Occurrence of epilepsy during the first 10 years after traumatic brain injury acquired in childhood up to the age of 18 years in the south western Swedish population-based series.

BACKGROUND: The risk of seizures is increased after a traumatic brain injury (TBI), but the impact and duration of this increased risk is not well characterized in children. OBJECTIVE: To identify post-traumatic epilepsy (PTE) and post-concussion symptoms 10 years after a TBI during childhood. RESEARCH DESIGN: The study is a population-based retrospective follow-up study. PROCEDURE: Ten years after brain injury all 165 survivors, who as children (<18 years) in 1987-1991 as residents in the south western Swedish health care region had had a TBI, were invited to participate in a follow-up. A questionnaire regarding medical conditions and medication was filled out by the patients themselves or their parents as was a 21-item questionnaire (PCSQ) regarding post-concussion symptoms. Of the surviving 165 individuals, 109 participated (67%). RESULTS: Eight of 109 developed immediate seizures. During the follow-up period 12/109 had developed active epilepsy. Of these 12, five had had immediate seizures. The incidence of developing PTE within 10 years after a TBI was thus in this series 11%. The relative risk to develop late onset post-traumatic epilepsy (> or =1 week after injury) for those who had had immediate seizures was 9.018 (p = 0.0003, 95% CI = 3.69-22.05). CONCLUSIONS: TBI is a relatively rare cause of epilepsy in childhood, although immediate seizures are associated with an increased risk of developing post-traumatic epilepsy.

Early community outreach intervention in children with acquired brain injury.

Ten patients with acquired brain injury were recruited over an 18 month period in the south-western health care region of Sweden in order to evaluate the costs and effectiveness of a multidisciplinary community outreach intervention programme. An experienced multidisciplinary project team was involved and patients underwent detailed functional, cognitive and motor assessments following initial contact within two weeks of injury, within six weeks of injury and at a 12-month follow-up. An individualized counselling programme was also offered. Of an expected recruitment number of 50 patients (based on epidemiological and population based figures) 10 children were reached, evaluated and followed; eight patients with traumatic brain injury (five severe, two moderate and one mild), and two patients with non-traumatic brain injury (both severe). At follow-up there was a significant improvement in motor function. No significant changes were seen in other areas of functional assessment or on neuropsychological measures although there were mild improvements in communication and behaviour functions. The financial costs per patient in the programme were deemed relatively modest compared with cost estimates of shorter-term in-patient rehabilitation. Time intensive interventions included supporting caregivers and school staff and the direct and indirect patient interventions were shown to enhance support and promote active involvement of local services.

Mild traumatic brain injuries: the impact of early intervention on late sequelae. A randomized controlled trial.

BACKGROUND: Positive results from early clinical intervention of mild traumatic brain injury (MTBI) patients by rehabilitation specialists have been reported. Various treatments have been used, but few controlled studies are published. We hypothesised that early rehabilitation of selected MTBI patients would reduce long term sequelae. METHOD: A randomised controlled trial with one year follow-up. Among 1719 consecutive patients with MTBI, 395 individuals, 16-60 years of age, met the MTBI definition. Exclusion criteria were: previous clinically significant brain disorders and/or a history of substance abuse. The control group (n = 131) received regular care. The intervention group (n = 264) was examined by a rehabilitation specialist. 78 patients were mainly referred to an occupational therapist. The problems were identified in daily activities and in terms of post-concussion symptoms (PCS), an individualised, tailored treatment was given. Primary endpoint was change in rate of PCS and in life satisfaction at one-year follow-up between the groups. FINDINGS: No statistical differences were found between the intervention and control groups. Patients who experienced few PCS two to eight weeks after the injury and declined rehabilitation recovered and returned to their pre-injury status. Patients who suffered several PCS and accepted rehabilitation did not recover after one year. INTERPRETATION: In this particular MTBI sample, early active rehabilitation did not change the outcome to a statistically-significant degree. Further studies should focus on patients with several complaints during the first 1-3 months and test various types of interventions.

Outcome after severe brain damage, what makes the difference?

OBJECTIVE: To assess and compare the consequences for outcome in terms of the dimensions of activity and participation for two groups: group A, which received early formalized rehabilitation, and group B, which received late or no formalized rehabilitation. RESEARCH DESIGN: A cross-sectional study. PROCEDURE: Twenty-six patients (A: n = 14 and B: n = 12) with severe brain damage were included. The participants were assessed a mean of 26.6 months (SD 7.1, median 25, range 14-41) after the incident using the structured form for the Swedish Neuro database, the Glasgow Outcome Scale (GOS), the Extended Glasgow Outcome Scale (GOSE) and the Functional Independence Measure (FIM). RESULTS: The study reveals a better outcome for group A. No patient remained in a vegetative state in group A as compared with three in group B. In group A, 50% were independent as compared with 17% in group B. The frequency of return to work was 43% in group A, but no patient in group B had returned to work.

How safe are childcare products, toys and playground equipment? A Swedish analysis of mild brain injuries at home and during leisure time 1998-1999.

The aim was to highlight the role of childcare products as causes for mild brain injury (concussion) in small children (0-4 years of age) and to determine the most dangerous products. By childcare products this report means the following items: child and baby furniture, nursing tables, baby walkers, toys, baby carriages, sport equipment for children, playground equipment and security equipment for children. The data were derived from the EHLASS (European Home and Leisure Accident Surveillance System) for 1998 and 1999 and covered a restricted population of Sweden (approximately 5 per cent). According to this register 182 mild brain injuries (concussions) were recorded following a fall, an accident or a blow to the head among children (0-4 years of age) during 1998 and 158 for 1999. Of those injuries, childcare products were the cause of the accident in 84 (46 per cent) and 76 (48 per cent) cases respectively for 1998 and 1999. The number of children admitted for hospital care was 68 (57/84) and 74 (56/76) per cent respectively. The home was the most common place of the accident and play and leisure activity were the most common activities. More than 50 per cent of these accidents took place during daytime. The product type that caused most accidents was nursery furniture and, in this category, the baby walker was the most dangerous. The product type that caused the second most frequent accidents was playground equipment.

Epidemiology of traumatic brain injury in children and adolescents in south-western Sweden.

The objectives of this study were to outline the incidence, gender distribution, external causes, severity and early outcome of traumatic brain injury (TBI). The subjects were children and adolescents in the south-western Swedish health care region, aged 0-17 y in 1987-1991 and fulfilling the criteria for TBI. Identification was made from the discharge registers of the hospitals in the region admitting patients with TBI, and outcome data were obtained from medical records. The mean incidence rate was 12/100,000 for TBI. The dominant external cause was traffic (60%), followed by falls (22%). At discharge, 49% of those surviving were healthy, 48% suffered from one functional impairment and 52% suffered from two or more impairments. In conclusion, although the incidence rate of TBI is low in Sweden, the condition causes permanent functional impairment in 6/100,000 cases every year.

Medical management in south-west Sweden of children and adolescents with serious traumatic brain injury.

The acute care, rehabilitation and follow-up of traumatic brain injury (TBI) was studied retrospectively in children in south-western Sweden who were injured in the period 1987-1991. There were 210 children of whom 165 were alive at discharge after acute stage care (mean 15.7 days). In this group, only 32/165 (19 per cent) received rehabilitation, 29 of whom were road traffic accident victims. Of the 133 children who did not receive rehabilitation, 52 were severely injured according to the GCS (GCS 3-7), 31 were moderately injured (GCS 8-12) and 50 mildly injured (GCS 13-15). As many as 73/165 (44 per cent) were admitted to a neurosurgical unit and 53/73 (73 per cent) of these underwent neurosurgical operations. Systematic follow-up on an out-patient basis took place in 128/165 subjects (78%). It is noteworthy that 27/92 (29%) of the patients admitted to a general surgical unit and 8/16 (50%) of the patients admitted to a neurosurgical unit were not followed up after acute care. Multiple regression analysis identified the length of unconsciousness and length of care in the acute stage as the only factors of significance for receiving rehabilitation and follow-up. We conclude that road traffic accident victims, despite the fact that their TBI was not significantly more severe than the other groups received rehabilitation more frequently. The unsystematic management of paediatric TBI revealed in this study calls for a formalized programme of firstline service, rehabilitation and follow-up.

Clinical outcome after near-fatal late shunt complication in hydrocephalus.

Shunt revision is inevitable in most shunted hydrocephalic children but the revisions rarely affect the prognosis markedly. This report presents the case of an otherwise healthy boy who, after an uneventful gestation and birth, manifested hydrocephalus in the neonatal period and was shunted at the age of 3 months. His subsequent development and school performance were normal until the age of 10 years, when he developed his first episode of shunt dysfunction. During the emergency shunt revision, intraventricular haemorrhage occurred, causing acute neurological symptoms and signs. In the promptly undertaken reoperation external drainage was inserted but accidentally without a functioning air needle. The intracranial pressure (ICP) rose to 40 cm H2O before correction. These incidents were followed by a 4-month period of unstable shunt function (12 reoperations) and deteriorating neurology. When stable shunt function was eventually achieved, he had severe contractures, minimal active motor function and no active speech. During a 2-year period of rehabilitation, he recovered almost normal motor function and normal intellectual function. Memory functions, vigilance and concentration span remained clearly subnormal. He returned to normal school and his performance is average. It is concluded that the relatively favourable outcome is the probable result of reversible partial herniation and increased ICP.

Quality of life and post-concussion symptoms in adults after mild traumatic brain injury: a population-based study in western Sweden.

OBJECTIVES: To study quality of life and subjective post-concussion symptoms in adults (16-60 years) with a mild traumatic brain injury (MTBI) 3 months and 1 year after injury. METHODS: Of a total of 489 patients 173 responded to questionnaires at 3 months and at 1 year, including the SF-36 health-related quality of life survey, which is a standardized measure validated for Swedish conditions. Post-concussion symptoms were rated as either existing or non-existing in a 21-item checklist [a modified version of Comprehensive Psychopathological Rating Scale (CPRS)]. RESULTS: SF-36 showed impaired scores in all dimensions. Existing post-concussion symptoms were reported by 1545%. Significantly, more symptoms were present at 3 months than at 3 weeks after injury. Furthermore, a significant correlation between higher rates of post-concussion symptoms and lower SF-36 scores was found. CONCLUSIONS: The SF-36 results were significantly impaired compared with an age- and gender-matched normative control group and the rate of post-concussion symptoms was significantly higher at 3 months than at 3 weeks after injury. As a significant correlation between higher rates of symptoms and low SF-36 scores was also found we assume SF-36 to be a sensitive enough measure of MTBI-related effects.

Rehabilitation and follow-up of children with severe traumatic brain injury.

We studied the outcome of 25 patients [12 girls and 13 boys; mean age 13.7 (SD 3.9 years)] with severe traumatic brain injury (TBI). The Glasgow Coma Scale (GCS) score 6 h after the injury was (mean) 4.5 (SD 2.7), and the mean duration of unconsciousness was 15.8 (SD 10.6) days. Being the most severely brain-injured children in the health care region, they were all referred to its only regional pediatric rehabilitation center during 1986-1990. At discharge, 1 patient was healthy, 1 was in a vegetative state and 18 had multiple impairments. Motor problems were present in 22, epilepsy in 7 and speech impairment in 14. It was not possible to assess cognition in 3 of the children, and 15 of the remaining 22 fell in the normal range. At follow up 2-6 years after trauma, all 23 survivors reported at least one sequela, and 21 had multiple sequelae. As many as two-thirds had normal I.Q. and only 3 were non-ambulatory, but behavioral and personality disturbances were so disabling that none of the patients in this group had been able to readjust to a normal life in society after the trauma.

Epidemiology of traumatic brain injury: a population based study in western Sweden.

BACKGROUND: This study on traumatic brain injury (TBI) is based on prospective and retrospective population based data from a head injury register in Borås. METHODS: Data was collected from the hospital emergency unit, the discharge register, the regional neurosurgical clinic and the coroner's records during 1 year. This district is mixed urban and rural with a population of 138 000. RESULTS: The 753 cases identified represent an incidence of 546 per 100 000 which includes deaths (0.7%), hospital admissions (67%) and attendance at the emergency department in patients not admitted (32%). Males (644 per 100 000), had 1.46 higher overall rate than females (442 per 100 000). The external causes were dominated by fall from same level (31%) and fall from different level (27%) followed by traffic accidents (16%) and persons hit by objects (15%). CONCLUSIONS: The incidence of TBI found in this study is high but well in accordance with earlier published Swedish studies.

Late outcome after severe traumatic brain injury in children and adolescents.

OBJECTIVES: Eighteen surviving adolescents with severe traumatic brain injury were re-examined a mean period of 7.1 years after their trauma in order to determine their life situation, motor, cognitive functions and pattern of handicap. METHODS: A structured interview, the EB test of motor function, Ravens's progressive matrices, Peabody's neuropsychological test, SPIQ and the WHO classification of handicap were used. RESULTS: The group had a mean WHO Classification of Handicap score of 1.61 (SD 1.60) revealing mild handicap, and performed as a group significantly subnormal (p < 0.0001) in gross motor, fine motor, sensibility and perception sub-tests. The EB test revealed a mean value of 2.23 (SD 0.89) corresponding to mild disability. The mean non-verbal IQ score of 93.1 (SD 13.9) and the verbal score of 93.4 (SD 14.8) were within normal limits. CONCLUSIONS: Only 28% of the group of surviving adolescent TBI victims functioned within normal limits. The most crucial disabling component was poor social integration, which was clearly demonstrated in the WHO score.

Computed tomography and single-photon emission computed tomography as diagnostic tools in acquired brain injury among children and adolescents.

Twenty children with acquired brain injuries were investigated with CT and SPECT. The findings were related to the clinical outcome judged at discharge following acute care after the injury and at follow-up 5 years later. The abnormalities that were found were classified for each lobe on a scale ranging from 0 (normal) to 5 (severe abnormality). The patients were divided into two groups showing mild and severe injury. CT and SPECT revealed similar results in the patients with severe injury, but in the group of mildly injured children the number of affected lobes and scores indicated by SPECT were significantly higher than those indicated by CT. SPECT also differentiated more effectively between the two outcome groups. This supports the hypothesis that SPECT could be used as an instrument to objectivise minor sequelae and that SPECT and CT are both useful methods for forecasting outcome.