Ten-year outcome of early childhood traumatic brain injury: Diffusion tensor imaging of the ventral striatum in relation to executive functioning.

PRIMARY OBJECTIVE: The long-term effects of TBI on verbal fluency and related structures, as well as the relation between cognition and structural integrity, were evaluated. It was hypothesized that the group with TBI would evidence poorer performance on cognitive measures and a decrease in structural integrity. RESEARCH DESIGN: Between a paediatric group with TBI and a group of typically-developing children, the long-term effects of traumatic brain injury were investigated in relation to both structural integrity and cognition. Common metrics for diffusion tensor imaging (DTI) were used as indicators of white matter integrity. METHODS AND PROCEDURES: Using DTI, this study examined ventral striatum (VS) integrity in 21 patients aged 10-18 years sustaining moderate-to-severe traumatic brain injury (TBI) 5-15 years earlier and 16 demographically comparable subjects. All participants completed Delis-Kaplan Executive Functioning System (D-KEFS) sub-tests. MAIN OUTCOMES AND RESULTS: The group with TBI exhibited lower fractional anisotropy (FA) and executive functioning performance and higher apparent diffusion coefficient (ADC). DTI metrics correlated with D-KEFS performance (right VS FA with Inhibition errors, right VS ADC with Letter Fluency, left VS FA and ADC with Category Switching). CONCLUSIONS: TBI affects VS integrity, even in a chronic phase, and may contribute to executive functioning deficits.

Corpus callosum diffusion anisotropy correlates with neuropsychological outcomes in twins disconcordant for traumatic brain injury.

Conventional and diffusion tensor MR imaging studies in twins sustaining severe pediatric traumatic brain injury identified reduction in fractional anisotropy (FA) in all regions of the corpus callosum, particularly the posterior body, rostral body, and genu, relative to healthy cotwins. FA from the rostrum, genu, anterior body, posterior body, and isthmus were correlated with measures of reading speed and comprehension; verbal working memory and math fact retrieval scores were correlated only with the rostral body FA.

Word fluency in relation to severity of closed head injury, associated frontal brain lesions, and age at injury in children.

Effects of closed head injury (CHI) severity, focal brain lesions, and age at injury on word fluency (WF) were studied longitudinally in 122 children (78 severe, 44 mild); 112 CHI patients (68 severe, 44 mild CHI) and 104 uninjured normal controls participated in a cross-sectional study. WF was measured by asking the child to generate as many words as possible beginning with a designated letter within 60 s, repeated for three letters. Intellectual ability, receptive vocabulary, narrative discourse, and word list recall were also measured. Results of the cross-sectional study showed a significant group effect with poorer WF in severe CHI than mild CHI and control groups. Growth curve analysis of longitudinal data revealed an interaction of age, follow-up interval, and CHI severity as WF recovery was slower after severe CHI in younger children as compared to severe CHI in older children or mild CHI in younger children. An interaction of left frontal lesion with age and interval indicated a more adverse effect on WF in older children. Right frontal lesion effect was nonsignificant and did not interact with age. Correlations of WF with receptive vocabulary, word list recall, and narrative discourse were moderate and weak with estimated intellectual ability. Differences in focal lesion effects after traumatic versus nontraumatic brain injury in children, the contribution of diffuse white matter injury, reduced opportunity for language development, and functional commitment of left frontal region at time of CHI were discussed.

Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children.

OBJECTIVE: To characterize neuroimaging, physical, neurobehavioral, and developmental findings in children with inflicted and noninflicted traumatic brain injury (TBI) and to identify characteristic features of inflicted TBI. METHODS AND PATIENTS: Forty children, 0 to 6 years of age, hospitalized for TBI who had no documented history of previous brain injury were enrolled in a prospective longitudinal study. TBI was categorized as either inflicted (n = 20) or noninflicted (n = 20) based on the assessment of hospital and county protective services. Glasgow Coma Scale scores and neonatal history were comparable in both groups. OUTCOME MEASURES: Acute computed tomography/magnetic resonance imaging studies and physical findings were evaluated. Glasgow Outcome Scale scores, cognitive development, and motor functioning were assessed an average of 1.3 months after TBI. chi2 analyses assessed differences in the distribution of findings in the inflicted and noninflicted TBI groups. RESULTS: Signs of preexisting brain injury, including cerebral atrophy, subdural hygroma, and ex vacuo ventriculomegaly, were present in 45% of children with inflicted TBI and in none of the children with noninflicted TBI. Subdural hematomas and seizures occurred significantly more often in children with inflicted TBI. Intraparenchymal hemorrhage, edema, skull fractures, and cephalohematomas were similar in both groups. Retinal hemorrhage was only identified in the inflicted TBI group. Glasgow Outcome Scale scores indicated a significantly less favorable outcome after inflicted than noninflicted TBI. Mental deficiency was present in 45% of the inflicted and 5% of the noninflicted TBI groups. CONCLUSIONS: Characteristic features of inflicted TBI included acute computed tomography/magnetic resonance imaging findings of preexisting brain injury, extraaxial hemorrhages, seizures, retinal hemorrhages, and significantly impaired cognitive function without prolonged impairment of consciousness.

Lifetime and novel psychiatric disorders after pediatric traumatic brain injury.

OBJECTIVE: To assess lifetime and current psychiatric disorders at least 1 year after traumatic brain injury (TBI) in children and adolescents. METHOD: Forty-six youths who sustained a TBI between the ages of 6 through 15 years were evaluated at least 1 year post-TBI to identify the presence of lifetime and/or novel psychiatric disorders. Semistructured interviews of the parent and child and standardized parent self-report rating instruments were used. RESULTS: Attention-deficit/hyperactivity disorder and depressive disorders were the most common lifetime and novel diagnoses. A wide variety and high rate of novel psychiatric disorders were identified; 74% of these disorders persisted in 48% of the injured children. Internalizing disorders were more likely to resolve than externalizing disorders. Both interviews and parent ratings were sensitive to current externalizing behaviors; interviews more often detected internalizing disorders, whereas parent ratings also identified cognitive difficulties. CONCLUSIONS: Findings were generally consistent with previous research demonstrating the high rate of novel psychiatric disorders following pediatric TBI. Psychiatric interviews were sensitive in identifying both lifetime and novel disorders.

Porteus Maze performance following traumatic brain injury in children.

To investigate planning in traumatically brain injured children, the authors gave the Porteus Maze Test (PMT; S. D. Porteus, 1959) to 276 pediatric patients who had sustained a traumatic brain injury (TBI) at least 3 years previously. Sensitivity of the PMT to TBI severity, age at test, and volume of focal brain lesions detected by magnetic resonance imaging was also studied. The Peabody Picture Vocabulary Test-Revised (L. M. Dunn & L. M. Dunn, 1981) was also administered as a control measure. Results indicated that the PMT was highly sensitive to TBI severity and to volume of circumscribed prefrontal lesions. In contrast to the PMT data, receptive vocabulary was related to injury severity but not to discrete prefrontal lesions. Implications for mechanisms of cognitive deficit after TBI in children are discussed.

Behavioral changes after closed head injury in children.

This study provides a longitudinal follow-up of the behavioral adjustment of 45 children with mild, moderate, and severe closed head injuries. Two measures of behavioral adjustment, the Child Behavior Checklist (CBCL) and the Vineland Adaptive Behavior Scales (VABS), were obtained from a parent at the time of injury and at 6 and 12 months postinjury. The severely injured children obtained significantly poorer VABS scores than children with mild and moderate injuries over the year-long follow-up. In addition, on the CBCL, severely injured children had more school problems and engaged in fewer social activities than mild and moderately injured children. These results show that severe head injury in children was associated with declines in adaptive functioning, whereas scores for children with mild and moderate injuries did not differ, nor did they deviate from average levels at any follow-up interval.

Gunshot wounds to the brain in children and adolescents: age and neurobehavioral development.

Neurobehavioral outcome after craniocerebral gunshot wounds was evaluated in a prospective, 3-year, longitudinal follow-up of a consecutive case series of 13 children and adolescents. The younger group was composed of seven children, ages 1.5 to 4 years, and the older group contained six children, ages 5 to 14. Outcome measures included the Glasgow Outcome Scale and neuropsychological assessment of intelligence, language, motor, memory, attention, academic achievement, and adaptive behavior. Glasgow Outcome Scale scores at baseline indicated moderate and severe disabilities in 69 and 23%, respectively. At the 3-year follow-up, 85% had moderate disabilities but only 8% were severely disabled. Significant and persistent neurobehavioral deficits varied with developmental level at the time of cerebral insult. Intellectual functioning was clearly more impaired in children younger than 5 years of age at the time of injury than in older children. Cognitive and motor factors were most closely related to deficits in the younger group. Disability in older children and adolescents was associated with impaired attention, adaptive behavior, and behavioral disturbance. Disabilities appear to be at least as severe in our sample after cerebral gunshot wounds as in our studies of severe pediatric closed-head injury. At the time of follow-up, younger children sustaining gunshot wounds had slightly lower intelligence quotient scores and similar receptive language, expressive language, and gross motor scores compared with children with severe closed-head injury. The older gunshot wound patients were significantly more impaired than patients with severe closed-head injuries on measures of adaptive behavior and attention.(ABSTRACT TRUNCATED AT 250 WORDS)

Intracranial penetration due to BB air rifle injuries.

The toy BB gun that was commonly available 20 years ago has been modernized into a weapon with lethal potential. We report four children who had intracranial penetration by BBs. Three were shot by another young child, and the fourth child was injured by an intoxicated adult. Two of the children have permanent, severe neurological sequelae. BB rifles should require the same safety precautions and considerations as more traditional firearms.

The results of treatment of gunshot wounds to the brain in children.

Thirty-three children ranging in age from 8 months to 15 years were treated for gunshot wounds to the brain. Half of the children were less than 10 years old. Fifty-eight percent died. Mortality was influenced by the trajectory of the bullet, intent to commit suicide, and the neurological status immediately after injury. The age and sex of the child and the caliber of the bullet did not influence survival. Three-fourths of the deaths occurred within 24 hours of injury, suggesting these patients had a mortal wound from the onset. Eleven of the children were attempting suicide, 9 of whom died; 13 were playing with a gun, 5 of whom died; 2 were shot as innocent bystanders to crimes in progress; 1 was shot while involved in a criminal act; 1 was shot in a hunting accident; and in 2 who died within minutes of arrival, the circumstances of the shooting were not documented. Of the survivors, none was left vegetative after 6 months, 3 had severe disabilities, 9 were moderately disabled, and 2 had a good outcome. The mortality rate is strikingly similar to that of adults with similar injuries; however, the morbidity appears to be less. On the other hand, with simple preventative measures, virtually each injury would have been avoided.

The Children's Orientation and Amnesia Test: relationship to severity of acute head injury and to recovery of memory.

The Children's Orientation and Amnesia Test (COAT) was developed to assess cognition serially during the early stage of recovery from traumatic brain injury in children and adolescents. The norms for the COAT, which is composed of 16 items evaluating general orientation, temporal orientation, and memory, were defined from data obtained from 146 children aged 3 to 15 years. In 37 patients with head injuries, the duration of posttraumatic amnesia, as indicated by the number of days COAT scores were in the impaired range, was significantly related to both verbal and nonverbal memory at the baseline and 6 and 12 months after injury. COAT scores were a better predictor of verbal and nonverbal memory performance than the Glasgow Coma Scale score at 6 and 12 months after the injury. This study shows that the COAT has adequate reliability and validity as a measure of the duration of posttraumatic amnesia in children and adolescents.

Memory functioning during the first year after closed head injury in children and adolescents.

Effects of the severity of closed head injury (CHI) on verbal learning and memory and visual recognition memory were studied at base line and on a 1-year follow-up examination in 58 pediatric admissions sampled from three age ranges, 6-8, 9-12, and 13-15 years. Within each age range, recovery of memory was compared in patients with mild to moderate CHI and survivors of severe injury. Consistent with previous findings obtained in head-injured children sampled from a wide age range, the present study confirms that memory deficit persists at least 1 year after severe CHI. Impairment of visual recognition memory was directly related to severity of CHI in all three age ranges. The severity of CHI was directly related to initial and residual verbal memory deficit in adolescents, but this effect was inconsistent in children. We suggest that the cerebral substrate for visual recognition memory was well established in all three age ranges and thus was vulnerable to the effects of injury. In contrast, verbal memory skills were undergoing rapid development in the adolescents, but were still immature in children. Extended follow-up could conceivably demonstrate the late appearance of verbal memory deficit in the children who had apparent sparing of function.

Magnetic resonance imaging after closed head injury in children.

Magnetic resonance imaging (MRI) was performed in a series of 21 children and adolescents who had been hospitalized after sustaining closed head injuries of varying severity at least 6 months previously. Areas of high intensity in the parenchyma were present in 8 of the 11 severely injured patients, whereas MRI findings were normal in all 10 patients with mild-to-moderate head injuries. Lesions involving the subcortical white matter were confined to severely injured patients whose clinical features were compatible with diffuse axonal injury. Neuropsychological assessment disclosed deficits primarily in the severely injured patients; these deficits were significantly associated with persistent lesions visualized by MRI. Serial MRI and neurobehavioral assessment following early injury may be useful in documenting cognitive impairment in relation to structural alterations of the young brain.

Crush head injuries in infants and young children neurologic and neuropsychologic sequelae.

Neurologic and neuropsychologic sequelae of crush head injury, which is produced by static forces occurring when the head is stationary and pinned against a rigid structure, were studied prospectively in a series of eight children ranging in age from 13 to 32 months. Hospital course, computed tomographic findings, and neurologic and developmental outcomes were examined. All children sustained pronounced cerebral trauma characterized by multiple fractures throughout the calvaria, extra-axial hemorrhages, and parenchymal contusions. Cranial nerve injuries were noted in three and hemiparesis in two of the cases. Two months after the injury, 63% of the children displayed deficits in either IQ or motor functioning. One year after the injury, five of the six children reevaluated had a good recovery. Motor scores were significantly lower than cognitive scores at baseline and showed the greatest degree of improvement over time. Neuropsychologic outcome after brain injury produced by static loading of the head is more favorable than from traumatic brain injury associated with dynamic loading.

Attentional disturbance after pediatric closed head injury.

The influence of severity of closed head injury and age on attentional functioning was prospectively investigated in 36 children (age range, 7 to 16 years) 6 months after injury. Children were placed into mild, moderate, and severe injury groups using established neurologic criteria. Each child received the Wechsler Intelligence Scale for Children-Revised Digit Span subtest and a continuous performance test. Children with severe closed head injury demonstrated significantly poorer continuous performance test scores than mildly or moderately injured children. Injury severity had no effect on Digit Span scores. Younger children exhibited more pronounced impairment on the continuous performance test relative to uninjured age peers. These results extend the persistence of attentional impairments beyond those of previous reports. Closed head injury is not associated with preferential sparing of sustained attention in younger children 6 months after injury. Brain injury earlier in life may result in delayed vulnerability of information processing skills.

Children's narratives following traumatic brain injury: linguistic structure, cohesion, and thematic recall.

Narrative discourse and intellectual functioning were examined 3 years following traumatic brain injury (TBI) in children 1 to 8 years of age at the time of injury. The language-impaired TBI group (n = 9) had language deficits during the subacute stage of recovery; their performance was contrasted with that of a TBI comparison group equated on neurologic and demographic variables that did not show subacute language impairment (n = 8) and a sibling comparison group (n = 9). The language-impaired TBI group had lower Verbal and Full-Scale IQ scores and produced fewer words and utterances than the sibling group on a story retelling task; their stories were characterized by fewer complete referential and lexical ties and more referential errors, indicating difficulty conjoining meaning across sentences. The language-impaired TBI group recalled approximately one-third of the propositions needed to maintain the story theme and made more errors sequencing the propositions than either the TBI or the sibling comparison groups. Group differences were not obtained on the Performance IQ scores or on measures of rate or fluency of speech production, mazes, use of conjunctives, or naming errors. The discourse deficiencies of children with TBI and acute language impairment were most pronounced at the level of cognitive organization of the text reflecting text macrostructure and were least apparent at the level of lexical and sentential organization reflecting text microstructure. Results are discussed in terms of the vulnerability of developing language abilities to disruption by brain injury.

Narrative discourse after closed head injury in children and adolescents.

This study examined narrative discourse in 20 children and adolescents at least 1 year after sustaining a head injury. Narratives were analyzed along the dimensions of language structure, information structure, and flow of information. Severity of impaired consciousness was associated with a significant reduction in the amount of language and information. The most important finding which emerged was the disruption in information structure. This pattern confirms the impression of disorganized discourse in severely injured children. Explanations for the disruption in information structure are explored in terms of the role of vocabulary, memory, and localization of lesion according to magnetic resonance imaging. In view of recent evidence that frontal lobe damage is associated with discourse formulation deficits in adults and is the most common site of focal lesion in closed head injury, we examined discourse patterns in individual patients with frontal lobe lesions. Preliminary data from our single-case studies suggest discourse patterns similar to those reported for adults with frontal lobe injuries.

Cognitive and neuroimaging findings in physically abused preschoolers.

AIMS: To characterise the cognitive, motor, and language skills of toddlers and preschoolers who had been physically abused and to obtain concurrent MRIs of the brain. METHODS: A between groups design was used to compare a sample of 19 children, aged 14-77 months, who had been hospitalised for physical abuse with no evidence of neurological injury to a comparison group of 19 children matched for age and socioeconomic status. Children underwent cognitive, language, and motor testing within three months of their discharge from the hospital. Caregivers of the injured children were interviewed and were asked to complete questionnaires to characterise the child's developmental level and behaviour just prior to the hospitalisation. RESULTS: Children who had been physically abused scored significantly lower than the comparison group on measures of cognitive functioning, motor skills, and language skills. The groups did not differ in child behaviour ratings completed by the caregivers. MRI of the brain was performed for 15 children in the physical abuse group; two were found to have significant cerebral atrophy. CONCLUSIONS: Children who have been physically abused are at high risk for delays in cognitive, motor, and language development. Standard of care for these children should include developmental testing as well as neuroimaging of the brain to detect occult brain injury.

Inflicted traumatic brain injury: relationship of developmental outcome to severity of injury.

Inflicted traumatic brain injury (TBI) is a frequent consequence of physical child abuse in infants and children. Twenty-eight children who were 2-42 months of age when hospitalized for moderate to severe TBI were enrolled in a prospective, longitudinal study of neurobehavioral outcome following acquired brain injury. Relative to a comparison group, the children with inflicted TBI had significant deficits in cognitive, motor and behavioral domains when assessed with the Bayley Scales of Infant Development-II 1 and 3 months after the injury. Nearly half of the injured children showed persisting deficits in attention/arousal, emotional regulation and motor coordination. Greater injury severity, as indicated by lower coma scale scores, longer periods of unconsciousness and the presence of edema/cerebral infarctions was associated with poorer outcomes in all domains.