Advanced Neuromonitoring and Imaging in Pediatric Traumatic Brain Injury

While the cornerstone of monitoring following severe pediatric traumatic brain injury is serial neurologic examinations, vital signs, and intracranial pressure monitoring, additional techniques may provide useful insight into early detection of evolving brain injury. This paper provides an overview of recent advances in neuromonitoring, neuroimaging, and biomarker analysis of pediatric patients following traumatic brain injury

A Pilot Study Identifying Brain-Targeting Adaptive Immunity in Pediatric Extracorporeal Membrane Oxygenation Patients with Acquired Brain Injury

OBJECTIVES: Extracorporeal membrane oxygenation provides short-term cardiopulmonary life support, but is associated with peripheral innate inflammation, disruptions in cerebral autoregulation, and acquired brain injury. We tested the hypothesis that extracorporeal membrane oxygenation also induces CNS-directed adaptive immune responses which may exacerbate extracorporeal membrane oxygenation-associated brain injury. DESIGN: A single center prospective observational study. SETTING: Pediatric and cardiac ICUs at a single tertiary care, academic center. PATIENTS: Twenty pediatric extracorporeal membrane oxygenation patients (0-14 yr; 13 females, 7 males) and five nonextracorporeal membrane oxygenation Pediatric Logistic Organ Dysfunction score matched patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Venous blood samples were collected from the extracorporeal membrane oxygenation circuit at day 1 (10-23 hr), day 3, and day 7 of extracorporeal membrane oxygenation. Flow cytometry quantified circulating innate and adaptive immune cells, and CNS-directed autoreactivity was detected using an in vitro recall response assay. Disruption of cerebral autoregulation was determined using continuous bedside near-infrared spectroscopy and acquired brain injury confirmed by MRI. Extracorporeal membrane oxygenation patients with acquired brain injury (n = 9) presented with a 10-fold increase in interleukin-8 over extracorporeal membrane oxygenation patients without brain injury (p \u3c 0.01). Furthermore, brain injury within extracorporeal membrane oxygenation patients potentiated an inflammatory phenotype in adaptive immune cells and selective autoreactivity to brain peptides in circulating B cell and cytotoxic T cell populations. Correlation analysis revealed a significant relationship between adaptive immune responses of extracorporeal membrane oxygenation patients with acquired brain injury and loss of cerebral autoregulation. CONCLUSIONS: We show that pediatric extracorporeal membrane oxygenation patients with acquired brain injury exhibit an induction of pro-inflammatory cell signaling, a robust activation of adaptive immune cells, and CNS-targeting adaptive immune responses. As these patients experience developmental delays for years after extracorporeal membrane oxygenation, it is critical to identify and characterize adaptive immune cell mechanisms that target the developing CNS

Is Hypothermia Therapy An Effective Treatment In Improving Survival Rates In Pediatrics Patients That Have Suspected Brain Injuries?

Objective: The objective of this selective EBM review is to determine whether or not therapeutic hypothermia is an effective treatment in improving survival rates in pediatric patients that have suspected brain injuries. Study Design: Two randomized control trials and one cohort analysis published in 2015 to 2016 were selected based on their relevance to the clinical question. Data Sources: Studies were obtained by searching PubMed, OVID, Medline databases. All articles were published in English and peer viewed journals. Outcome Measured: The outcome measured was survival rates at 12-month post injury compared between the groups that received therapeutic hypothermia or normotherapy in pediatric patients. Results: All three studies reviewed did not find a statistically significant improvement in survival rates at 12 months with the use of therapeutic hypothermia in pediatric patients with brain injuries. There was a variation between studies on therapeutic hypothermia technique and duration utilized, injury to treatment times, as well as type of brain injury sustained. Conclusions: The results of the systematic review of the three studies showed that therapeutic hypothermia does not improve survival rates at the 12-month mark following an acute brain injury in pediatric patients at this time. However, it should be stated that further investigation in the subject matter should include similar hypothermia therapy techniques, faster injury to treatment times, and larger sample sizes

Delayed and progressive damages to juvenile mice after moderate traumatic brain injury

Symptoms are commonly more severe in pediatric traumatic brain injury (TBI) patients than in young adult TBI patients. To understand the mechanism, juvenile mice received a controlled cortical impact (CCI) injury at moderate level. Tissue lesion and cell death were measured and compared to our previous reports on brain injury in the young adult mice that received same level of impact using same injury device. Tissue lesion and cell death in the cortex was much less in the juvenile mouse brain in the first few hours after injury. However, once the injury occurred, it developed more rapidly, lasted much longer, and eventually led to exaggerated cell death and a 32.7% larger tissue lesion cavity in the cortex of juvenile mouse brain than of young adult mouse brain. Moreover, we found significant cell death in the thalamus of juvenile brains at 72 h, which was not commonly seen in the young adult mice. In summary, cell death in juvenile mice was delayed, lasted longer, and finally resulted in more severe brain injury than in the young adult mice. The results suggest that pediatric TBI patients may have a longer therapeutic window, but they also need longer intensive clinical care after injury

Diverging volumetric trajectories following pediatric traumatic brain injury.

Traumatic brain injury (TBI) is a significant public health concern, and can be especially disruptive in children, derailing on-going neuronal maturation in periods critical for cognitive development. There is considerable heterogeneity in post-injury outcomes, only partially explained by injury severity. Understanding the time course of recovery, and what factors may delay or promote recovery, will aid clinicians in decision-making and provide avenues for future mechanism-based therapeutics. We examined regional changes in brain volume in a pediatric/adolescent moderate-severe TBI (msTBI) cohort, assessed at two time points. Children were first assessed 2-5 months post-injury, and again 12 months later. We used tensor-based morphometry (TBM) to localize longitudinal volume expansion and reduction. We studied 21 msTBI patients (5 F, 8-18 years old) and 26 well-matched healthy control children, also assessed twice over the same interval. In a prior paper, we identified a subgroup of msTBI patients, based on interhemispheric transfer time (IHTT), with significant structural disruption of the white matter (WM) at 2-5 months post injury. We investigated how this subgroup (TBI-slow, N = 11) differed in longitudinal regional volume changes from msTBI patients (TBI-normal, N = 10) with normal WM structure and function. The TBI-slow group had longitudinal decreases in brain volume in several WM clusters, including the corpus callosum and hypothalamus, while the TBI-normal group showed increased volume in WM areas. Our results show prolonged atrophy of the WM over the first 18 months post-injury in the TBI-slow group. The TBI-normal group shows a different pattern that could indicate a return to a healthy trajectory

Frequency of neuroimaging for pediatric minor brain injury is determined by the primary treating medical department

To investigate the use of neuroimaging in children and adolescents with minor brain injury in pediatric and non-pediatric departments.In this observational cohort study data were extracted from a large German statutory health insurance (AOK Plus Dresden ∼3.1 million clients) in a 7-year period (2010-2016). All patients with International Classification of Diseases (ICD) code S06.0 (concussion; minor brain injury; commotio cerebri) aged ≤ 18 years were included. Demographic and clinical data were analyzed by logistic regression analysis for associations with the use of CT and MRI (independent variables: gender, age, length of stay, pediatric vs non-pediatric department, university vs non-university hospital).A total of 14,805 children with minor brain injuries (mean age 6.0 ± 5.6; 45.5% females) were included. Treatment was provided by different medical departments: Pediatrics (N = 8717; 59%), Pediatric Surgery (N = 3582, 24%), General Surgery (N = 2197, 15%), Orthopedic Trauma Surgery (N = 309, 2.1%). Patients admitted to pediatric departments (Pediatrics and Pediatric Surgery) underwent head CT-imaging significantly less frequently (3.8%) compared to patients treated in non-pediatric departments (18.5%; P < .001; General Surgery: 15.6%; Orthopedic Trauma Surgery: 39.2%). Logistic regression confirmed a significantly higher odds ratio (OR) for the use of cranial CT by the non-pediatric departments (OR: 3.2 [95-%-CI: 2.72-3.76]).CT was significantly less frequently used in pediatric departments. Educational efforts and quality improvement initiatives on physicians, especially in non-pediatric departments may be an effective approach to decreasing rates of CT after minor traumatic brain injuries

Non-visible penetrating brain trauma: a case report

Objective: One of the most frequent causes of death and acquired disability in the pediatric population is the Traumatic Brain Injury (TBI). TBI is secondary to falls, road traffic and vehicle collisions, child abuse and assaults. Penetrating brain injury is a severe form of traumatic brain injury. Blunt head injury is more frequent than TBI in children, but the second one carries a poor prognosis and a worse outcomes. Case Presentation: We report a pediatric case of penetrating craniofacial trauma, caused by a pencil in to the eye, and the successful of multidisciplinary management. Conclusion: Traumatic head injuries in children are frequently seen in the emergency ward, but the penetrating head injuries are unusual in young children. This case shows the importance of the 'first golden hour' after head trauma. The collaboration between team members, added to a promptly and invasive strategy, allowed to reduce neurological sequelae

A cognitive profile of South African children with traumatic brain injury

Includes bibliographical references (leaves 86-105).Research conducted on pediatric populations have shown that an event such as a traumatic brain injury (TBI) experienced in childhood can lead to persistent neuropsychological deficits months, even years post-injury. However, there still exists a dearth of research on pediatric TBI (pTBI), more so in developing countries like South Africa as most pediatric studies have been conducted on Western populations. This situation underlines the need for more research in the field of pTBI