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P212 Headache in children: does age make a difference?
Posters P212 Headache in children: does age make a difference? S. Ravid1 *, J. Genizi1 , E. Shahar1 . 1 Pediatric Neurology, Mayer Children’s Hospital, Haifa, Israel Objective: To compare the learning profile, psychosocial factors, and headache type and clinical features in children of different age groups. Methods: A retrospective records review was conducted on all children presenting to the clinic for primary headache throughout a 1-year period. Charts were reviewed for headache characteristics and diagnosis based on ICHD-I criteria, the child’s learning profile, and associated behavioral and social factors. Clinical indications for neuroimaging and their results were also recorded. Patients were divided according to the age of headache presentation to 3 groups: early onset (under 7 years), prepuberty (7−11 years), and adolescence (12−16 years). The above mentioned evaluation was compared between 3 groups. Results: 108 patients were included at the study. 37 were under 7years, 41 were between 7−11years, and 30 were 12−16 year old. The diagnosis of migraine was more common in the adolescence group comparing to early onset, and the prepubertal group (47% vs. 22% and 32%; p < 0.0014). No significant differences were found between the age groups with regard to headache disability, abnormal neuroimaging results, school performance, associated learning disabilities, or attention deficit disorder. Nevertheless in the early onset group patients had a significantly higher prevalence of behavioral problems (27% vs. 14% and 13%; p < 0.067). Conclusion: Our results suggest that the age of headache onset does not predict relentless headache disability or school performance in children. We may reassure parents that early onset headache does not imply a more severe course or etiology of disease, although behavioral problems may be more common in these children. Reference(s) [1] Brna PM, Dooley JM. Headaches in the pediatric population. Semin Pediatr Neurol (2006) 13: 222 230. [2] Miltunberg D, Louw DF, Sutherland GR. Epidemiology of childhood brain tumors. Can J Neurol Sci (1996) 23:118 122. [3] Wang SJ, Fuh JL, Lu SR, Juang KD. Chonic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology (2006) 66(2): 193 197. [4] Strine TW, Okoro CA, McGuire LC, Balluz LS. The associations among childhood headaches, emotional and behavioral difficulties, and health care use. Pediatrics (2006) 117:1728 1735. [5] Anttila P, Sourander A, Metsahonkala L, Aromaa M, Helenius H, Sillanpaa M. Psychiatric symptoms in children with primary headache. J Am Acad Child Adolesc Psichiatry (2004) 43: 412 419. [6] Pine DS, Cohen P, Brook J. The association between major depression and headache: longitudinal epidemiological study in youth. J Child Adolesc Psychopharmacol (1996) 6: 153 164. [7] Balottin U, Termine C, Nicoli F, Quadrelli M, Ferrari-Ginevra O, Lanzi G. Idiopathic headache in children under six years of age: a follow up study. Headache (2005) 45: 705−15.
P213 Magnetic resonance spectroscopy predicts outcome in children with nonaccidental trauma S. Ashwal1 *, G. Aaen1 , C. Sheridan2 , C. Colbert3 , M. McKenney4 , D. Kido3 , B.A. Holshouser3 . Departments of Pediatrics (Divisions of 1 Child Neurology & 2 Forensic Medicine) and 3 Radiology, and 4 School of Medicine, Loma Linda University, Loma Linda, CA, USA Objective: We evaluated proton magnetic resonance spectroscopic imaging (MRSI) findings in children with traumatic brain injury due to nonaccidental trauma (NAT) early after injury to determine if brain metabolite changes predicted outcome. Patients and Methods: Proton MRSI (1.5T) was acquired (mean 5 d, range 1−30 d) through the level of the corpus callosum in 109 children with confirmed NAT. Regional metabolite
S87 ratios for N-acetylaspartate (NAA)/total creatine (Cr), NAA/ total choline (Cho), Cho/Cr and presence of lactate were measured. Long term outcomes defined as >6 months were collected in 44/109 infants (age 6±6 mo; range 2−20 mo). We dichotomized patients into Good (normal, mild, moderate; n = 32) and Poor (severe, vegetative or dead; n = 12) outcome groups. Results: Infants with poor outcomes were more likely to have lower GCS scores, suffered a cardiopulmonary arrest, been intubated, have retinal hemorrhages, non-reactive pupils and an external ventricular drain placed. They were also more likely on MRI to have intra-axial hemorrhages, global ischemia or extra-axial hemorrhages. Strong correlations were found between reduced NAA/Cr and NAA/Cho ratios (mean total, corpus callosum, frontal white matter (FWM)) and poor outcomes (p < 0.01). Patients with evidence of global ischemic injury as determined by MRI and MRS had much poorer outcomes than those with focal ischemic injury. A logistic regression model using, age, initial GCS, presence of retinal hemorrhages, mean total NAA/Cr ratios and lactate presence correctly predicted outcome in 100% of subjects. Conclusions: Reduced NAA (i.e. neuronal loss/dysfunction) and elevated lactate (altered energy metabolism) correlate with poor neurological outcomes in infants with NAT. MRI or MRS evidence of global ischemic injury is an important predictor of outcome. Our data suggest that MRS performed early after injury can be used for long-term prognosis. P214 Prevalence of cerebral microhemorrhage on susceptibility weighted imaging and correlation with long term outcome in pediatric no S. Ashwal1 *, C. Cobert1 , G. Aaen1 , C. Sheridan1 , D. Kido1 , B.A. Holshouser1 . Departments of Pediatrics (Divisions of 1 Child Neurology and 3 Forensic Medicine) and 2 Radiology, and 4 School of Medicine, Loma Linda University Children’s Hospital, Loma Linda, CA, USA Objective: Susceptibility Weighted Imaging (SWI) is a 3D GRE MRI sequence that enhances the ability to detect blood products in the brain. We used SWI to determine the frequency of cerebral microhemorrhage in children with nonaccidental trauma (NAT) and to determine the value of SWI in predicting long-term outcome. Patients and Methods: MRI, SWI and Proton MRSI (1.5T) were acquired (mean 5d) through the level of the corpus callosum in 56 children (mean age 7 mos) with confirmed NAT. Patients were dichotomized into having (MH+) or not having (MH+) microhemorrhages. We also categorized patients into Good (normal, mild, moderate; n = 32) and Poor (severe, vegetative or dead; n = 12) outcome groups. Results: No differences were observed in age or time to MRI between the MH+ and MH− groups. However, patients with MH had lower GCS scores (8±4) than those without MH (11±4). Patients without MH also were 2 times more likely to have a good outcome than patients with MH (95% CI = 1.1−3.9). Patients with good outcomes were also less likely to have evidence of global ischemic injury (p < 0.002) but we did not observe any differences in the occurrence of abnormal CT scan findings or MRI evidence of extra-axial hemorrhage or contusion. A logistic regression model using, age and initial GCS score predicted 82.1% of outcomes. Adding the presence of microhemorrhages to this base model only slightly increased the ability to predict overall outcome to 83.9%. However, adding the presence of global ischemia further improved outcome prediction to 90.6%. Conclusions: The absence of MH on SWI predicts a good outcome whereas evidence of ischemia on DWI predicts a poor outcome. Together, these variables improved prediction of long-term outcome after NAT compared to clinical variables.
P213 Magnetic resonance spectroscopy predicts outcome in children with nonaccidental trauma S. Ashwal1 *, G. Aaen1 , C. Sheridan2 , C. Colbert3 , M. McKenney4 , D. Kido3 , B.A. Holshouser3 . Departments of Pediatrics (Divisions of 1 Child Neurology & 2 Forensic Medicine) and 3 Radiology, and 4 School of Medicine, Loma Linda University, Loma Linda, CA, USA Objective: We evaluated proton magnetic resonance spectroscopic imaging (MRSI) findings in children with traumatic brain injury due to nonaccidental trauma (NAT) early after injury to determine if brain metabolite changes predicted outcome. Patients and Methods: Proton MRSI (1.5T) was acquired (mean 5 d, range 1−30 d) through the level of the corpus callosum in 109 children with confirmed NAT. Regional metabolite
S87 ratios for N-acetylaspartate (NAA)/total creatine (Cr), NAA/ total choline (Cho), Cho/Cr and presence of lactate were measured. Long term outcomes defined as >6 months were collected in 44/109 infants (age 6±6 mo; range 2−20 mo). We dichotomized patients into Good (normal, mild, moderate; n = 32) and Poor (severe, vegetative or dead; n = 12) outcome groups. Results: Infants with poor outcomes were more likely to have lower GCS scores, suffered a cardiopulmonary arrest, been intubated, have retinal hemorrhages, non-reactive pupils and an external ventricular drain placed. They were also more likely on MRI to have intra-axial hemorrhages, global ischemia or extra-axial hemorrhages. Strong correlations were found between reduced NAA/Cr and NAA/Cho ratios (mean total, corpus callosum, frontal white matter (FWM)) and poor outcomes (p < 0.01). Patients with evidence of global ischemic injury as determined by MRI and MRS had much poorer outcomes than those with focal ischemic injury. A logistic regression model using, age, initial GCS, presence of retinal hemorrhages, mean total NAA/Cr ratios and lactate presence correctly predicted outcome in 100% of subjects. Conclusions: Reduced NAA (i.e. neuronal loss/dysfunction) and elevated lactate (altered energy metabolism) correlate with poor neurological outcomes in infants with NAT. MRI or MRS evidence of global ischemic injury is an important predictor of outcome. Our data suggest that MRS performed early after injury can be used for long-term prognosis. P214 Prevalence of cerebral microhemorrhage on susceptibility weighted imaging and correlation with long term outcome in pediatric no S. Ashwal1 *, C. Cobert1 , G. Aaen1 , C. Sheridan1 , D. Kido1 , B.A. Holshouser1 . Departments of Pediatrics (Divisions of 1 Child Neurology and 3 Forensic Medicine) and 2 Radiology, and 4 School of Medicine, Loma Linda University Children’s Hospital, Loma Linda, CA, USA Objective: Susceptibility Weighted Imaging (SWI) is a 3D GRE MRI sequence that enhances the ability to detect blood products in the brain. We used SWI to determine the frequency of cerebral microhemorrhage in children with nonaccidental trauma (NAT) and to determine the value of SWI in predicting long-term outcome. Patients and Methods: MRI, SWI and Proton MRSI (1.5T) were acquired (mean 5d) through the level of the corpus callosum in 56 children (mean age 7 mos) with confirmed NAT. Patients were dichotomized into having (MH+) or not having (MH+) microhemorrhages. We also categorized patients into Good (normal, mild, moderate; n = 32) and Poor (severe, vegetative or dead; n = 12) outcome groups. Results: No differences were observed in age or time to MRI between the MH+ and MH− groups. However, patients with MH had lower GCS scores (8±4) than those without MH (11±4). Patients without MH also were 2 times more likely to have a good outcome than patients with MH (95% CI = 1.1−3.9). Patients with good outcomes were also less likely to have evidence of global ischemic injury (p < 0.002) but we did not observe any differences in the occurrence of abnormal CT scan findings or MRI evidence of extra-axial hemorrhage or contusion. A logistic regression model using, age and initial GCS score predicted 82.1% of outcomes. Adding the presence of microhemorrhages to this base model only slightly increased the ability to predict overall outcome to 83.9%. However, adding the presence of global ischemia further improved outcome prediction to 90.6%. Conclusions: The absence of MH on SWI predicts a good outcome whereas evidence of ischemia on DWI predicts a poor outcome. Together, these variables improved prediction of long-term outcome after NAT compared to clinical variables.