Spätfolgen nach Schädelhirntraumen im Säuglings- und Kleinkindalter (1.–5. Lebensjahr)

Abstract

The prognosis of brain injury in young children has generally been considered favorable up to the present. However, longterm follow-up studies in recent years have suggested that expectations for survival and improvement after serious brain injury are less favorable in infants and young children than in older children, adolescents and young adults (13, 24, 25, 29). Since there are few reports in the literature on late sequelae of serious brain injury in infants and young children, we have collected our own follow-up studies in order to contribute to the fund of knowledge concerning brain injury in this age group.

The report is based on a collective treated on the neurosurgical service in Klinikum Westend, Berlin. 62 children up to the age of 5 years were admitted with compound fractures or serious closed brain injuries in the period between 1962 and 1971. The length of the period of unconsciousness following injury was used as a parameter for judging the seriousness of closed brain injuries. Very few young children survived coma lasting more than 1 day, and only 1 infant survived a coma lasting more than 1 week. In addition to children with compound fractures and those with closed brain injury and a period of unconsciousness lasting more than 1 day, we included children with periods of unconsciousness lasting from 1 to 24 hours, with post-traumatic complications with or without unconsciousness and with surgically-treated growing fractures and depressed fractures accompanied by cerebral contusion.

The battered child syndrome was a frequent source of injury in the first 2 years of life. The 3 and 4 year olds were more commonly victims of traffic accidents. Falls from various heights were rather uniformly distributed over the first 5 years of life (Fig. 1).

12 of 62 children died in the acute phase (Fig. 2). Extracranial factors were the cause of death in 2 cases, space-occupying intra-cranial hemorrhage in 4 others, hydrocephalus with brain prolaps into a growing fracture in one case and rapidly-developing cerebral edema in extensive brain contusions in all others.

Extensive neurologic, electroencephalographic, radiological, psychiatric and psychological studies were performed in 35 of the 50 survivors. A CT-scan was performed in 22 cases. The interval between injury and follow-up studies ranged from 4 to 14 years.

6 patients with compound fractures had relatively benign courses (Table I). 2 patients with parietal lobe injuries developed persistent hemiplegia, and 1 child with a comminuted fracture of the anterior fontanelle and an extremely grave condition in the early post-traumatic period suffered a decline in intelligence and developed a serious personality disorder. The rest of the patients were found to have mild behavioral disturbances and selective weaknesses in test performance. The electroencephalogram demonstrated focal activity in all cases and, in 4 patients, seizures activity in the absence of clinically evident seizures. Brain-tissue defects of varying size were found in the CT-scan (Fig. 3).

The 8 patients with closed brain injury and coma lasting more than 1 day demonstrated serious neurologic deficits and psycho-organic sequelae (Table II). The neurologic deficits, present in all cases, consisted primarily of extensive hemiplegia or tetraplegia. Organic brain syndromes were present in all but one patient. Post-traumatic epilepsy developed in 5 cases. The most serious sequelae were found in 2 children who had been battered in the first year of life. Their development in speech, mental faculties and motor function came to a complete halt. 2 other children who had been beaten repeatedly became mentally retarded. CT-scans showed dilatation of the ventricles consequent on atrophy of the white matter in one case, and unilateral cortical atrophy in the other (Fig. 4). The EEG demonstrated pathological changes in every case. Permanent psycho-organic and neurologic deficits were found in 5 of the 6 patients whose period of post-traumatic unconsciousness lasted from 1 to 24 hours (Table III). The electroencephalogram showed focal activity and spikes-and-waves patterns, while the CT-scan demonstrated brain-tissue defects in 4 cases. 7 children were unconscious for very short periods. Of interest in this group is the case of a 4 year old girl with epidural hematoma who presented with progressive neurologic symptoms, but without a secondary loss of consciousness. The children in this group had normal psychological and neurologic findings, though the follow-up EEG demonstrated focal activity and seizure potentials, even after relatively limited injury (Table IV).

Similarly, the 8 patients with depressed or growing fractures and circumscribed brain contusions demonstrated no neurologic or psycho-organic deficits but showed focal activity in the EEG. Seizure potentials were recorded in 3 patients from this group.

On the basis of this study, one may conclude that frequency and gravity of neurologic and psycho-organic sequelae increase with increasing length of the period of post-traumatic unconsciousness (Fig. 6). In addition, other factors, such as extent and location of the primary lesion and herniation caused by cerebral edema, must be taken into consideration. Hydrocephalus with an increase in intracranial pressure is a special danger in young children and may cause irreparable brain damage if surgical decompression is not performed. Late sequelae of brain injury are clearly more severe in infants and young children than in schoolchildren and adolescents, about whom we reported earlier (29). Our results correspond to those reached by Brink et al. (4) and Gros et al. (14). Since the number of cases observed in the single hospital is small, it would appear useful to combine the resources of several institutions in order to study both the prognosis of serious brain injury in early life and the possibilities of improving the prognosis.

Prognosis of brain injuries

Zusammenfassung

Die Arbeit beschäftigt sich mit den Überlebens- und Heilungschancen nach schweren Schädelhirntraumen im Säuglings- und Kleinkindalter. Nach Besprechung der tödlichen Verläufe werden die Nachuntersuchungsergebnisse von 35 im 1.–5. Lebensjahr verletzten Kindern, die im Zehnjahreszeitraum von 1962–1971 in der Neurochirurgischen Universitäts-Klinik aufgenommen worden waren, mitgeteilt. Die Beobachtungsdauer betrug mindestens 4 Jahre, längstens 14 Jahre. Insgesamt bestätigen die Katamnesen die bereits von anderer Seite geäußerte Ansicht, daß die Prognose bei Säuglingen und Kleinkindern ungünstiger ist als bei älteren Kindern und Jugendlichen. Besonders schwerwiegende neurologische und psychische Verletzungsfolgen kamen nach Schädelhirntraumen, die durch Mißhandlungen in den beiden ersten Lebensjahren hervorgerufen waren, zur Beobachtung. Da die Zahl unserer Beobachtungen und auch die anderer Kliniken jeweils nur klein ist, sollte der Frage nach der Prognose schwerer Schädelhirntraumen im frühen Lebensalter und den Möglichkeiten ihrer Verbesserung durch gemeinschaftliche Untersuchungen mehrerer Kliniken nachgegangen werden.