- Michael G. DeGroote School of Medicine, McMaster University, 1280 Main St. W., Hamilton, Ontario, Canada L8S 4K1, USA
- Department of Psychology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, Arizona 85006, USA
- Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, Arizona 85006, USA
Ratan D. Bhardwaj
Department of Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix Children's Hospital, 1919 E. Thomas Rd., Phoenix, Arizona 85006, USA
DOI:10.4103/2152-7806.143742Copyright: © 2014 Badhiwala JH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Badhiwala JH, Blackham JR, Bhardwaj RD. Neuropsychiatric changes following penetrating head injury in children. Surg Neurol Int 31-Oct-2014;5:154
How to cite this URL: Badhiwala JH, Blackham JR, Bhardwaj RD. Neuropsychiatric changes following penetrating head injury in children. Surg Neurol Int 31-Oct-2014;5:154. Available from: http://sni.wpengine.com/surgicalint_articles/neuropsychiatric-changes-following-penetrating-head-injury-in-children/
Background:Penetrating head injuries demand the prompt attention of a neurosurgeon. While most neurosurgical centers are experienced in the acute management of these injuries, less is known about the long-term neuropsychiatric sequelae of penetrating head trauma. In adults, direct injury to the frontal lobe classically has been associated with mental status changes. However, there is less published data in children.
Case Description:We report the case of a 12-year-old boy who suffered a penetrating head injury to the frontal lobes secondary to a self-inflicted gunshot wound, and experienced subsequent resolution of pre-existing bipolar disorder and new onset of attention deficit hyperactivity disorder.
Conclusion:Children with penetrating head injury require close multidisciplinary follow-up in order to monitor, and accordingly implement management strategies, for associated sequelae, including behavioral and neuropsychiatric changes.
Keywords: Behavior, frontal lobe, neuropsychiatry, penetrating head injury, traumatic brain injury
It has been 165 years since Phineas Gage's famous accident – the “American Crowbar Case.”[
Penetrating head injury is rare in children and has been the subject of a few case reports. Its exact incidence is unknown. Reports have been published of pediatric penetrating head injury resulting from metal nails and rods, pencils, kitchen utensils, power tools, stab wounds, and gunshot wounds (GSWs).[
A 12-year-old boy with a 2-year history of bipolar I disorder presented to the hospital with a self-inflicted GSW to the head. This attempted suicide occurred in the context of a major depressive episode. On presentation, the boy's Glasgow Coma Scale (GCS) score was 6. Entry and exit wounds were evident in the left frontal and right temporal regions, respectively. He was fluid resuscitated.
Computed tomography (CT) head revealed bony, soft tissue, and parenchymal injury consistent with a GSW to bilateral frontal lobes [
The patient was rushed to the operating room (OR) for bifrontal craniectomy. Active bleeding from the right distal middle cerebral artery (MCA) was identified and hemostasis achieved. The hematoma associated with the bullet's tract in the right frontal lobe was drained, the falx cerebri crossed, and the hematoma from the left frontal lobe also evacuated. An external ventricular drain (EVD) was inserted.
The patient had a long and complicated hospital stay, including development of a left hemiplegia. Magnetic resonance imaging (MRI) of the head and magnetic resonance angiogram (MRA) of the circle of Willis done on post-operative day 4 showed multiple areas of restricted diffusion in the right MCA distribution, parasagittal frontal lobes, and left frontal lobe, with scattered areas of hemorrhage [
Approximately 2 years prior to the accident, this boy was seen by the psychiatry service for mood lability, anxiety, depression, psychomotor agitation, indiscretion, irritability, and grandiose ideas. His symptoms were consistent with bipolar I disorder by Diagnostic and Statistical Manual of Mental Disorders (DSM) IV criteria, and he was started on lamotrigine and risperidone, with a good response. By 7 months following the accident, the boy's symptoms of bipolar disorder had regressed completely and he no longer required mood-stabilizing or antipsychotic drugs. His depressive symptoms were maintained in full remission for >8 months on citalopram. However, he demonstrated continued hyperactivity, distractibility, and impulsivity. He would poke, pinch, and bite family members and relatives (behaviors not previously demonstrated) and think it was playful. He would also make threatening statements (i.e. “I am going to kill myself” or “I am going to kill someone”), for example, when angered or being disciplined by his mother. These were impulsive statements that he did not wish to carry out minutes after calming down. On examination, he was distractible, requiring persistent redirection. He was given a diagnosis of attention deficit hyperactivity disorder (ADHD) and started initially on methylphenidate and later switched to atomoxetine due to poor tolerance (i.e. side effect of dysphoria). He has demonstrated a good response to therapy. Formal neuropsychological testing was done 6 months following the injury. The patient obtained a full scale IQ score of 93 (average) on the Wechsler Intelligence Scale for Children-IV (WISC-IV). He showed above average verbal comprehension, average working memory, and below average perceptual reasoning and processing speed. Measures of executive function revealed difficulty with inhibition, processing speed, inattention, and alternating attention. The boy's academic functioning was above age-appropriate norms, with the exception of math and reading fluency tasks.
There are three critical dimensions to the case we have presented that should be considered:
Anatomical – i.e. the physical element of traumatic brain injury (TBI), frontal lobe damage Psychiatric/behavioral – i.e. the outward clinical manifestations, including personality changes, regression of bipolar disorder, onset of ADHD, etc Neuropsychological – the link between the former two, i.e. the changes in neurological/psychological function resulting from physical injury to the frontal lobe, and leading to the behavioral or psychiatric disturbances observed clinically.
Anatomical – i.e. the physical element of traumatic brain injury (TBI), frontal lobe damage
Psychiatric/behavioral – i.e. the outward clinical manifestations, including personality changes, regression of bipolar disorder, onset of ADHD, etc
Neuropsychological – the link between the former two, i.e. the changes in neurological/psychological function resulting from physical injury to the frontal lobe, and leading to the behavioral or psychiatric disturbances observed clinically.
The frontal lobe – in particular, prefrontal cortex – is traditionally considered the control center of executive functions.[
In 2002, Anderson[
Anatomical → neuropsychological
There is mounting evidence linking childhood TBI with deficits in executive function crossing each of the above domains.[
Neuropsychological → psychiatric/behavioral
In turn, deficits in executive function have been shown to underlie several psychiatric disorders and behavioral disturbances in children. Poor response inhibition, phonetic fluency, planning, processing speed, and working memory are seen in children with ADHD.[
Anatomical → psychiatric/behavioral
It follows from the above discussion that childhood TBI may have important psychobehavioral sequelae. Indeed, a high rate of novel psychiatric disorders is seen in children after head injury, including ADHD, oppositional defiant disorder (ODD), depression, anxiety, post-traumatic stress symptoms, obsessive–compulsive symptoms, and in very rare reports, bipolar disorder.[
Most of the available studies on the neuropsychological and behavioral outcomes of childhood TBI, as discussed above, have examined closed (i.e. diffuse) head injuries. Thus, it is difficult to discern the isolated effects of frontal lobe injury from these reports. To that end, there is scant literature on the executive function and behavioral sequelae following penetrating head injury in pediatric patients, and in particular, causing primarily frontal lobe damage.
We have described the case of a 12-year-old boy with a past history of bipolar disorder who suffered a GSW penetrating bilateral frontal lobes. Post-injury neuropsychological testing revealed deficits in attention, response inhibition, and processing speed, with normal working memory and IQ. After the injury, this boy's bipolar disorder resolved and he developed a novel psychiatric diagnosis – ADHD. This boy's bipolar disorder has been in complete remission without treatment for over 1.5 years, and his ADHD is well controlled with stimulant medication. While ADHD is frequently reported after childhood head injury, to our knowledge, this would be the first report of regression of bipolar disorder following pediatric TBI. Nonetheless, an important consideration in the differential diagnosis of our patient is organic personality disorder, termed “Personality Change Due to a General Medical Condition” on DSM-IV. Following TBI, a constellation of changes in enduring patterns of behavior (i.e. personality) may develop with characteristics that resemble borderline personality disorder, including irritability and impulsivity.[
The case detailed here is of a child, and the striking neuropsychiatric changes observed clinically may thereby be attributable to early neural and functional plasticity and early vulnerability.[
Postmortem studies have suggested continued maturation of the white matter tracts of the brain into the third decade of life.[
Based on our experience reported here, healthcare practitioners should be aware of the below issues in following a patient after penetrating head injury involving the frontal lobes:
Penetrating injury to the frontal lobe may lead to executive function deficits; hence, neuropsychological testing should form an important component of post-injury follow-up These patients should be monitored for behavioral changes and/or the development of novel psychiatric disorders post-injury; if appropriate, a referral to Child Psychiatry should be arranged Close psychiatric follow-up and assessment is important, especially in patients with a positive past psychiatric history; these patients may experience complete remission of past, and/or the development of novel, psychiatric diagnoses, necessitating change in management.
Penetrating injury to the frontal lobe may lead to executive function deficits; hence, neuropsychological testing should form an important component of post-injury follow-up
These patients should be monitored for behavioral changes and/or the development of novel psychiatric disorders post-injury; if appropriate, a referral to Child Psychiatry should be arranged
Close psychiatric follow-up and assessment is important, especially in patients with a positive past psychiatric history; these patients may experience complete remission of past, and/or the development of novel, psychiatric diagnoses, necessitating change in management.
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