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SUMMARY A detailed neuropathological examination has been undertaken on a consecutive series of head injuries dying in the Institute of Neurological Sciences, Glasgow, between 1968-72 (151 cases) and 1981-82 (112 cases)

SUMMARY Deep intracerebral (basal ganglia) haematomas were found post mortem in 63 of 635 fatal non-missile head injuries. In patients with a basal ganglia haematoma, contusions were more severe, there was a reduced incidence of a lucid interval, and there was an increased incidence of road (22%) females; the age range was 9 weeks to 89 years; and the duration of survival ranged from 1 hour to 14 years 3 months. The majority of the injuries were attributable to road traffic accidents (335; 53%), or to falls (221; 35%). Of the remaining 79 cases, 31 were assaults, three were crush injuries, 14 were other types of injury, while in the remaining 31 cases the circumstances of the injury were not known. There was a fracture of the skull in 478 (75%) of the cases. The clinical records were assessed with particular reference to any deterioration in the level of consciousness after a lucid interval, defined as whether or not the patient had talked a short time after the injury.'0 A full post-mortem examination was undertaken in every case and the brain removed by one of us so that a careful note could be made of any extracerebral lesions, such as the tightness of the dura, and the presence of blood in the extradural or subdural spaces. The brains were then suspended in 10% formol saline for 3-4 weeks before dissection: the cerebral hemispheres were sliced in the coronal plane, the cerebellum at right angles to the folia, and the brain stem horizontally.'" Comprehensive histological studies were undertaken in 434 of the 635 cases. These included the preparation of 30 pm celloidin sections stained by Nissl's method with cresyl violet and by Woelke's modification of Heidenhain's technique for myelin. Representative blocks were also taken from the cerebral hemispheres, the cerebellum

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SUMMARY A comprehensive neuropathological study was undertaken on 87 children aged between 2 and 15 years with fatal head injuries to identify those features which occurred at the time of head injury (fractured skull, contusions, intracranial haematoma and diffuse axonal injury) and those which were subsequently produced by complicating processes (hypoxic brain damage, raised intracranial pressure, infection and brain swelling). The types of brain damage identified were remarkably similar to those seen in adults. The only difference was the prevalence of diffuse brain swelling in children.Trauma is a major cause of death in children,' and in school children it is the most common single cause. Of all accidental deaths, the greatest number are due to head injury."4In our previous studies on fatal non-missile head injury we already drew attention to the prevalence of diffuse brain swelling in children and adolescents5 but *did not study in depth all the types of brain damage that occur in children. There may, therefore, be other differences between the types of brain damage that occur in children and in adults which so far have been overlooked, a knowledge ofwhich might contribute to the management of head injury in children. There are no very good reasons for assuming that there are many differences in the types of brain damage sustained67 as the biomechanics of the injury are similar in all age groups other than in infancy and non-accidental injury, but the time seemed right to analyse in detail brain damage in fatal head injury in children as recorded in our comprehensive database. Material and methodsBetween 1968 and 1982 full necropsies were performed on 635 cases of fatal non-missile head injuries which had been managed by the department of neurosurgery at this institute. There were 497 males and 138 females with an age range of 9 weeks to 89 years (median 36 years) and a duration of survival from one hour to 14 years three months (median two to three days). The brains and spinal cords were fixed in 10% formol saline for at least three weeks before dissection. The cerebral hemispheres were cut in a standard manner8 in the coronal plane, the cerebellum at right angles to Accepted for publication 4 August 1988 18 the folia, and the brain stem horizontally. Comprehensive histological studies, including the examination of large celloidin sections of brain, were carried out on 434 of the 635 cases. Macroscopic and histological abnormalities were recorded on a series of line diagrams of the cerebral hemispheres, the cerebellum, and the brain stem. All abnormalities were then transferred to a proforma and the data stored and analysed on the University of Glasgow's mainframe computer.The present analysis is based on 87 children aged between 2 and 15 years on whom comprehensive histological studies were undertaken. Cases less than 2 years of age were excluded as before this age the brain, skull base, and calvaria differ from those of the adult.9 The clinical records of the children were assessed to establish whether...

A series of 118 patients with diffuse traumatic brain swelling was studied retrospectively in order to compare the clinical findings in children with those in adults, and to determine the occurrence of neurological deterioration and outcome. The computerized tomography (CT) picture of absent third ventricle and basal cisterns was used to identify the cases. Although this condition has been associated with children, we found the same number of children and adults (59 cases each). Secondary deterioration (decline in consciousness, the development of new focal neurological signs, or an increase in intracranial pressure) occurred in 40% of cases and was more common in adults than children. Features that were significantly associated with deterioration were the presence of prolonged coma (> 1 hour) after the injury, CT signs of diffuse axonal injury or subarachnoid hemorrhage, or a recorded episode of hypotension. A moderate or good recovery at 6 months was achieved by 70 patients (59%), but 45 patients had a poor outcome (severe disability in nine, vegetative state in three, and death in 33) and this was often a consequence of secondary deterioration. In three patients, the outcome was not known. The combination of a severe initial injury, secondary insult, and diffuse swelling is associated with a poor outlook, particularly in adults. The CT appearance of diffuse swelling may develop more readily in children because of the lack of cerebrospinal fluid available for displacement. In children, diffuse swelling may have a relatively benign course unless there is a severe primary injury or a secondary hypotensive insult.

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A previously described method of quantifying cerebral contusions in man (the contusion index) caused by non-missile head injury has been modified and applied to a larger series of cases, and used to assess contusions in experimental head injuries. The initial findings in man have been confirmed, viz. that contusions are most severe in the frontal and temporal lobes; that contusions may be entirely absent in a patient dying as a result of a head injury; that there is no correlation between the severity of contusions and the nature of the injury; that the concept of contrecoup must continue to be questioned; that contusions are more severe in patients who have a fracture of the skull in comparison to those who do not; that contusions are more severe in patients who do not experience a lucid interval than in those who do; and that contusions are less severe in patients with diffuse axonal injury than in those who do not have diffuse axonal injury. The distribution of contusions in subhuman primates is similar to that seen in man, and they occur more frequently with short duration than with long duration acceleration.