerability than controls.

Accidental and abusive head injury in young children.

Children commonly present for medical care after sustaining head trauma. In children younger than 2 years of age, the practitioner must distinguish accidental head injury from abusive head injury. The following article discusses the evaluation of children with head injury and how to make the distinction between accidental and abusive head injury.

Development of a novel method to predict disability after head trauma in children

Background/Purpose: Although analysis of functional independence measures (FIM) at discharge are useful for assessing extent of disability in head-injured children, there is no reliable method to predict the severity of disability at the time of admission. The authors developed a novel method to predict severe disability after head trauma on admission. Methods: Head-injured patients, 2 to 16 years old, with FIM recorded at discharge (n = 3,491) were identified in our state trauma database for the period from 1993 through 1996. Patients categorized as completely dependent by one or more of the FIM (Feeding, Locomotion, Expression, Transfer Mobility, Social Interaction) were classified as disabled. Probability of disability (PD) was estimated based on regression weights for Glasgow Coma Scale (GCS), Injury Severity Score (ISS), age, and number of anatomic regions injured. Observed to expected disability rates were compared using a test data set of 2,553 patients entered in the database between 1997 through 1999. Results: There was no statistically significant difference between observed and expected disability across all PD intervals, which suggests that the PD accurately predicted disability. Conclusions: PD offers a novel and reliable method for early prediction of likelihood of disability in children who sustain head trauma. Routine use of the PD may lead to earlier intervention to improve long-term results in head-injured children. J Pediatr Surg 38:482-485. Copyright 2003, Elsevier Science (USA). All rights reserved.

Hypothalamic-Pituitary-Adrenal Axis and Interleukin-6 Activity in Children with Head Trauma and Syndrome of Inappropriate Secretion of Antidiuretic Hormone

Arginine vasopressin (AVP; anti-diuretic hormone) and corticotropin-releasing hormone are the two major secretagogues of hypophyseal adrenocorticotropin (ACTH). Interleukin-6 (IL-6) is a potent stimulator of the human hypothalamic-pituitary-adrenal axis (HPA) and a secretagogue of both parvocellular and magnocelullar AVP. We have previously suggested that IL-6-stimulated AVP secretion may be the origin of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) in inflammatory conditions. To further elucidate the relationship between IL-6 and SIADH as well as IL-6 and HPA axis activity, we studied eight previously healthy children (age 6.3 +/- 4.8 [mean +/- SD] years, weight 23.8 +/- 10.5 kg) who--after sustaining head trauma--presented SIADH during hospitalization (for 7.1 +/- 3.8 days) in the pediatric intensive care unit (P-ICU). Routine blood samples were taken twice daily at 08:00 and 20:00 hours. All children but one survived. Measurements included blood and urine osmolality (BlOsm and UrOsm, respectively), serum cortisol (F) and IL-6, plasma ACTH and AVP. Correlations were assessed with linear regression among the areas under the curve (AUC) of BlOsm, UrOsm, ACTH, F, IL-6 and AVP, separately for BlOsm values <280 mOsm (SIADH phase) and > or = 280 mOsm (non-SIADH phase). During the SIADH phase AVP-AUC correlated positively with IL-6-AUC (r = +0.96, p<0.05), BlOsm-AUC correlated positively with AVP-AUC and F-AUC (r = +0.95 and +0.98, p<0.05, respectively) and F-AUC correlated positively with ACTH-AUC (r = +0.99, p<0.05). During the non-SIADH phase ACTH-AUC correlated positively with BlOsm-AUC (r = +0.96, p<0.05). IL-6 secreted during an aseptic inflammatory state, such as sustaining head trauma with SIADH, is quantitatively correlated to AVP, indicating that this cytokine is directly and/or indirectly involved in the pathogenesis of SIADH.

Surgical correction of excyclotorsion due to bilateral superior oblique muscle paralysis

Torsional diplopia developed in a 41-year-old man after he sustained severe head trauma and bilateral paralysis of the superior oblique muscles. Funduscopy revealed bilateral excyclotorsion. The patient underwent a modified Harada-Ito operation in both eyes. Fundus photographs showed bilateral excyclotorsion preoperatively and correction to the normal position after surgery.

Treatment of Post-Concussion Syndrome Following Mild Head Injury

Approximately 38% of patients who sustain head trauma characterized by a brief disturbance of consciousness and clinically unremarkable neuroradiologic findings meet International Classification of Diseases 10th edition (ICD-10) diagnostic criteria for postconcussion syndrome (PCS). Physicians treat a majority of cases with nonsteroidal analgesics or antidepressants, and refer about 40% for psychological consultation. Psychological treatment typically involves education, reassurance, and reattribution of symptoms to benign causes. A review of controlled treatment outcome studies conducted over the past 2 decades in Scandinavia, Great Britain, Canada, and the United States suggests that early single session treatment can prevent the syndrome as effectively as traditional outpatient therapy. Several standardized, empirically supported treatment manuals are available.

Prevalence of headaches in football players.

Football coaches and team physicians rely heavily on players' reports of symptoms in deciding whether a player may return to the game after sustaining head trauma. The decision is made difficult by the wide variety of associated symptoms, some of which (e.g., headache is among the most common) may or may not be associated with serious head injury. More information is needed about the clinical significance of football-related headache. To assess the frequency of headache associated with playing football, we analyzed responses to our questionnaire asking about incidence, frequency, and outcome of football-related headache from 443 football players (320 from college, 123 from high school). Eighty-five percent of respondents reported previous headache related to hitting in football. Asked specifically about their most recent game, 21% of respondents reported having had headache during that game. Of players who had headache, only 19% informed the team physician, trainer, or coach, and only 6% were removed from the game. Twenty-seven percent of respondents reported previous diagnosis of cerebral concussion by medical personnel. Defensive backs (25%), defensive linemen (19%), and offensive linemen (18%) were most likely to have headache, related to hitting. Our data confirm that posttraumatic headache is commonly associated with football participation and often goes unreported. Given that the most serious complications of head injuries (e.g., second-impact syndrome) occur infrequently, headache as an isolated symptom lacks specificity in predicting such complications in football players. Therefore, unless it persists or is accompanied by additional symptoms, headache alone may not reliably suggest the need to remove players from the game.

First published record of a neurosurgical procedure on the North American continent, Mexico City, by Pedro Arias de Benavides, 1561: Secretos de Chirurgia, Valladolid, Spain, 1567.

The first published account of a neurosurgical intervention performed on the North American continent is described. The operation took place in Mexico City in 1561. The neurosurgical intervention was performed by a Spanish surgeon, Pedro Arias de Benavides, on a 13-year-old boy who had sustained head trauma that caused an open depressed cranial fracture and exposed the cerebrum. A description of this case was first published in Valladolid, Spain, 6 years after the event, in a book entitled Secretos de Chirurgia ("Secrets of Surgery").

Association of burners with cervical canal and foraminal stenosis.

The purpose of this study was to determine whether the burner phenomenon is associated with cervical canal and foraminal stenosis in a scholastic population. Lateral cervical radiographs were reviewed for 64 athletes, 15 to 18 years of age, who had sustained at least one burner. Controls consisted of age-matched athletes who had sustained head or neck trauma without evidence of the burner phenomenon (N = 32). Pavlov ratios were calculated for levels C-3 through C-6; both mean minimum and mean average ratios were determined. Available oblique radiographs from both the study (N = 31) and control (N = 15) groups were then used to calculate the foramen/vertebral body ratio--a measure of relative foraminal height. Significant differences were found between the burner and control groups for the mean minimum and mean average Pavlov ratios and foramen/vertebral body ratios. Scholastic athletes sustaining the burner phenomenon have an increased risk of cervical canal and foraminal stenosis as measured by the Pavlov and foramen/vertebral body ratios, respectively. The foramen/vertebral body ratio is an easily reproducible and reliable means of assessing foraminal dimensions from oblique radiographs and controls for x-ray magnification and rotation. Foraminal stenosis assessment may prove useful in predicting burner risk, especially in athletes with extension-compression injuries.

Serious Head Injury in Falls of Less than 20 Feet: Think Abuse

Source: Lallier M, Bouchard S, St-Vil D, et al. Falls from heights among children: a retrospective review. J Pediatr Surg. 1999:34;1060–1063.Lallier et al report on 64 patients from 1 to 18 years of age (mean age 7.4 years) who fell 10 feet or more as identified by retrospective chart review of 1,410 patients admitted after falls to Sainte-Justine Hospital in Montreal, Canada, from 1994–1997. Fifty (78%) fell from a height of 20 feet or less and 14 from a height of greater than 20 feet. Seventy percent (45) of the patients were male. Thirty-six percent of the patients were less than 4 years of age and 70% were less than 10 years old. Falls were from balconies (23%), windows (20%), and trees (14%). Two patients had minimal or no injuries, 55 (86%) sustained only a single major injury, and 7 had multiple system injuries. Head injuries were most frequent, occurring in 25 patients (39%), followed by extremity fractures (34%), abdominal injuries (12%), maxillofacial (8%), and spine injuries (6%). Twenty-two (88%) of the patients with head injuries were less than 10 years old and 48% were less than 5 years old. Among those with head trauma, 10 patients sustained skull fractures, 8 had concussion, and 7 had intra-cranial injuries. In contrast, abdominal injuries were more common in older children with 75% of these injuries occurring in children over 5 years of age. Abdominal injuries included splenic trauma in 5, kidney injury in 3, pancreatic trauma in 2, diaphragmatic injury in 2, and retro-peritoneal hematoma in 1.Of the 25 children sustaining head trauma, epidural hematoma occurred in 1 (4%) and subarachnoid hemorrhage occurred in 3 (12%). Concussion was seen in 8 (32%) and brain contusion seen in 3 (12%). There were no subdural hematomas. The only death in this series occurred after a 5-story, 50-foot fall. The authors’ conclusion was that significant injuries were infrequent in falls from less than 20 feet and most fall injuries in young children involved the head or musculoskeletal systems.More data are presented in this report to support the conclusion that children rarely sustain intra-cranial bleeding from falls under 20 feet.1,2 The only death in the series occurred after a plunge from 5 stories. Subdural hematoma was not recorded in any of the fall victims, and subarachnoid hemorrhage in only 2. Significant injuries (as opposed to linear skull fractures or minor soft tissue injuries) are not likely to be produced by short falls, and serious life-threatening injuries (with the exception of epidural hematomas) are virtually never caused by short falls. Abuse should be suspected in infants and young children who have significant head injuries—those involving subdural or subarachnoid hemorrhages—because these rarely occur in short falls.This is another in a series of papers on falls in children.3,4 The message from all of them is remarkably similar: serious injuries, especially serious head injuries, occurring in children are unlikely to be due to short (less than 20-foot) falls. Child abuse is a much more likely possibility.

The effects of Gass' (1991) neurocorrection factor on MMPI-2 profiles of individuals who have sustained closed head trauma

The effects of Gass' (1991) neurocorrection factor on MMPI-2 profiles of individuals who have sustained closed head trauma

Posttraumatic carotid cavernous fistula: frequency analysis of signs, symptoms, and disability outcomes after angiographic embolization.

To increase awareness and understanding of posttraumatic carotid cavernous fistula (PTCCF) with the intent to expedite diagnosis and treatment of this disabling injury, a 14-year retrospective review of patients with angiographically identified PTCCF was conducted at this Level I trauma center. A frequency analysis of signs, symptoms, and disability was performed. The impact on disability of demographics, number of embolization attempts required for closure of the PTCCF, and time from injury to diagnosis was assessed by t test for independent samples. Nine patients were diagnosed with 10 PTCCFs. Mean patient age was 41.5 years. All patients with PTCCF had basilar skull fracture, loss of consciousness, bruit, and chemosis; 90% had exophthalmos; 70% had visual changes; 50% complained of headache; and 80% had some lasting disability. Mean age of patients with partial to total disability was 47 years, while the mean age of patients without lasting disability was 19.5 years (p = 0.013). No statistical correlation could be found between disability and sex, blunt versus penetrating injury, days to diagnosis, or number of embolization attempts. Patients sustaining head trauma with basilar skull fractures and presenting with the described signs and symptoms should be evaluated for PTCCF. Risk of disability does not appear to be influenced by number of attempts at embolization or time to diagnosis. However, age may have a significant impact on outcome.

Epidemiology and prevention of traffic injuries to urban children and adolescents.

To describe the incidence of severe traffic injuries before and after implementation of a comprehensive, hospital-initiated injury prevention program aimed at the prevention of traffic injuries to school-aged children in an urban community. Hospital discharge and death certificate data on severe pediatric injuries (ie, injuries resulting in hospital admission and/or death to persons age <17 years) in northern Manhattan over a 13-year period (1983-1995) were linked to census counts to compute incidence. Rate ratios with 95% CIs, both unadjusted and adjusted for annual trends, were calculated to test for a change in injury incidence after implementation of the Harlem Hospital Injury Prevention Program. This program was initiated in the fall of 1988 and continued throughout the study period. It included 1) school and community based traffic safety education implemented in classroom settings in a simulated traffic environment, Safety City, and via theatrical performances in community settings; 2) construction of new playgrounds as well as improvement of existing playgrounds and parks to provide expanded off-street play areas for children; 3) bicycle safety clinics and helmet distribution; and 4) a range of supervised recreational and artistic activities for children in the community. Traffic injuries were a leading cause of severe childhood injury in this population, accounting for nearly 16% of the injuries, second only to falls (24%). During the preintervention period (1983-1988), severe traffic injuries occurred at a rate of 147.2/100 000 children <17 years per year. Slightly <2% of these injuries were fatal. Pedestrian injuries accounted for two thirds of all severe traffic injuries in the population. Among school-aged children, average annual rates (per 100 000) of severe injuries before the intervention were 127.2 for pedestrian, 37.4 for bicyclist, and 25.5 for motor vehicle occupant injuries. Peak incidence of pedestrian and bicyclist injuries occurred during the summer months and afternoon hours, whereas motor vehicle occupant injuries showed little seasonal variation and were more common during evening and night-time hours. Age-specific rates showed peak incidence of pedestrian injuries among 6- to 10-year-old children, of bicyclist injuries among 9- to 15-year-old children, and of motor vehicle occupant injuries among adolescents between the ages of 12 and 16 years. The peak age for all traffic injuries combined was 15 years, an age at which nearly 3 of every 1000 children each year in this population sustained a severe traffic injury. Among children hospitalized for traffic injuries during the preintervention period, 6.3% sustained major head trauma (including concussion with loss of consciousness for >/=1 hour, cerebral laceration and/or cerebral hemorrhage), and 36.9% sustained minor head trauma (skull fracture and/or concussion with no loss of consciousness >/=1 hour and no major head injury). The percentage of injured children with major and minor head trauma was higher among those injured in traffic than among those injured by all other means (43.2% vs 14.2%, respectively; chi2 = 336; degrees of freedom = 1). The percentages of children sustaining head trauma were 45.4% of those who were injured as pedestrians, 40.2% of those who were injured as bicyclists, and 38.9% of those who were injured as motor vehicle occupants. During the intervention period, the average incidence of traffic injuries among school aged children declined by 36% relative to the preintervention period (rate ratio:.64; 95% CI:.58,.72). After adjusting for annual trends in incidence, pedestrian injuries declined during the intervention period among school aged children by 45% (adjusted rate ratio:.55; 95% CI:.38,.79). No comparable reduction occurred in nontargeted injuries among school-aged children (adjusted rate ratio:.89; 95% CI:.72, 1.09) or in traffic injuries among younger children who

Percutaneous endoscopic gastrostomy reduces total hospital costs in head-injured patients

Background: Gastrostomies provide reliable long-term enteral access in patients with traumatic brain injuries. The impact of technique of gastrostomy on total hospital cost is not known. Methods: A retrospective analysis of patients who sustained head trauma and required gastrostomies for long-term enteral access between 1 July 1990 and 1 July 1996 was performed. Results: The patients who received percutaneous endoscopic gastrostomies (PEG) were similar to patients who received Stamm gastrostomies (OPEN) with respect to age, injury severity score, mechanism of injury, associated injuries, complication rates, and deaths. Total hospital costs ($ × 10 3) were lower for patients who had PEGs placed in the intensive care unit (78.2 ± 37.4) or endoscopy suite (71.9 ± 37.7) compared with PEGs placed in the operating room (122.4 ± 75.7) or OPEN gastrostomies (119.8 ± 65.1). Conclusions: In head-injured patients, PEGs are a reliable method of obtaining long-term enteral access with a complication rate equivalent to Stamm gastrostomies. If performed in either the intensive care unit or the endoscopy suite, PEGs are associated with significantly reduced total hospital costs.

Hearing impairment among young Chinese in an urban area

To evaluate hearing levels among young Chinese in an urban area, audiometry was carried out in Jinan city, Shandong Province, China. The subjects were 442 healthy school children and students ranging in age from 6–19 y. All subjects were asked to complete a brief questionnaire on otological symptoms, personal histories and use of noisy playthings. Audiometric threshold testing was performed at the audiometric frequencies of 0.5, 1, 2, 4 and 8 kHz. Logistic regression analysis was used to analyse the items of personal histories related to hearing impairment. Forty-five subjects (10% of the subjects) were classified as abnormal. Nineteen ears of the abnormal subjects showed 4 kHz-dip and 38 ears showed high-frequency hearing impairment. Lower prevalence of hearing impairment was found when compared with young Chinese in a rural area (20%). The logistic regression analysis showed that head trauma may be the cause of hearing impairment among young Chinese in urban areas. Otological examinations for all children sustaining head trauma are recommended.

Hearing impairment among young Chinese in an urban area.

To evaluate hearing levels among young Chinese in an urban area, audiometry was carried out in Jinan city, Shandong Province, China. The subjects were 442 healthy school children and students ranging in age from 6-19 y. All subjects were asked to complete a brief questionnaire on otological symptoms, personal histories and use of noisy playthings. Audiometric threshold testing was performed at the audiometric frequencies of 0.5, 1, 2, 4 and 8 kHz. Logistic regression analysis was used to analyse the items of personal histories related to hearing impairment. Forty-five subjects (10% of the subjects) were classified as abnormal. Nineteen ears of the abnormal subjects showed 4 kHz-dip and 38 ears showed high-frequency hearing impairment. Lower prevalence of hearing impairment was found when compared with young Chinese in a rural area (20%). The logistic regression analysis showed that head trauma may be the cause of hearing impairment among young Chinese in urban areas. Otological examinations for all children sustaining head trauma are recommended.

Assessment of endocrine functions in children following severe head trauma

The goal of the present study was to assess endocrine functions in children following severe head trauma. Subjects included 21 children between the ages of 3 years and 18 years 6 months, referred to the Pediatric Rehabilitation Unit at Sheba Medical Center, Israel, between 1984 and 1995. Each was examined 4 months to 11 years following the first admission, undergoing a complete physical examination, including neurologic assessment, biochemical and baseline endocrine profiles, and bone age determination. A GnRH stimulation test was performed in prepubescent children who had advanced bone age. Sixteen children had experienced the head trauma before, or at onset of puberty, according to their chronologic ages. Two children had completed puberty before the head trauma. A 12-year-old male who sustained head trauma at 10 years 6 months of age was found to have Tanner grade 3 pubertal stage and advanced bone age. In addition, 3 prepubescent children also had advanced bone age with no other signs of precocious puberty and a normal GnRH test. For all children studied, the biochemical and hormonal laboratory measurements were in the normal range. Endocrine abnormalities were not found in children examined 4 months or more following severe head trauma. We conclude that clinical monitoring of endocrine status after severe head trauma is sufficient; specific hormonal measurements are not required unless warranted by abnormal physical signs.

Chronic Pain is Associated with Deficits in Information Processing

Beginning with the theoretical premise that pain stimuli are liable to perturb the ordinary dynamical state of the brain, we hypothesized that individuals in pain may experience impaired information processing. A sample of 19 persons complaining of chronic pain and a comparison sample of 25 persons having sustained head trauma were obtained by retrospective chart review. The chronic-pain group consisted of 19 persons whose primary complaint was significant chronic pain, with no known history of head trauma or neurologic disorder. The comparison group consisted of 25 persons who had sustained mild to moderate head traumas. All subjects were administered information processing and motor subtests of the Human Performance Measurement System, a computerized set of measures. Both groups obtained mean z scores below the normative mean on all measures except visual digit span. There were no differences between groups on motor measures, visual digit span, and visual-spatial memory. On 2 of 6 information-processing tests, pain patients performed more poorly than head-trauma patients. The results suggest that pain may disrupt cognitive performances which depend on intact speed and capacity of information processing.

Frontal Lobe Changes after Severe Diffuse Closed Head Injury in Children

In view of the pathophysiology and biomechanics of severe closed head injury (CHI) in children, we postulated that the frontal lobes sustain diffuse injury, even in the absence of focal brain lesions detected by magnetic resonance imaging (MRI). This study quantitated the morphological effects of CHI on the frontal lobes in children who sustained head trauma of varying severity. The MRI findings of 14 children who had sustained severe CHIs (Glasgow Coma Scale score of < or = 8) were compared with the findings in a matched group of 14 children having sustained mild head injuries (Glasgow Coma Scale score of 13-15). The patients ranged in age from 5 to 15 years at the time of their MRIs, which were acquired at least 3 months postinjury. MRI findings revealed no focal areas of abnormal signal in the frontal lobes. Volumetric analysis disclosed that the total prefrontal cerebrospinal fluid increased and the gray matter volume decreased in the patients with severe CHI, relative to the mildly injured comparison group. Gray matter volume was also reduced in the orbitofrontal and dorsolateral regions of the brains of children with severe CHI, relative to the children who sustained mild head trauma. These volumetric findings indicate that prefrontal tissue loss occurs after severe CHI in children, even in the absence of focal brain lesions in this area. Nearly two-thirds of the children who sustained severe CHIs were moderately disabled after an average postinjury interval of 3 years or more, whereas 12 of the 14 patients with mild CHIs attained a good recovery (2 were moderately disabled) by the time of study.(ABSTRACT TRUNCATED AT 250 WORDS)