Linda J. Michaud

Predictors of survival and severity of disability after severe brain injury in children.

Seventy-five children, 16 years of age or younger, consecutively admitted to a level I trauma center over a 2-year period with severe nonpenetrating traumatic brain injuries were studied to assess factors predictive of survival and level of disability. The mortality rate was 33%; 31% had good recovery, 12% had moderate disability, 19% had severe disability, and 5% remained in a vegetative state. Factors were analyzed separately for potential effects on survival and, with fatalities excluded, for potential effects on the level of disability in survivors. Clinical status in the field and emergency room, although highly associated with survival, was less predictive of the level of disability in survivors. Glasgow Coma Scale scores 72 hours after injury, especially the motor component, were significantly better predictors of quality of survival. The severity of the brain injury and the presence and severity of extracranial injuries were strongly related both to survival and quality of survival. Chest injuries, in particular, were associated with increased mortality and morbidity, as was level of oxygenation; these factors were highly correlated. Factors most significantly predictive of survival were severity of total injuries as assessed with the Injury Severity Score and pupillary responses in the emergency room; factors most predictive of disability were Glasgow Coma Scale motor responses 72 hours after injury and level of oxygenation in the emergency room. These findings of differential predictive factors for outcomes of survival versus quality of survival have implications relevant both to clinical care and to research involving severely brain-injured children.

Association between injury indices and outcome after severe traumatic brain injury in children

OBJECTIVESn(1) To determine whether indices of traumatic brain injury (TBI) in children are associated with outcome at hospital discharge and 5 to 7 years later; (2) to describe persisting disabilities.nnnDESIGNnRetrospective, uncontrolled study of a cohort of children with severe, nonpenetrating TBI.nnnSETTINGnConsecutive admissions to a level 1 trauma center over 2 years.nnnSUBJECTSnSeventy-five children younger than 17 years old were previously studied to identify predictors of disability at acute care discharge. Thirty-three of the 50 survivors (66%) were enrolled.nnnMAIN OUTCOME MEASURESnA database of variables abstracted from medical records was available from the previous study. Subjects were surveyed about premorbid problems, school, employment, and current function, and school records were reviewed. Using all information, a Glasgow Outcome Scale (GOS) score was assigned 5 to 7 years after TBI. Associations between database variables and GOS score at discharge and follow-up were examined using nonparametric analyses. The odds ratio for good recovery was calculated for all significant associations.nnnRESULTSnLate GOS was good recovery for 27%, moderate disability for 55%, and severe disability for 18%. Discharge GOS scores were related (p < or = .01) to the head Abbreviated Injury Scale score, Injury Severity Scale score, Glasgow Coma Scale (GCS) score measured in the field and at 6, 24, and 72 hours, the length of coma, and initial discharge site. Late GOS scores were related (p < or = .01) to the same variables except the field and 6-hour GCS scores, as well as pupillary responses in the field and the discharge GOS. At follow-up, 64% were independent in mobility, 70% in self-care, and 24% in cognitive items on the Functional Independence Measure. Seventy percent of children received special education services. Employment histories were poor. Most subjects were not receiving neurological or rehabilitation follow-up.nnnCONCLUSIONSnEarly and late outcome after severe TBI are related to variables measured at and after injury. Subjects had long-term educational and vocational problems but often did not utilize the medical model of neurorehabilitation.

Elevated initial blood glucose levels and poor outcome following severe brain injuries in children

To determine whether elevations in blood glucose levels were related to neurologic outcomes following severe brain injuries in children, 54 patients 16 years of age or younger admitted to a regional trauma center with a Glasgow Coma Scale score of 8 or less over a 2-year period were retrospectively reviewed. The mean initial blood glucose level on hospital admission was significantly higher in the 16 patients with outcomes of death or vegetative state in comparison with that of the 38 patients with outcomes of good recovery, moderate disability,or severe disability (288 mg/100 mL vs. 194 mg/100 mL, t = -2.74, p = 0.01). Blood glucose levels correlated significantly with indicators of the severity of the brain injury, which were also related to outcome. In contrast, blood glucose levels did not correlate with indicators of the severity of the extracranial injuries, although the latter were significantly related to outcome. Logistic regression analysis resulted in a model for prediction of outcome which included the Glasgow Coma Scale score on admission and the initial blood glucose level. The odds ratio of a poor outcome in this model in patients with blood glucose levels greater than or equal to 250 mg/100 mL relative to those with lower levels was 8.3 (95% confidence interval 1.3-53.6). A simple prognostic score was derived from the logistic regression which improved upon the prediction of outcome using the Glasgow Coma Scale score alone in those patients with initial blood glucose levels greater than or equal to 250 mg/100 mL.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemangioblastoma of the conus medullaris associated with cutaneous hemangioma

A 6-month-old infant is reported with a spinal cord hemangioblastoma located in the conus medullaris associated with an overlying congenital dermal sinus and cutaneous capillary hemangioma. There were no neurologic deficits either preoperatively or following removal of the tumor. The skin and spinal cord lesions were believed to represent an isolated vascular malformation. This spinal cord hemangioblastoma is unusual because of the age of the patient, manner of clinical presentation, location in the caudal spinal cord, and pathologic characteristics. We review the literature and discuss the associations of spinal cord hemangioblastomas with cutaneous and other lesions.

EMG and MRI are Independently Related toShoulderExternal Rotation Function inNeonatalBrachial Plexus Palsy

Background Few studies exist with regard to the ability of electromyography (EMG) and volumetric magnetic resonance imaging (MRI) of the infraspinatus muscle to complement the physical assessment of active global shoulder external rotation (GER) in the neonatal brachial plexus palsy (NBPP) population. Therefore, the purpose of this study was to evaluate the relationships of EMG and MRI with active GER based on analysis of the infraspinatus muscle. Methods Seventy-four NBPP patients (mean age, 5 y 1 m; range, 1 y 1 m to 13 y 3 m) who had undergone physical examination of the shoulder, EMG evaluation of the infraspinatus muscle, and shoulder MRI were included in this study. The outcome variable active GER was dichotomized into <0 degree active GER (poor) and ≥0 degree active GER (good). The interference pattern on EMG of the infraspinatus muscle was graded on a 6-point scale and dichotomized into ⩽4 and ≥5. On shoulder MRI, infraspinatus muscle volume was measured. The infraspinatus muscle interference pattern and volume were compared with active GER. Results Interference pattern on EMG of the infraspinatus muscle was significantly related to the Mallet Score (P=0.0022), with a poor interference pattern associated with an approximately 7 times higher likelihood [odds ratio=7.391; 95% confidence interval (2.054, 26.588)] of poor active GER. Infraspinatus muscle volume decrease on MRI was also significantly related to active GER (P=0.0413), with each percent volume decrease corresponding to an increase of 0.094 in the odds of having a poor Mallet Score for active GER [odds ratio=1.094; 95% confidence interval (1.004, 1.193)]. Conclusions The interference pattern of the infraspinatus muscle on EMG and the infraspinatus muscle volume on MRI are strongly related to active GER as assessed by the Mallet Score. Integrating clinical assessment with electrophysiological and imaging findings may improve the accuracy in evaluating shoulder dysfunction in NBPP and provide improved guidance in selecting interventions specific to the patients pattern of deficits. Level of Evidence Diagnostic study, level II.

Split cord malformation.

Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. Previously published, in part, as Tsai TJ, Michaud LJ: Split cordmalformation in a child with left foot pronation: A case report. PM R 2009;1:S232. Presented as a poster at the American Academy of Physical Medicine and Rehabilitation 70th Annual Assembly, Austin, Texas, 2009.

Poster 321: “I Forget To Use My Arm When I Dance”: TMS Evidence of Learned Non-Use in Birth Brachial Plexus Palsy: A Case Report

Patients or Programs: 4 cases of pediatric transverse myelitis (TM). Program Description: Patient (Pt) #1: 12-year-old girl with TM at T10 to conus medullaris with sudden onset of bilateral lower extremity (BLE) weakness. She was moderate to maximal assist (max A) in activities of daily living (ADL) and unable to ambulate. Her course was complicated by urinary incontinence, deep vein thrombosis and acute worsening of TM. She improved to modified independence level (mod I) for ambulation and most ADL. Pt #2: 9-year-old boy (M) with progressive BLE weakness diagnosed with TM 4 days after a viral infection. His course was uncomplicated and he was bowel and bladder continent. He required minimal to maxA with ADL on admission and ambulated with circumduction. He improved to supervision for his ADL and ambulated with minimal assist. Pt #3: 13-year-old M with numbness and weakness in all 4 extremities diagnosed with TM at C1-C4 on magnetic resonance imaging (MRI) 18 days after his varicella and hepatitis A vaccines. He required max A for bed mobility (BM), was dependent in his ADL and unable to ambulate on admission. His course was complicated by restrictive pulmonary disease and neurogenic bowel and bladder retention. He is currently continuing inpatient rehabilitation. Pt #4: 13-year-old M diagnosed with TM at C3-T4 after 1 day of BLE weakness and urinary incontinence. He required max A in BM, transfers and ambulation. At discharge he was independent in BM, transfers, bowel and bladder management and mod I with ambulation. Setting: Pediatric acute rehabilitation unit. Results: TM pts vary greatly in their functional abilities preand post-rehabilitation. Discussion: TM is caused by spinal cord inflammation and has various etiologies and outcomes, with the most prevalent deficits in bowel and bladder functions, and ambulation difficulties. Improvements in MRI to localize lesions has led to advances in understanding the disease, the ability to provide anticipatory guidance, and the ability to differentiate it from multiple sclerosis and other postinflammatory conditions. Conclusions: Understanding TM, its causes, course, and complications allows the rehabilitation team to maximize functional gains by better targeting medical and rehabilitation management to overcome both current and future obstacles.