[Non syndromic craniosynostosis]. / Les craniosténoses non syndromiques.

Craniosynostosis are rare congenital malformations of the skull resulting from the premature fusion of one or several cranial sutures. Prevalence is considered in approximately 1 on 2000 births. Non syndromic craniosynostosis (NSC) or isolated form are the most frequent forms (85 % of the cases). They are classified most of the time according to the synostotic suture(s) and the engendered cranial deformation: sagittal synostosis or scaphocephaly, metopic synostosis or trigonocephaly, bicoronal synostosis or brachycephaly, coronal synostosis or plagiocephaly and oxycephaly. Although the multifactorial origin is commonly admitted, the precise mechanisms which lead to the premature fusion of a suture, remain incompletely resolute. The main risks are the intracranial high blood pressure and its consequences on the psychomotor development, the visual or respiratory infringement which can require a surgery in emergency. The treatment is realized by multidisciplinary teams allowing to provide a strategy adapted to every situation. The decision-making process depends on patient's age, on the type and severity of the craniosynostosis, and on the patient's health. This surgery is ideally performed before the age of 1 year and indication only in morphological purpose is widely recognized to avoid any social damage to the child. The follow-up is essential and is made throughout the growth in particular to detect a recurrence or the evolution towards a complex form of craniosynostosis.

[Rational use of distraction osteogenesis in craniofacial surgery]. / Utilisation rationnelle de la distraction osseuse en chirurgie craniofaciale.

Distraction osteogenesis, initially developed by Ilizarov for limb, is the tissular extension caused by the progressive space of the osseous pieces following an osteotomy. Distraction is osteogenesic and histogenic. Twenty-five years ago, at the instigation of McCarthy, this technique was used to handle the craniofacial malformations in the various floors of the face : mandibular, mediofacial and cranial. The most wide-spread protocols respect a latency period from 0 to 7 days, a rhythm of distraction from 1 to 2mm a day in 2 at 4 times and a period of consolidation from 4 to 8 weeks. Distraction is the result of the inventiveness of the pioneers then the work to always adapt to the multiple complex clinical situations. The surgeon has to choose between internal or external materials allowing a mono- or multi-vectorial extension, in osseous and/or dental anchoring. The mandibular distraction is very effective for the treatment of the secondary obstructive syndromes in the unilateral or bilateral severe hypomandibular malformations. She also allows desobstruction of the superior airways within the framework of the mediofacial hypoplasies as well as the secondary treatment of the growth defects in cleft lips and palates. Finally, the distraction osteogenesis enhanced reliability of the fronto-facial advancement in early and secondary treatment of craniofaciosynostosis. This is a real support of the facial growth, which has to be included in a plan of global treatment.

Non-dysraphic intramedullary spinal cord lipoma of the child: Report of 3 cases.

BACKGROUND AND PURPOSE: Non-dysraphic intramedullary spinal cord lipomas (NDSCL) represent 1% of spinal cord tumors. They are less frequent than dysraphic spinal cord lipomas and clinical presentation is unspecific. There are no guidelines on surgical management. MATERIAL AND METHODS: We report three observations of NDSCL in children, focusing on the clinical presentation, surgical management and postoperative outcome. RESULTS: The patients, one female and two males, aged from 5 months to 10 years presented with neurological deterioration, pain, spinal rigidity and in two cases, a subcutaneous mass. Spinal MRI found intradural lipomas without spina bifida, located in the cervico-thoracic area in all cases. The lipoma extended to the medulla oblongata in two cases and was in the lumbar region in the third. These lipomas were massive, requiring decompression surgery. Surgery confirmed the lipoma to be subpial. We performed debulking of the lipoma without attempting total resection, and with or without dural plasty and laminoplasty, followed by minerva cast in two cases, and avoidance of standing in the youngest. Satisfactory recovery occurred in all three cases. After a follow-up between 4 months and 9 years, the outcome was favorable in all cases, and no patient presented with secondary spinal deformation or lipoma progression. CONCLUSION: NDSCL is a rare entity, which often manifests with progressive pain and neurological deficits. In our experience, partial resection with or without dural plasty and laminoplasty has been associated with satisfactory postoperative outcomes and no recurrence of symptoms. We should be attentive to the risk of postoperative spinal deformity in these young patients.

Endonasal endoscopic approach for removal of intranasal nasal glial heterotopias.

BACKGROUND: Nasal Glial Heterotopias also called Nasal Gliomas (NG) are rare congenital tumours of the midline frontonasal space arising from a normal neurectodermal tissue entrapped during the closure of the anterior neuropore. Historically, such tumours were approached using a frontal craniotomy. The study aims to evaluate a fully endonasal endoscopic approach for intranasal NG removal. METHODS: We report a retrospective study of intranasal and mixed NG treated using endonasal endoscopic techniques and computer assisted navigation system from 1997 to 2010 in two tertiary referral centres of Paediatric Otolaryngology. All tumours were investigated using two imaging modalities: craniofacial MRI and CT-scan. RESULTS: Fifteen patients were included (0 to 14 years of age). All tumours were totally removed and no recurrence was observed after a mean follow-up of 32 months. A skull base plasty was done in 13 cases to cover a bony defect or to treat a cerebrospinal leak. Nasal packing was usually removed 24 hours after surgery and all children were discharged home after 2 to 4 days. CONCLUSION: Removal of intranasal NGs using an endonasal endoscopic approach and a dedicated computer assisted navigation system is a safe and efficient procedure. Early management is recommended to treat neonatal airway obstruction.

Spontaneous disappearance of brain arteriovenous malformation: A case series.

OBJECTIVE: Brain arteriovenous malformation (BAVM) is defined as abnormal communication between cerebral of arteries and veins, without capillaries. Clinically, it may involve intracranial hemorrhage or seizures. Complete spontaneous resolution, known as BAVM disappearance, has been reported in rare cases. METHODS: We retrospectively collated all cases of BAVM in Lille University Hospital, from 2005 to 2018, and identified all cases of spontaneous BAVM disappearance on angiography (nidus and early venous drainage). RESULTS: There were 4 cases of spontaneous BAVM disappearance, in 3573 patients: i.e., prevalence of 0.1%. Sex ratio was 2:2; ages ranged from 14 to 46 years; nidus size was generally small (<20mm); 3 of the 4 patients had superficial venous drainage. Revelation of BAVM was by hemorrhage in 3 cases and by seizure in 1. There were no cases of recanalization at 1 year's follow-up. CONCLUSION: Spontaneous BAVM disappearance is rare. Associated factors may include small nidus, superficial venous drainage and hemorrhage.

Is malignant edema and hemorrhage after occlusion of high-flow arteriovenous malformation related to the size of feeding arteries and draining veins?

OBJECTIVE: Our study aimed to identify predictive factors for malignant post-treatment edema and hemorrhage in patients who underwent microsurgical treatment of arteriovenous malformation (AVM) in our institution. METHODS: The study included 72 patients treated by microsurgery for cerebral symptomatic and/or ruptured AVM between 2010 and 2020. Six patients developed postprocedural malignant edema and hemorrhage (group M); the other 66 patients had no malignant edema and hemorrhage (group NM). In each patient, flow was assessed indirectly by summing the diameters of all feeding arteries to obtain an overall diameter (ODA), and similarly for draining veins (ODV). High-flow was defined as a delay between feeding artery injection and draining vein injection (DAV)<1 second on dynamic digital subtraction angiography. Univariate analysis was performed. RESULTS: Mean ODA and ODV were respectively 11mm (±8.2) and 11mm (±5.3) in group M and 2.9mm (±1.4) and 3.7mm (±1.3) in group NM (P=0.001). High-flow AVM was demonstrated in 4 out of 5 patients (85%) in group M and in 14 out of 55 (25%) in group NM (P=0.02). Associated aneurysm was seen in 5 patients in group M (83%) and in 11 in group NM (17%) (P=0.001). CONCLUSION: High-flow AVM may be associated with higher risk of postoperative edema and hemorrhage. Multidisciplinary discussion is mandatory in these cases, to define a pre-therapeutic plan for progressive staged vascular malformation occlusion.

Medulloblastoma: Clinical presentation.

Medulloblastomas present generally a-specifically as a fast-evolving posterior fossa tumor. Medical literature is poor concerning clinical features of medulloblastomas and their potential significance. In the present study, we reviewed 91 pediatric observations of medulloblastomas treated in Lille between 1997 and 2017. Clinical and epidemiological variables were collected and intercorrelated. They were also compared with anatomical and pathological findings, and outcome, with the aim of defining clinical-pathological entities. We also compared the group with 32 cases of posterior fossa ependymoma and 130 cases of cerebellar astrocytoma treated during the same period. We found that in medulloblastomas, the M/F ratio was higher and diagnostic delay was shorter than in astrocytomas. Also, the mean age was older than in ependymomas. Intracranial hypertension was constant; we further observed that altered general status was common (16.5%) and correlated with a metastatic tumor. We delineated two clusters: the "nodular" cluster, which associates young age, cerebello-pontine angle tumor, herniation, desmoplastic tumor, and tumor predisposition syndrome; and the "metastatic" cluster, which associates altered status, initial metastases, hydrocephalus, and diagnostic delay. Meticulous collection of clinical data at the initial phase is integral part of the oncological evaluation, with a search for genetic and prognostic risk factors, which then permits us to define clinical-pathological entities.

What remains of non-syndromic bicoronal synostosis?

More and more genetic syndromes are associated with bicoronal synostosis (BCS), making non-syndromic BCS (NSBCS) a shrinking entity. However, the numerical importance and clinical impact of syndromic BCS (SBCS) versus NSBCS have not been much studied. We retrospectively reviewed our experience with BCS over the last four decades in order to compare prevalence trends in SBCS and NSBCS. 195 patients were treated for BCS during the period 1978-2017: 104 (53.3%) were syndromic, 24 (12.3%) showed clinical and/or familial features suggesting a syndrome, although without final diagnostic confirmation, and 7 (3.5%) had associated extra-cranial malformations suggesting a syndromic context without identified genetic mutation; the remaining 61 (31.3%) were purely NSBCS. Surgery was required earlier in SBCS (21.7months, 95%CI 18.4-25.1) than in NSBCS (29.5months 95%CI 26.4-32.7). Prevalence of hydrocephalus and tonsillar herniation was significantly lower in NSBCS, and mortality concerned only SBCS. Prevalence of NSBC decreased significantly over the study period, likely because of more accurate testing, and decreased slightly over the last decade, possibly because of prenatal testing and abortion. NSBCS is now much less common than SBCS, and has a less aggressive clinical course, with lower rates of hydrocephalus, tonsillar herniation and mortality. This subgroup also deserves attention because it is likely that new discoveries are still to be made.

The metopic suture: Natural history.

The metopic suture (MS) is one of the main sutures of the calvaria; premature closure is responsible for trigonocephaly, while persistence (metopism) is considered a normal variant. The ages of onset and completion of MS closure and prevalence of metopism in normal children are poorly documented. We studied the pattern of MS closure on 3D-CT scans of 477 children admitted for head trauma since 2012. We also studied the prevalence of trigonocephaly and the sex ratio in our clinical series of patients with all types of synostosis diagnosed during the last 4 decades. In the majority of children, MS closure started at 4 months and was complete at 9 months. The prevalence of metopism was stable after 1 year of age, at 5.1%; it was more than twice as frequent in girls (F/M ratio 2.1, non-significant). Our trigonocephaly series and the literature show a steady increase in prevalence over recent decades. During the same period, the prevalence of metopism decreased steadily. Data from comparative anatomy and paleoanthropology suggest that postnatal MS persistence in our species results from the risk of dystocia caused by the closed pelvis associated with bipedalism. The increasing incidence of trigonocephaly appears to parallel the fall in prevalence of metopism. The increasing use of cesarean section may have eliminated a potent selection factor in favor of postnatal persistence of the MS.

[The transition from childhood to adulthood in neurosurgery: a description]. / La transition de l'enfant à l'adulte en neurochirurgie: exposition du problème.

The transition from childhood to adulthood is a difficult period for neurosurgical patients, who are at risk of interrupted follow-up, causing delayed diagnosis of complications and compromised outcome. Many of these patients harbor chronic diseases that have an impact on their adult life, may present new developments and sometimes decompensate suddenly. The authors review their experience with 601 patients treated for hydrocephalus, myelomeningocele, or tumors, and followed after their 20th birthday. Mortality, morbidity and socioprofessional outcome statistics are provided, showing the magnitude of the health problem in this population. The authors then review the obstacles to the transition from childhood to adulthood and propose possible solutions. Some problems stem from the patient's lack of information, remedied by early education. Others involve physicians, whose skills may be fragmented and who lack clinical data; this requires greater awareness of this entity, inclusion of lectures on this topic in the medical curriculum and increased clinical research in this field. Finally, obstacles in hospital organization and healthcare financing require that patient support groups and medical societies unite to lobby for improvements. The problems related to the transition from childhood to adulthood in neurosurgery is a complex one, requiring all participants to be involved in the possible solutions. This endeavor should be regarded as an integral part of the duties of both pediatric and adult neurosurgeons.

[Follow-up of adult patients treated during childhood for hydrocephalus]. / Suivi à l'âge adulte des patients traités dans l'enfance pour hydrocéphalie.

The hydrocephalic patient is at risk throughout life of developing complications that may be severe or even fatal. The neurological, developmental, social and occupational outcome is affected by the sequelae of the initial disease and the consequences of intracranial hypertension, but also by imaginary obstacles. Unless proved otherwise, the patient with a shunt must be considered shunt-dependent; shunt independence is rare and must be proved following a rigorous protocol. The hydrocephalic patient should therefore be followed regularly and for life in neurosurgery to screen for and prevent complications as much as possible. Follow-up also allows patient education and coordination by the neurosurgeon and other specialists such as the neurologist and the physical therapist. Organizing the follow-up of the hydrocephalic patient into adulthood is the responsibility of the neurosurgeon in charge; the modalities of this follow-up will vary depending on local conditions. The patient should be educated on the need for this follow-up and prepared for this transition long before it occurs.

[Follow-up of adult patients with myelomeningocele]. / Suivi à l'âge adulte des patients porteurs de myéloméningocèle.

The adult outcome of spina bifida patients is fraught with multiple problems reflecting the multisystemic nature of the disease. These problems result in both mortality, actually caused in most cases by the shunt, and morbidity, mostly affecting locomotion and sphincter control. These patients can thus lose ambulation and suffer from worsening incontinence and kidney function. The result in the vast majority of cases is a poor functional and socioprofessional outcome. The patients' demands regarding their occupational and affective lives, as well as procreation, must be heard. This requires a multidisciplinary approach, and pediatric and adult, as well as patient education and financial support for maintaining the patient's autonomy and medical acts allowing the viability of continued medical care.

[Benign intracranial hypertension: the role of medical treatment]. / Hypertension intracrânienne bénigne: place du traitement médical.

The goal of medical treatment in benign intracranial hypertension (BIH) is to treat intracranial hypertension symptoms as well as to preserve vision. Reducing the production rate of cerebrospinal fluid can be achieved using acetazolamide and/or furosemide (carbonic anhydrase inhibitors), although acetazolamide is the most effective drug. The use of steroids is debatable in BIH. This review focuses on the pathophysiology of these medications, followed by the report of a series of 16 pediatric patients suffering from BIH (1996-2006). BIH was idiopathic for eight children. Depletive lumbar punctures were effective, but this result was often transient. All children were treated with acetazolamide. Doses of acetazolamide (10-20mg/kg per day) must be given every 8h to respect its kinetics. This treatment has to be continued for at least several months and decreasing the dosage must be progressive. Hypokalemia is always prevented with oral potassium. There was only one true treatment failure requiring surgery. The authors therefore advise acetazolamide as a first-line treatment (combined with etiologic treatment, if available, in cases of nonidiopathic situations) in BIH.

[Phacomatosis and genetically determined tumors: the transition from childhood to adulthood]. / Phacomatoses et tumeurs génétiquement déterminées: la transition enfant-adulte.

Phacomatoses, or neurocutaneous disorders, are a group of congenital and hereditary diseases characterized by developmental lesions of the neuroectoderm, leading to pathologies affecting the skin and the central nervous system. There is a wide range of pathologies affecting individuals at different moments of life. The genetics is variable: while neurofibromatosis 1 and 2, tuberous sclerosis and von Hippel-Lindau disease are all inherited as autosomal dominant traits, Sturge-Weber syndrome is sporadic. Other neurocutaneous disorders can be inherited as autosomal recessive traits (i.e., ataxia-telangiectasia), X-linked (i.e., incontinentia pigmenti) or explained by mosaicism (i.e., hypomelanosis of Ito, McCune-Albright syndrome). In this review, we discuss the major types of neurocutaneous disorders most frequently encountered by the neurosurgeon and followed beyond childhood. They include neurofibromatosis types 1 and 2, tuberous sclerosis, Sturge-Weber syndrome and von Hippel-Lindau disease. In each case, a review of the literature, including diagnosis, genetics and treatment will be presented. The lifespan of the disease with the implications for neurosurgeons will be emphasized. A review of cases, including both pediatric and adult patients, seen in neurosurgical practices in the Lille, France and Lausanne, Switzerland hospitals between 1961 and 2007 is presented to illustrate the pathologies seen in different age-groups. Because the genes mutated in most phacomatoses are involved in development and are activated following a timed schedule, the phenotype of these diseases evolves with age. The implication of the neurosurgeon varies depending on the patient's age and pathology. While neurosurgeons tend to see pediatric patients affected with neurofibromatosis type 1, tuberous sclerosis and Sturge-Weber syndrome, there will be a majority of adult patients with von Hippel-Lindau disease or neurofibromatosis type 2.

[Epilepsy surgery in France]. / La chirurgie de l'épilepsie en France Evaluation de l'activité

We report here the results of the first survey on epilepsy surgery activity in France. Data from a questionnaire sent to 17 centers practicing epilepsy surgery were analyzed. All centers responded; however, all items were not completely documented. Over 50 years, more than 5000 patients have been operated on for drug-resistant epilepsy and more than 3000 patients underwent some invasive monitoring, most often SEEG. Currently, nearly 400 patients (including more than 100 children) are operated on yearly for epilepsy in France. Over a study period varying among centers (from two to 20 years; mean, 9.5 years), results from more than 2000 patients including one-third children were analyzed. Important differences between adults and children, respectively, were observed in terms of location (temporal: 72% versus 4.3%; frontal: 12% versus 28%; central: 2% versus 11%), etiology (hippocampal sclerosis: 41% versus 2%; tumors 20% versus 61%); and procedures (cortectomy: 50% versus 23%; lesionectomy: 8% versus 59%), although overall results were identical (seizure-free rates following temporal lobe surgery: 80.6% versus 79%; following extratemporal surgery: 65.9% versus 65%). In adults, the best results were observed following temporomesial (TM) resection associated with hippocampal sclerosis or other lesions (class I: 83% and 79%, respectively), temporal neocortical (TNC) lesional (82%), while resections for cryptogenic temporal resections were followed by 69% (TM) and 63% (TNC) class I outcome. Extratemporal lesional resections were associated with 71% class I outcome and cryptogenic 43%. In children, the best results were obtained in tumor-associated epilepsy regardless of location (class I: 80%). A surgical complication occurred in 8% after resective surgery - with only 2.5% permanent morbidity - and 4.3% after invasive monitoring (mostly hemorrhagic). Overall results obtained by epilepsy surgery centers were in the higher range of those reported in the literature, along with a low rate of major surgical complications. Growing interest for epilepsy surgery is clearly demonstrated in this survey and supports further development to better satisfy the population's needs, particularly children. Activity should be further evaluated, while existing epilepsy surgery centers as well as healthcare networks should be expanded.

The transition from child to adult in neurosurgery.

The transition from child to adult is a growing concern in neurosurgery. Data documenting long-term follow-up are necessary to define this population's healthcare needs. In order to evaluate the problems posed by the child-to-adult transition in neurosurgery, we have studied the neurological, functional and social outcome of patients treated in our department for tumor of the central nervous system, hydrocephalus or myelomeningocele, and followed beyond the age of eighteen years. A large number of patients suffered from chronic ailments, either sequelae of their initial disease, or delayed complications of their initial treatment, with significant morbidity. The mortality during adulthood was 4.6% in the tumor group, 1.1% in the hydrocephalus group, and zero in the spina bifida group. The proportion of patients employed in normal jobs was 35.6, 18.7 and 11.5% for tumors, hydrocephalus and myelomeningocele respectively. IQ score and performance at school generally overestimated the capacity for social integration. Based on these data and on the available literature, we tried to identify the problems and devise solutions for the management of the transition from child-to-adulthood transition. Many problems present during childhood persist to adulthood, some of which are made more acute because of a more competitive environment, the lack of structures and inadequate medical follow-up. The transition from child to adult must be managed jointly by pediatric and adult neurosurgeons. More clinical research is required in order to precisely evaluate the problems posed by adult patients treated during childhood for the different neurosurgical diseases. Based on these data, a concerted trans-disciplinary approach is necessary, tailored to the specific needs of patients suffering from different diseases.

Grade 1 Spetzler and Martin cerebral ruptured arteriovenous malformations treated by microsurgery: Poor functional outcome is related to injury from haemorrhage.

INTRODUCTION: Ruptured arteriovenous malformations (rAVM) are life-threatening diseases. OBJECTIVE: To evaluate the outcome of patients with grade 1 SPM rAVM after microsurgical treatment. MATERIALS AND METHOD: We retrospectively included 64 consecutive operated patients with a grade 1 SPM rAVM in our institution between 2002 and 2012. Complications related to the surgical procedure were recorded. All patients were re-evaluated 3months after treatment using the modified Rankin Scale score (mRS). Persistent neurological disorders were evaluated 1year after bleeding. Conventional cerebral angiography was performed for each patient immediately after surgical treatment and 1year later. RESULTS: The mean age at diagnosis was 30.8 years. Initial WFNS score was grade 1 in 25 patients, grade 2 in 11 patients, grade 3 in 10 patients, grade 4 in 9 patients and grade 5 in 9 patients. No remnant was left and a new surgery was performed only in a single patient who was initially operated-on under emergency conditions with limited preoperative investigations due to a poor clinical grade. Early postoperative complications related to the surgical procedure were recorded in 7 patients. The mRS score 3months after treatment was ≤2 in 53 patients (83%). Persistent neurological disorders were recorded in 40 patients (62.5%). High initial WFNS score (>2) and the hydrocephalus were significantly associated (P<0.05) to a bad functional outcome (mRS>2). CONCLUSION: Grade 1 rAVM is a life-threatening disease concerning in most cases young patients. Long-term morbidity is often related to the hemorrhagic brain damage and rarely to the AVM resection.

Standard-risk medulloblastoma treated by adjuvant chemotherapy followed by reduced-dose craniospinal radiation therapy: a French Society of Pediatric Oncology Study.

OBJECTIVE: The primary objective of this study was to decrease the late effects of prophylactic radiation without reducing survival in standard-risk childhood medulloblastoma. PATIENTS AND METHODS: Inclusion criteria were as follows: children between the ages of 3 and 18 years with total or subtotal tumor resection, no metastasis, and negative postoperative lumbar puncture CSF cytology. Two courses of eight drugs in 1 day followed by two courses of etoposide plus carboplatin (500 and 800 mg/m(2) per course, respectively) were administered after surgery. Radiation therapy had to begin 90 days after surgery. Delivered doses were 55 Gy to the posterior fossa and 25 Gy to the brain and spinal canal. RESULTS: Between November 1991 and June 1998, 136 patients (median age, 8 years; median follow-up, 6.5 years) were included. The overall survival rate and 5-year recurrence-free survival rate were 73.8% +/- 7.6% and 64.8% +/- 8.1%, respectively. Radiologic review showed that 4% of patients were wrongly included. Review of radiotherapy technical files demonstrated a correlation between the presence of a major protocol deviation and treatment failure. The 5-year recurrence-free survival rate of patients included in this study with all optimal quality controls of histology, radiology, and radiotherapy was 71.8% +/- 10.5%. In terms of sequelae, 31% of patients required growth hormone replacement therapy and 25% required special schooling. CONCLUSION: Reduced-dose craniospinal radiation therapy can be proposed in standard-risk medulloblastoma provided staging and radiation therapy are performed under optimal conditions.

[Functional status, scholastic placement after rehabilitation and follow-up of children with traumatic brain injury: a retrospective study of 48 patients]. / Statut fonctionnel, orientation scolaire en fin de rééducation et organisation du suivi d'enfants traumatisés crâniens: étude rétrospective de 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.