Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management

In utero and post-natal opioid exposure followed by mild traumatic brain injury contributes to cortical neuroinflammation, mitochondrial dysfunction, and behavioral deficits in juvenile rats

Maternal opioid use poses a significant health concern not just to the expectant mother but also to the fetus. Notably, increasing numbers of children born suffering from neonatal opioid withdrawal syndrome (NOWS) further compounds the crisis. While epidemiological research has shown the heightened risk factors associated with NOWS, little research has investigated what molecular mechanisms underly the vulnerabilities these children carry throughout development and into later life. To understand the implications of in utero and post-natal opioid exposure on the developing brain, we sought to assess the response to one of the most common pediatric injuries: minor traumatic brain injury (mTBI). Using a rat model of in utero and post-natal oxycodone (IUO) exposure and a low force weight drop model of mTBI, we show that not only neonatal opioid exposure significantly affects neuroinflammation, brain metabolites, synaptic proteome, mitochondrial function, and altered behavior in juvenile rats, but also, in conjunction with mTBI these aberrations are further exacerbated. Specifically, we observed long term metabolic dysregulation, neuroinflammation, alterations in synaptic mitochondria, and impaired behavior were impacted severely by mTBI. Our research highlights the specific vulnerability caused by IUO exposure to a secondary stressor such as later life brain injury. In summary, we present a comprehensive study to highlight the damaging effects of prenatal opioid abuse in conjunction with mild brain injury on the developing brain.

Stem Cell Therapy in Children with Traumatic Brain Injury

Pediatric traumatic brain injury is a cause of major mortality, and resultant neurological sequelae areassociated with long-term morbidity. Increasing studies have revealed stem cell therapy to be a potential new treatment. However, much work is still required to clarify the mechanism of action of effective stem cell therapy, type of stem cell therapy, optimal timing of therapy initiation, combination of cocurrent medical treatment and patient selection criteria. This paper will focus on stem cell therapy in children with traumatic brain injury.

Age predicts likelihood for surgery for pediatric tbi: an analysis of 1745 hospitlizations from a Chinese Children's Hospital

PURPOSE

We tested the role of age and sex in surgery following pediatric TBI hospitalization.

METHODS

Records of 1745 children hospitalized at a pediatric neurotrauma center in China included age, sex, cause of injury, diagnosis of injury, days of hospitalization, in-house rehabilitation, Glasgow Coma Scale score, mortality, 6-month post-discharge Glasgow Outcome Scale score, and surgery intervention. The children were 0-13 years (M= 3.56 years; SD = 3.06), with 47.4% 0-2 years of age.

RESULTS

The mortality rate was 1.49%. Logistic regression on 1027 children with epidural hematoma, subdural hematoma, intracerebral hemorrhage, and intraventricular hemorrhage showed that controlling for other variables, the odds for younger children to receive surgery was statistically lower for epidural hematomas (OR = 0.75; 95% CI = 0.68-0.82), subdural hematomas (OR = 0.59; 95% CI = 0.47-0.74), and intraventricular hemorrhage (OR = 0.52; 95% CI = 0.28-0.98).

CONCLUSIONS

While severity of TBI and type of TBI were expected predictors for surgery, a younger age also predicted a significantly lower likelihood of surgery in our sample. Sex of the child was unrelated to surgical intervention.

Family-centred service in paediatric acquired brain injury rehabilitation: perspectives of children and adolescents and their families

PURPOSE

Family-centred service is considered best practice in paediatric acquired brain injury (ABI) rehabilitation. However, there is no universal model to guide clinicians and services in implementing this approach with a lack of research evidence informed by the lived experience of families. This study explored experiences of family-centred service during rehabilitation from the perspectives of parents/caregivers, siblings, and children/adolescents with ABI.

MATERIALS AND METHODS

Semi-structured interviews were conducted with participants from eight families, and included 10 parents/caregivers, five siblings, and four children/adolescents with moderate to severe ABI. Interview transcripts and additional data were analysed using constructivist grounded theory methods.

RESULTS

Two themes and five sub-themes were developed: (1) Working together as a team: Valuing clinicians' expert knowledge; Doing rehabilitation together; and Sharing family knowledge; and (2) Navigating rehabilitation as a family: Recognising family needs; Juggling family life; and Making rehabilitation work for the family. Participants reflected on the centrality of the child/adolescent with ABI during rehabilitation, and the ways that family needs, life, and involvement in rehabilitation change over time.

CONCLUSIONS

These findings highlight the importance of clinicians actively seeking to understand families' unique contexts, needs, and priorities during rehabilitation through two-way information sharing with families. Through developing a greater understanding of families' unique contexts, clinicians can be better placed to tailor rehabilitation according to their unique circumstances and needs.Implications for rehabilitationRehabilitation involves active collaboration between families and clinicians that is responsive to changing needs over time.Family involvement in rehabilitation is shaped by family life, and families have unique needs following paediatric acquired brain injury.It is important that clinicians strive to develop an understanding of families' unique needs, values, preferences, and lives to determine how to best support and involve them in rehabilitation.

An international survey of assessment and treatment practice for discourse in paediatric Acquired Brain Injury

PURPOSE

Guidelines recommend routine discourse assessment and treatment in paediatric acquired brain injury (ABI) but provide little guidance for clinical practice. The degree to which this has influenced the nature of discourse assessment and treatment in clinical practice has not been examined in detail.

METHOD

Speech-language pathologists working in paediatric ABI (clients aged <18 years) in Australia, New Zealand, the UK, the USA, Canada, and the Asia Pacific region were invited to complete a survey of discourse assessment and intervention practices (n = 77).

RESULT

Clinicians from Australia and New Zealand comprised over half of a responses (53%). The largest proportion had over 10 years' experience (60%), worked in the metropolitan area (58%), and with secondary school-age children (64%). Routine discourse assessment was undertaken by 80% of respondents, focussing on a limited range of genres. No preferred intervention approach was identified. One-quarter of clinicians routinely considered holistic factors during clinical decision-making. Limited normative data and treatment evidence, insufficient time and training were identified as clinical barriers.

CONCLUSION

Assessment practices were consistent with guidelines, yet interventions were highly variable, reflecting limited evidence, client heterogeneity, time constraints, and limited training. A biopsychosocial approach to practice was evident, yet a focus on impairment level factors was prominent. Findings support the need for standardised discourse assessment and discourse intervention methods. Translation into practice guidelines would promote consistency and confidence in clinical practice.

Correlation Between Clinical Findings at Admission and Glasgow Outcome Scale Score in Children with Traumatic Brain Injury

OBJECTIVE

Traumatic brain injury has different pathophysiology and outcomes in children and adults. This study investigated the relationship between clinical and laboratory findings at admission and Glasgow Outcome Scale (GOS) score in children with traumatic brain injury.

METHODS

This prospective cross-sectional single-center study enrolled 444 children 1-16 years old admitted to the neurosurgery ward from 2016 to 2020. Clinical data and laboratory information were extracted from the records of these patients at admission, and the relationship with GOS score at discharge was investigated.

RESULTS

The 444 patients include 249 (56.08%) boys and 195 (43.92%) girls with a mean age of 7.32 ± 4.4 years. There was no correlation between GOS score and sex (P = 0.12), age (P = 0.16), serum potassium level (P = 0.08), platelet level (P = 0.21), and blood glucose (P = 0.18). There was a significant relationship between GOS score and hypotension (P = 0.03), hyponatremia (P = 0.04), prothrombin time (P = 0.03), partial thromboplastin time (P = 0.03), pupil size (P = 0.02), pupil reaction to light (P = 0.04), and Glasgow Coma Scale score (P = 0.04).

CONCLUSIONS

Clinical and laboratory findings such as hypotension, hyponatremia, prothrombin time, partial thromboplastin time, pupil size, pupil reaction to light, and Glasgow Coma Scale score at admission could affect GOS score at discharge and result in poor outcomes in children with traumatic brain injury.

Epidemiological study of paediatric traumatic brain injury in Brazil

Background

Traumatic brain injury (TBI) has a high economic and social impact on the family dynamics, particularly among children. High-quality and comprehensive epidemiological studies about TBI in this population are limited worldwide, specifically in Latin America. Therefore, this study aimed to elucidate the epidemiology of TBI among children in Brazil and its effects on the public health system.

Methods

This epidemiological (cohort) retrospective study collected data from the Brazilian healthcare database between 1992 and 2021.

Results

The mean annual volume of hospital admission (HA) due to TBI in Brazil was 29,017. Moreover, the incidence of TBI in the paediatric population was 45.35 admissions per 100,000 inhabitants/year. Furthermore, approximately 941 paediatric hospital deaths per year were caused by TBI, with an in-hospital lethality rate of 3.21%. The average annual financial transfer for TBI was 12,376,628 USD, and the mean cost per admission was 417 USD. In addition, the mean length of hospital stay was 4.2 days. Notably, the length of stay in the hospital was longer among males, Afro-Brazilians patients and individuals aged 15-19 years.

Conclusion

Paediatric TBI is an important public health issue worldwide with high social and economic costs. The incidence of paediatric TBI in Brazil is similar to that in developing countries. Moreover, male predominance (2.3:1) was observed in relation paediatric TBI. Notably, during the pandemic, the incidence of paediatric HA has decreased. To the best of our knowledge, this is the first epidemiological study that specifically evaluates paediatric TBI in Latin America.

High-Fat Diet Exacerbates Stress Responsivity in Juvenile Traumatic Brain Injury

Abstract Traumatic brain injury (TBI) is one of the leading causes of death for children in the United States. Juveniles are more likely to sustain TBIs than most other age groups, and TBI has been shown to result in increased anxiety and stress behaviors. In addition, the hypothalamic-pituitary-adrenal (HPA) axis has previously been shown to become dysregulated after a TBI. Further, many children consume diets high in saturated fats and refined sugars, which are also connected to alterations in HPA axis function and behavior disorders. The goal of the current study was to identify a potential relationship between high-fat diet (HFD) consumption and TBI on HPA axis function in juvenile rats. In the present study, male juvenile Long-Evans rats were fed either a combination of an HFD with a high-fructose corn syrup solution or a standard chow diet. On post-natal Day 30, subjects sustained either a sham TBI or a TBI via the Closed-Head Injury Model of Engineered Rotational Acceleration (CHIMERA). Subjects participated in a trial of the open field test (OFT) following injury. In addition, some rats performed in an acute restraint stress test. All subjects were euthanized 7 days post-injury. Brain and blood plasma samples were collected for use in real-time polymerase chain reaction (RT-PCR), immunohistochemistry, and corticosterone or adrenocorticotropic hormone (ACTH) assays. Immediately following TBI, injured juveniles had increased time to righting and walking, with HFD-fed TBI rats having increased time to walking over Chow-fed TBI rats. HFD-fed TBI rats had a reduced number of entries to the center of the OFT, in addition to reduced time spent in the center compared with HFD Sham controls and Chow TBI rats. During the acute restraint stress test, HFD-fed TBI rats had elevated pre-stress ACTH and corticosterone and post-stress ACTH levels. Pre-stress ACTH levels were significantly elevated in HFD TBI compared with Chow TBI. Further, pre-stress ACTH:corticosterone ratios were elevated in HFD TBI compared with Chow TBI. cFos immunoreactivity in the paraventricular nucleus (PVN) of the hypothalamus following the acute restraint stress test was elevated in HFD-fed TBI rats. HFD TBI rats had greater activation of cFos in the PVN compared with Chow TBI. In addition, RT-PCR showed significantly reduced expression of relevant HPA axis genes, NR3C1, NR3C2, and CRHR2, in the hypothalamus of TBI subjects compared with Sham subjects. Further, AVP and CRHR2 in the hypothalamus were significantly reduced in HFD TBI compared with Chow TBI. These results offer evidence that TBI paired with high-fat diet consumption can cause HPA axis dysfunction, resulting in more anxiety-like behaviors.

Advanced Neuromonitoring Modalities on the Horizon: Detection and Management of Acute Brain Injury in Children

Timely detection and monitoring of acute brain injury in children is essential to mitigate causes of injury and prevent secondary insults. Increasing survival in critically ill children has emphasized the importance of neuroprotective management strategies for long-term quality of life. In emergent and critical care settings, traditional neuroimaging modalities, such as computed tomography and magnetic resonance imaging (MRI), remain frontline diagnostic techniques to detect acute brain injury. Although detection of structural and anatomical abnormalities remains crucial, advanced MRI sequences assessing functional alterations in cerebral physiology provide unique diagnostic utility. Head ultrasound has emerged as a portable neuroimaging modality for point-of-care diagnosis via assessments of anatomical and perfusion abnormalities. Application of electroencephalography and near-infrared spectroscopy provides the opportunity for real-time detection and goal-directed management of neurological abnormalities at the bedside. In this review, we describe recent technological advancements in these neurodiagnostic modalities and elaborate on their current and potential utility in the detection and management of acute brain injury.

Psychometric Properties of the German Version of the Quality of Life after Brain Injury Scale for Kids and Adolescents (QOLIBRI-KID/ADO) Using Item Response Theory Framework: Results from the Pilot Study

Health-related quality of life (HRQOL) is an important indicator for recovery after pediatric TBI. To date, there are a few questionnaires available for assessing generic HRQOL in children and adolescents, but there are not yet any TBI-specific measures of HRQOL that are applicable to pediatric populations. The aim of the present study was to examine psychometric characteristics of the newly developed Quality of Life After Brain Injury Scale for Kids and Adolescents (QOLIBRI-KID/ADO) questionnaire capturing TBI-specific HRQOL in children and adolescents using an item response theory (IRT) framework. Children (8-12 years; n = 152) and adolescents (13-17 years; n = 148) participated in the study. The final version of the QOLIBRI-KID/ADO, comprising 35 items forming 6 scales, was investigated using the partial credit model (PCM). A scale-wise examination for unidimensionality, monotonicity, item infit and outfit, person homogeneity, and local independency was conducted. The questionnaire widely fulfilled the predefined assumptions, with a few restrictions. The newly developed QOLIBRI-KID/ADO instrument shows at least satisfactory psychometric properties according to the results of both classical test theoretical and IRT analyses. Further evidence of its applicability should be explored in the ongoing validation study by performing multidimensional IRT analyses.

Hemorrhagic Shock Due to Traumatic Anterior Cerebral Artery Aneurysm: A Case Report

Massive subdural hematomas are known to cause hemorrhagic shock in infants and young children. Traumatic cerebral aneurysms are rare and are often noticed in the subacute phase with disorientation due to the rupture of a pseudoaneurysm. No previous studies appear to have clarified the diagnosis of and therapeutic interventions for traumatic cerebral aneurysms identified from computed tomography (CT) on admission. The present case involved an open skull fracture resulting in hemorrhagic shock due to subcutaneous extravasation from an anterior cerebral artery (ACA) pseudoaneurysm. A seven-year-old boy was accidentally struck by a car after running out into a road. He had an open fracture of the skull and contrast-enhanced CT of the head showed subcutaneous extravasation from the ACA. The patient developed hemorrhagic shock that resolved following the embolization of the ACA with n-butyl-2-cyanoacrylate. Head trauma can cause hemorrhagic shock in the presence of an open wound due to a skull fracture. Contrast-enhanced CT of the head on admission is useful for diagnosis.

Conventional MR Imaging in Trauma Management in Pediatrics

Traumatic brain injury (TBI) is a major cause of death and disability in children across the world. The aim of initial brain trauma management of pediatric patients is to diagnose the extent of TBI and to determine if immediate neurosurgical intervention is required. A noncontrast computed tomography is the recommended diagnostic imaging choice for all patients with acute moderate to severe TBI. This article outlines the current use of conventional MR imaging in the management of pediatric head trauma and discusses potential future recommendations.

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France

Importance

Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines.

Objectives

To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request.

Design, Setting, and Participants

This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022.

Exposure

All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines.

Main Outcomes and Measures

Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture.

Results

Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians.

Conclusion and Relevance

In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.

Invasive Neuromonitoring Modalities in the Pediatric Population

Invasive neuromonitoring has become an important part of pediatric neurocritical care, as neuromonitoring devices provide objective data that can guide patient management in real time. New modalities continue to emerge, allowing clinicians to integrate data that reflect different aspects of cerebral function to optimize patient management. Currently, available common invasive neuromonitoring devices that have been studied in the pediatric population include the intracranial pressure monitor, brain tissue oxygenation monitor, jugular venous oximetry, cerebral microdialysis, and thermal diffusion flowmetry. In this review, we describe these neuromonitoring technologies, including their mechanisms of function, indications for use, advantages and disadvantages, and efficacy, in pediatric neurocritical care settings with respect to patient outcomes.

Fish oil fat emulsion alleviates traumatic brain injury in mice by regulation of microglia polarization

Microglia activation, a hallmark of brain neuroinflammation, contributes to the secondary damage following traumatic brain injury (TBI). To explore the potential roles of different fat emulsions-long chain triglyceride (LCT) / medium chain triglyceride (MCT) and fish oil (FO) fat emulsion in neuroprotection and neuroinflammation in TBI, in this study, we first generated the controlled cortical impact (CCI) model of TBI mice. Then either LCT/MCT or FO fat emulsion treated mice were studied by Nissl staining to assess the lesion volume. Sham and TBI mice treated with 0.9% saline were used as controls. The fatty acid composition in different TBI mouse brains was further evaluated by gas chromatography. Immunofluorescent staining and quantitative RT-PCR both demonstrated the suppression of pro-inflammatory microglia and upregulated anti-inflammatory microglia in FO fat emulsion treated TBI brain or primary microglia induced by lipopolysaccharide (LPS) in vitro. Furthermore, motor and cognitive behavioral tests showed FO fat emulsion could partially improve the motor function in TBI mice. Together, our results indicate that FO fat emulsion significantly alleviates the TBI injury and neuroinflammation probably by regulating microglia polarization.

Ocular Motor Nerve Palsy After Traumatic Brain Injury: A Claims Database Study

BACKGROUND

Traumatic brain injury (TBI) is one of the common causes of ocular motor nerve (oculomotor nerve [CN3], trochlear nerve [CN4], and abducens nerve [CN6]) palsies, but there has been no large study of ocular motor nerve palsy caused by TBI. This study aimed to investigate the characteristics of and differences in ocular motor nerve palsy after TBI, according to patient age and severity of TBI.

METHODS

This was a population-based retrospective cohort study that included patients who had ocular motor nerve palsy after TBI with ≥6 months of continuous enrollment using claims data from the IBM MarketScan Research Databases (2007-2016). We assessed sex, age at the first diagnosis of TBI, the severity of TBI, and the rates of strabismus procedures according to the age and severity of TBI. The rates of muscle transposition surgery and chemodenervation in CN3, CN4, and CN6 palsy were investigated.

RESULTS

A total of 2,606,600 patients with TBI met the inclusion criteria. Among them, 1,851 patients (0.071%) had ocular motor nerve palsy after TBI. The median age of the patients was 39 (Q1-Q3: 19-54) years, and 42.4% of the patients were female. The median continuous enrollment period after the first diagnosis of TBI was 22 (Q1-Q3: 12-38) months. Of the 1,350,843 children with TBI, 454 (0.026%) had ocular motor nerve palsy. Of the 1,255,757 adults with TBI, 1,397 (0.111%) had ocular motor nerve palsy. Among these 1,851 patients, CN4 palsy (697, 37.7%) occurred most frequently, and strabismus procedures were performed in 237 patients (12.8%). CN6 palsy developed most frequently in children. More children (16.5%) underwent strabismus surgeries than adults (11.6%) ( P = 0.006). The proportion of CN4 palsy (52.3%) was higher while the proportion of CN3 palsy (15.5%) was lower in patients with mild TBI than in patients with moderate-to-severe TBI ( P < 0.001).

CONCLUSIONS

CN4 palsy developed most frequently among patients of all ages, and only approximately 13% of the patients underwent strabismus procedures for ocular motor nerve palsy after TBI. The rate of development of ocular motor nerve palsy was approximately 4.3 times lower in children than adults, and children most frequently had CN6 palsy after TBI.

Mitophagy and Traumatic Brain Injury: Regulatory Mechanisms and Therapeutic Potentials

Traumatic brain injury (TBI), a kind of external trauma-induced brain function alteration, has posed a financial burden on the public health system. TBI pathogenesis involves a complicated set of events, including primary and secondary injuries that can cause mitochondrial damage. Mitophagy, a process in which defective mitochondria are specifically degraded, segregates and degrades defective mitochondria allowing a healthier mitochondrial network. Mitophagy ensures that mitochondria remain healthy during TBI, determining whether neurons live or die. Mitophagy acts as a critical regulator in maintaining neuronal survival and healthy. This review will discuss the TBI pathophysiology and the consequences of the damage it causes to mitochondria. This review article will explore the mitophagy process, its key factors, and pathways and reveal the role of mitophagy in TBI. Mitophagy will be further recognized as a therapeutic approach in TBI. This review will offer new insights into mitophagy's role in TBI progression.

A bibliometric analysis on traumatic brain injury in forensic medicine of a half-century (1972-2021)

Traumatic brain injury (TBI) is among the most common injuries in forensic medicine, the identification of which is of particular importance in forensic practice. To reveal the circumstances and trends of TBI in the forensic field, we used the Web of Science (WoS) database for comprehensive retrieval. We made a metrological analysis of 1,089 papers in the past 50 years (1972-2021). The United States and Germany have the most forensic research on TBI. Diffuse axonal injury (DAI) has been the focus of attention for many years, and much effort has been devoted to its diagnosis in forensic pathology. Infants and children are the subgroups of most concern, especially in infant and child abuse cases. Research on identifying shaken baby syndrome has received increasing attention in recent years. Overall, our study provides a comprehensive list and analysis of the articles regarding TBI in legal medicine, which may shed light on recognizing the trends and research hotspots in this field.

Thromboelastography and Its Use in Pediatric Trauma Patients

BACKGROUND/PURPOSE

Thromboelastography's (TEG's) use in pediatric trauma patients is not widely studied. Identifying clotting cascade defects can direct decision making regarding blood product transfusion.

METHODS

We performed a single-center retrospective review of all level 1 pediatric trauma patients. Data collected included demographics, diagnoses, Injury Severity Score, intensive care unit length of stay (ICU LOS), mortality, TEG values, and blood products received. We identified TEG values associated with mortality, ICU LOS, and need for blood product transfusion.

RESULTS

A total of 237 trauma 1 patients were identified. After exclusions, 148 patients were included for analysis. Most patients were below TEG transfusion cut points. Patients with elevated reaction time, K value, and fibrinolysis at 30 minutes had increased odds of mortality with odds ratios of 1.71 (95% confidence interval [CI], 1.22-2.40), 1.94 (95% CI, 1.23-3.05), and 1.15 (95% CI, 1.03-1.28), respectively. For ICU LOS, elevated reaction time, K value, and fibrinolysis at 30 minutes, α angle, and maximum amplitude demonstrated hazard ratios of 0.76 (95% CI, 0.65-0.88), 0.82 (95% CI, 0.64-1.0), 0.95 (95% CI, 0.88-0.99), 1.05 (95% CI, 1.02-1.08), and 1.04 (95% CI, 1.01-1.06), respectively. There was no association between TEG and blood product transfusion.

CONCLUSIONS

Coagulopathic patients based on TEG had higher mortality. All TEG values, as they moved toward transfusion-trigger cut points, were associated with increased mortality.

It's a Hard Knock Life: How Kids With Mild Traumatic Brain Injuries Are Treated

OBJECTIVES

The diagnosis and treatment of mild traumatic brain injuries (mTBIs) by emergency medicine providers is greatly varied. Because of the frequency and long-term consequences associated with pediatric head injuries, it is crucial that adequate counseling is provided in acute care settings. The purpose of our study is to evaluate existing practices at Loyola University Medical Center emergency department to address inconsistencies in diagnostic or discharge practices and determine future quality improvement measures.

METHODS

A retrospective cohort study was conducted at an academic hospital emergency department of patient records from 2017 to 2020. Demographic, diagnostic, and discharge data were summarized, and Pearson χ2 tests and Fisher exact tests were performed to determine associations among patient characteristics and provider practices.

RESULTS

A total of 1160 patients met inclusion criteria for analysis. In terms of diagnostic procedure, 31.6% of providers did not uniformly use existing screening criteria, such as PECARN, to determine if CT scans were needed for mTBI evaluation. Most discharge instructions were based on a generalized template on epic (91.9%). Only a minority of providers prepared patient-specific instructions through written, verbal, or other supplemental materials. The most common formats included epic only (46.1%), epic and personalized written instructions (20.2%), and epic and verbal instructions (12.4%). Follow-up care instructions were provided to 93% of patients who received discharged instructions, mainly for primary care (96.7%), sports medicine (1.58%), neurology (0.65%), or other providers (1.11%).

CONCLUSIONS

There is a lack of consistency in the evaluation and education of mTBI in pediatric patients. There is a need for personalized discharge instructions to ensure adequate patient and parent understanding and compliance. Further studies looking at long-term outcomes in these patients would also be beneficial.

Investigation of the effectiveness of vagus nerve stimulation for pediatric drug-resistant epilepsies secondary to nonaccidental trauma

PURPOSE

Epilepsy following non-accidental trauma (NAT) occurs in 18% of pediatric patients. About 33% of patients with epilepsy develop drug-resistant epilepsy. For these patients, vagus nerve stimulation (VNS) is a palliative treatment option. We aimed to investigate the effectiveness of VNS among pediatric NAT-related epilepsy patients compared to those with non-NAT-related epilepsy.

METHODS

We performed an 11-year retrospective analysis of VNS implantations for drug-resistant epilepsy at UPMC Children's Hospital of Pittsburgh. Patients were split into two groups: NAT vs. non-NAT. The primary outcome was the attainment of ≥ 50% seizure frequency reduction at 1-year post-VNS implantation. Fisher's exact tests and Wilcoxon rank-sum tests were used to compare groups. Significance was assessed at the alpha = 0.05 level.

RESULTS

This analysis included data from 370 pediatric VNS patients, of whom 9 had NAT-related epilepsy. NAT patients had a significantly younger age of epilepsy onset than non-NAT patients (0.3 years vs. 3.3 years). Otherwise, there were no statistically significant baseline differences between groups, including patient sex and quantity of antiseizure medications pre-VNS. Overall, 71% of NAT patients experienced ≥ 50% seizure frequency reduction compared to 48% of non-NAT patients (p = 0.269).

CONCLUSION

VNS may allow a higher proportion of pediatric patients with NAT-related epilepsy to achieve ≥ 50% seizure frequency reduction compared to other epilepsy etiologies. While the results of this study were not statistically significant, the effect size was large. Our results underscore the need for larger, multi-center studies to validate the effectiveness of VNS for this patient population.

Underreporting of Traumatic Brain Injuries in Pediatric Craniomaxillofacial Trauma: A 20-Year Retrospective Cohort Study

BACKGROUND

Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes.

METHODS

An institutional review board-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P≤ 0.05 was considered statistically significant.

RESULTS

Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05).

CONCLUSIONS

Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Psychometric Properties of the German Version of the Rivermead Post-Concussion Symptoms Questionnaire in Adolescents after Traumatic Brain Injury and Their Proxies

The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) assesses post-concussion symptoms (PCS) after traumatic brain injury (TBI). The current study examines the applicability of self-report and proxy versions of the German RPQ in adolescents (13-17 years) after TBI. We investigated reliability and validity on the total and scale score level. Construct validity was investigated by correlations with the Post-Concussion Symptoms Inventory (PCSI-SR13), Generalized Anxiety Disorder Scale 7 (GAD-7), and Patient Health Questionnaire 9 (PHQ-9) and by hypothesis testing regarding individuals' characteristics. Intraclass correlation coefficients (ICC) assessed adolescent-proxy agreement. In total, 148 adolescents after TBI and 147 proxies completed the RPQ. Cronbach's α (0.81-0.91) and McDonald's ω (0.84-0.95) indicated good internal consistency. The three-factor structure outperformed the unidimensional model. The RPQ was strongly correlated with the PCSI-SR13 (self-report: r = 0.80; proxy: r = 0.75) and moderately-strongly with GAD-7 and PHQ-9 (self-report: r = 0.36, r = 0.35; proxy: r = 0.53, r = 0.62). Adolescent-proxy agreement was fair (ICC [2,1] = 0.44, CI_95% [0.41, 0.47]). Overall, both self-report and proxy assessment forms of the German RPQ are suitable for application in adolescents after TBI. As proxy ratings tend to underestimate PCS, self-reports are preferable for evaluations. Only if a patient is unable to answer, a proxy should be used as a surrogate.

Family-centred service in paediatric acquired brain injury rehabilitation: Bridging the gaps

Background

Children and adolescents who sustain an acquired brain injury (ABI) can experience acute and ongoing difficulties in a range of cognitive and functional domains, and their families often experience significant life changes and challenges. Family-centred service is therefore considered best practice in paediatric ABI rehabilitation. Despite widespread acceptance of family-centred service in this context, recent literature indicates that family needs are often unrecognised and unmet following paediatric ABI. Although family-centred service was introduced in the field of developmental disability over five decades ago, there remains a lack of clarity about how this approach is implemented in practice. Additionally, limited literature has discussed the implementation of family-centred service in paediatric ABI rehabilitation despite key differences between ABI and developmental disability, including nature and timing of onset, rehabilitation foci, and impacts on families.

Aims

In this review, we aim to: (i) outline common sequelae of paediatric ABI with a focus on family outcomes; (ii) summarise paediatric rehabilitation and highlight opportunities for family support and involvement; (iii) discuss and synthesise literature across paediatric ABI rehabilitation and family-centred service to highlight gaps in knowledge and practice; and (v) identify clinical implications and future research directions.

Conclusions

There is a clear need for greater clarity and consensus regarding the implementation of family-centred service in paediatric ABI rehabilitation. This review highlights the importance of providing professional development opportunities for clinicians to increase competency in practising in a family-centred manner, and opportunities to actively involve, empower and support families within rehabilitation. This review also emphasises the importance of services implementing relevant supports to address family needs where possible and developing clear referral pathways so that families can access further support elsewhere when needed.

Pediatric traumatic brain injury in a high-income developing country: experience at a level 1 neuro-trauma center

BACKGROUND

Data on the incidence, prevalence and mortality of pediatric traumatic brain injuries (TBIs) in developing countries are not readily available or do not exist.

AIM

The aim of this study was to study the epidemiology of pediatric TBI in developing countries.

METHODS

A retrospective study was conducted in a high-volume Neurosurgery Department where we reviewed pediatric cases presenting with TBI between January 2015 and December 2019. Data were collected from the electronic medical records including the patients' demographics, neuro-vital signs, mechanism of TBI and treatment types. Radiological images were screened, and patients were classified according to the type of intracranial hemorrhage. The patient's outcome and Glasgow Coma Scale on discharge were also recorded.

RESULT

Nine hundred and eighty-five cases with TBI were admitted over the period of 5 years. The average age was 53.3 months standard deviation (SD) of 39.4. Male gender accounted for 63.7% of the cases. The most common mechanisms of injuries were falls and road traffic accidents/motor vehicle collisions (63.3%, 18.3%), respectively. Nausea and vomiting followed by altered consciousness and drowsiness were the commonest presenting symptoms. Mild TBI accounted for 85.2% of the cases and the majority (92.08%) were treated conservatively (P < 0.005). 93.3% of the cases were categorized as mild head injury upon discharge. The mortality rate was 1.6% in severe TBI cases.

CONCLUSION

Children less than 4 years of age were highly affected by TBI. This study gives emergency physicians and neurosurgeons in developing countries an expectation about TBI in pediatric cases and the immediate management to prevent further complications.

The effect of birth order on length of hospitalization for pediatric traumatic brain injury: an analysis of the 1987 Finnish birth cohort

Purpose

This study examines the relationship between birth order and length of hospitalization due to pediatric traumatic brain injury (TBI).

Methods

We prospectively followed 59,469 Finnish newborns from 1987 until age 18 years. Data on first diagnosis of TBI was recorded within the 1987 Finnish Birth Cohort (FBC). Hospitalization period was divided into two categories: 2 days or less and more than 2 days. The latter was considered in this study as longer hospitalization.

Results

Compared with first born siblings, later born siblings had an increased risk of a longer hospitalization for TBI (12.7% of fourth or higher born birth children diagnosed with TBI were hospitalized for 2 or more days, 11.3% of first born, 10.4% of third born and 9.0% of second born). Fourth or higher born children were more likely to experience a repeat TBI; 13.4% of fourth or higher born children diagnosed with TBI had 2–3 TBIs during the study period compared to 9% of third born, 7.8% of second born and 8.8% of the first born. Injuries in the traffic environment and falls were the most common contributors to pediatric TBI and occurred most frequently in the fourth or higher birth category; 29.3% of TBIs among fourth or higher birth order were due to transport accidents and 21% were due to falls.

Conclusions

This study revealed a significant increase in risk for longer hospitalization due to TBI among later born children within the same sibling group. The study provides epidemiological evidence on birth order as it relates to TBI, and its potential to help to explain some of the statistical variability in pediatric TBI hospitalization over time in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00919-x.

Multiple Head Rotations Result in Persistent Gait Alterations in Piglets

Multiple/repeated mild traumatic brain injury (mTBI) in young children can cause long-term gait impairments and affect the developmental course of motor control. Using our swine model for mTBI in young children, our aim was to (i) establish a reference range (RR) for each parameter to validate injury and track recovery, and (ii) evaluate changes in gait patterns following a single and multiple (5×) sagittal rapid non-impact head rotation (RNR). Gait patterns were studied in four groups of 4-week-old Yorkshire swine: healthy (n = 18), anesthesia-only sham (n = 8), single RNR injury (n = 12) and multiple RNR injury (n = 11). Results were evaluated pre-injury and at 1, 4, and 7 days post-injury. RR reliability was validated using additional healthy animals (n = 6). Repeated mTBI produced significant increases in gait time, cycle time, and stance time, as well as decreases in gait velocity and cadence, on Day One post-injury compared to pre-injury, and these remained significantly altered at Day Four and Day Seven post-injury. The gait metrics of the repeated TBI group also significantly fell outside the healthy RR on Day One, with some recovery by Day Four, while many remained altered at Day Seven. Only a bilateral decrease in hind stride length was observed at Day Four in our single RNR group compared to pre-injury. In sum, repeated and single sagittal TBI can significantly impair motor performance, and gait metrics can serve as reliable, objective, quantitative functional assessments in a juvenile porcine RNR TBI model.

The epidemiology of pediatric traumatic brain injury presenting at a referral center in Moshi, Tanzania

Background

Over 95% of childhood injury deaths occur in low- and middle-income countries (LMICs). Patients with severe traumatic brain injury (TBI) have twice the likelihood of dying in LMICs than in high-income countries (HICs). In Africa, TBI estimates are projected to increase to upwards of 14 million new cases in 2050; however, these estimates are based on sparse data, which underscores the need for robust injury surveillance systems. We aim to describe the clinical factors associated with morbidity and mortality in pediatric TBI at the Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania to guide future prevention efforts.

Methods

We conducted a secondary analysis of a TBI registry of all pediatric (0–18 years of age) TBI patients presenting to the KCMC emergency department (ED) between May 2013 and April 2014. The variables included demographics, acute treatment and diagnostics, Glasgow Coma Scores (GCSs, severe 3–8, moderate 9–13, and mild 14–15), morbidity at discharge as measured by the Glasgow Outcome Scale (GOS, worse functional status 1–3, better functional status 4–6), and mortality status at discharge. The analysis included descriptive statistics, bivariable analysis and multivariable logistic regression to report the predictors of mortality and morbidity. The variables used in the multivariable logistic regression were selected according to their clinical validity in predicting outcomes.

Results

Of the total 419 pediatric TBI patients, 286 (69.3%) were male with an average age of 10.12 years (SD = 5.7). Road traffic injury (RTI) accounted for most TBIs (269, 64.4%), followed by falls (82, 19.62%). Of the 23 patients (5.58%) who had alcohol-involved injuries, most were male (3.6:1). Severe TBI occurred in 54 (13.0%) patients. In total, 90 (24.9%) patients underwent TBI surgery. Of the 21 (5.8%) patients who died, 11 (55.0%) had severe TBI, 6 (30.0%) had moderate TBI (GCS 9–13) and 3 (15.0%) presented with mild TBI (GCS>13). The variables most strongly associated with worse functional status included having severe TBI (OR = 9.45) and waiting on the surgery floor before being moved to the intensive care unit (ICU) (OR = 14.37).

Conclusions

Most pediatric TBI patients were males who suffered RTIs or falls. Even among children under 18 years of age, alcohol was consumed by at least 5% of patients who suffered injuries, and more commonly among boys. Patients becoming unstable and having to be transferred from the surgery floor to the ICU could reflect poor risk identification in the ED or progression of injury severity. The next steps include designing interventions to reduce RTI, mitigate irresponsible alcohol use, and improve risk identification and stratification in the ED.

Misdiagnosis of Pediatric Concussions in the Emergency Department: A Retrospective Study

OBJECTIVE

We aimed to determine the rate and predictors of correctly diagnosed concussions in the pediatric emergency department and to describe the characteristics, presentation, and management of concussions in children presenting for minor head injury.

METHODS

We included 186 patients aged 5 to 18 years presenting within 24 hours of minor head injuries and met our diagnostic criteria for concussion. We compared patients correctly diagnosed with a concussion with those who were not. Our main outcome was the rate and predictors of misdiagnoses.

RESULTS

Of the patients, 5.4% were correctly diagnosed. Amnesia was the only variable associated with correct diagnoses (40.0% vs 10.2%, P = 0.02). The most common mechanism of injury was fall (8.4%); the most frequent symptoms were nausea/vomiting (42.5%), and 48.4% had a brain computed tomography scan done.

CONCLUSIONS

The high rate of concussion misdiagnosis puts into question the usability of current concussion guidelines, their accuracy, and barriers to translation into clinical practice.

Profile of Pediatric Traumatic Brain Injury in South-West Nigeria

BACKGROUND

Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children. In Nigeria, there is paucity of information about TBI in children. We describe the profile of pediatric TBI in a university hospital in South-West Nigeria.

METHODS

A retrospective study of children who had TBI from 2012 to 2022 was performed. Data were extracted from the neurosurgery database. Patient demographics, etiology/patterns of injuries, clinical/radiologic findings, management, and outcomes were assessed. We performed simple descriptive analyses.

RESULTS

Pediatric TBIs represented 20% (128) of the head injury admissions (631). There was male preponderance (male/female = 1.8:1); most patients were adolescents (29%). In total, 61%, 18%, and 21% had mild, moderate, and severe TBI, respectively. Road traffic crashes were responsible for 74% of cases, with motorcycle accidents (46%) much greater than motor vehicular accidents (28%), mostly pedestrian (51%). Fall from heights accounted for 21%, mostly in toddlers. A total of 70% had associated injuries, mainly skull fractures (54%) and soft-tissue injuries (47%). In total, 31% had post-traumatic seizures. Only 40 (31%) had a cranial computed tomography scan. Common findings were contusions in 70%, extradural hematomas in 28%, and intracranial aerocoeles in 18%. There were no neurosurgical lesions in 20%. Six had operative intervention. Mortality rate was 12%. In total, 84% had good recovery. The average follow-up period was 7 months.

CONCLUSIONS

Children account for a large number of TBIs in our environment, which are mostly from road traffic crashes and falls. Only a few received computed tomography scan of the brain. Most cases had nonoperative care, and outcomes are worse with increasing severity of head injury. Specific preventive measures need to be formulated and/or enforced by governments at all levels.

Association between Day-to-Day Pulsatility Index Change and Neurocognitive Outcomes in Pediatric Traumatic Brain Injury

Traumatic brain injury (TBI) remains a significant cause of morbidity and mortality in children despite advances in prevention and mitigation strategies. Transcranial Doppler (TCD) ultrasound measures cerebral arterial circulation and allows for the calculation of pulsatility indices (PIs), which provides an assessment of cerebral blood flow changes. Yet, the use of PIs in children with TBI is not well understood. In this study, we defined the day-to-day (DTD) PI change of the anterior cerebral circulation and describe its relationship with injury characteristics and neurocognitive outcomes in children with TBI. A prospective observational parent study of 42 children, 2 months to 15 years of age, with mild or moderate-severe TBI who had serial TCDs provided data for this analysis. Both the mean and variation of DTD PI change were evaluated in the context of injury severity, injury sidedness, and neurocognitive outcome. In those with a unilateral injury, a larger mean DTD PI change in both the injured and uninjured side was found in those with a worse Glasgow Outcome Scale-Extended Pediatrics score at discharge. A larger variation in PI was associated with a worse neurocognitive outcome, irrespective of injury severity. Therefore, the mean and variation of DTD PI change may serve as a potential cerebral vascular biomarker of ongoing secondary injury. The use of PI measurements in the monitoring of children with TBI may provide clinicians with new diagnostic and prognostic insights to inform therapeutic interventions and recovery strategies. However, a larger prospective study is needed to confirm these findings and elucidate potential mechanistic links between DTD PI and clinical outcome measures. To our knowledge, this study is the first of its kind to evaluate the use of PI changes in cerebral vasculature in pediatric TBI patients admitted to the hospital.

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience

Background: Intracranial hypertension (IC-HTN) is significantly associated with higher risk for an unfavorable outcome in pediatric trauma. Intracranial pressure (ICP) monitoring is widely becoming a standard of neurocritical care for children. Methods: The present study was designed to evaluate influences of IC-HTN on clinical outcomes of pediatric TBI patients. Demographic, injury severity, radiologic characteristics were used as possible predictors of IC-HTN or of functional outcome. Results: A total of 118 pediatric intensive care unit (PICU) patients with severe TBI (sTBI) were included. Among sTBI cases, patients with GCS < 5 had significantly higher risk for IC-HTN and for mortality. Moreover, there was a statistically significant positive correlation between IC-HTN and severity scoring systems. Kaplan−Meier analysis determined a significant difference for good recovery among patients who had no ICP elevations, compared to those who had at least one episode of IC-HTN (log-rank chi-square = 11.16, p = 0.001). A multivariable predictive logistic regression analysis distinguished the ICP-monitored patients at risk for developing IC-HTN. The model finally revealed that higher ISS and Helsinki CT score increased the odds for developing IC-HTN (p < 0.05). Conclusion: The present study highlights the importance of ICP-guided clinical practices, which may lead to increasing percentages of good recovery for children.

Application of Image Processing Technology in the Diagnosis of Football Injury

With the hot development of football, sports injuries caused by football have also received special attention. In football games, although there are medical staff on and off the field always on call to protect the safety of players, because of the complexity of diagnosis work, medical staff can easily lead to diagnostic errors due to factors such as fatigue, which seriously affects the condition of athletes. Image processing is a technology that uses computer to process images, which can greatly overcome the uncertain factors brought by manual diagnosis. Based on this, this paper uses image processing technology and pattern recognition as technical means to explore the specific application of image processing in football injury diagnosis. This paper firstly takes football clubs as the main research object and analyzes and explores the specific utility of image segmentation and feature recognition in sports injury image processing. Then, starting from the relevant image features, the paper analyzes and compares the sensitivity of support vector machine pattern recognition and neural network pattern recognition in football injury diagnosis. This article comprehensively summarizes the application of image processing technology in the diagnosis of football injuries and puts forward constructive suggestions for its subsequent development. Experiments show that the effect of pattern recognition is often different for different injury parts of football. Among them, the sensitivity of pattern recognition based on image processing can reach 68.9%, and the detection rate of football injuries can also be maintained at about 81.2%. This fully shows that image processing technology can play an active role in the actual football injury diagnosis, and provide very valuable information for clinical diagnosis.

Sex specific effects of buprenorphine on behavior, astrocytic opioid receptor expression and neuroinflammation after pediatric traumatic brain injury in mice

Children who suffered traumatic brain injury (TBI) often experience acute and chronic pain, which is linked to a poor quality of life. Buprenorphine (BPN) is commonly used to treat moderate to severe persistent pain in children, however, the efficacy and safety profile of BPN in the pediatric population is still inconclusive. This study investigated the sex-specific effects of BPN on body weight, motor coordination and strength, expression of opioid receptors in the white matter astrocytes, and neuroinflammation in a mouse impact acceleration model of pediatric TBI. Male and female littermates were randomized on postnatal day 20-21(P20-21) into Sham, TBI + saline and TBI + BPN groups. Mice in the TBI + saline and TBI + BPN groups underwent TBI, while the Sham group underwent anesthesia without injury. BPN (0.075 mg/kg) was administered to the TBI + BPN mice at 30 min after injury, and then every 6-12 h for 2 days. Mice in the TBI + saline group received the same amount of saline injections. The impact of BPN on body weight, motor function, opioid receptor expression, and neuroinflammation was evaluated at 1-day (d), 3-d and 7-d post-injury. We found that 1) TBI induced significant weight loss in both males and females. BPN treatment improved weight loss at 3-d post-injury in females. 2) TBI significantly impaired motor coordination and strength. BPN improved motor coordination and strength in both males and females at 1-d and 3-d post-injury. 3) TBI significantly decreased exploration activity at 1-d post-injury in males, and at 7-d post-injury in females, while BPN improved the exploration activity in females. 4) TBI significantly increased mRNA expression of mu-opioid receptors (MOR) at 7-d post-injury in males, but decreased mRNA expression of MOR at 1-d post-injury in females. BPN normalized MOR mRNA expression at 1-d post-injury in females. 5) MOR expression in astrocytes at corpus callosum significantly increased at 7-d post-injury in male TBI group, but significantly decreased at 1-d post-injury in female TBI group. BPN normalized MOR expression in both males and females. 6) TBI significantly increased the mRNA expression of TNF-α, IL-1β, IL-6 and iNOS. BPN decreased mRNA expression of iNOS, and increased mRNA expression of TGF-β1. In conclusion, this study elucidates the sex specific effects of BPN during the acute phase after pediatric TBI, which provides the rationale to assess potential effects of BPN on chronic pathological progressions after pediatric TBI in both males and females.

Decision-making challenge of Ping-Pong Fractures in children: systematic review of literature

Ping-pong fractures (PPF) have become less frequent and no definite predictors to determine which fractures will elevate spontaneously and which should undergo surgical treatment have not been clearly defined. Herein, the authors present a revision of the literature, in which 54 papers were included, with a total of 228 children studied. Patients who underwent surgery accounted for 30%; elevation through obstetrical vacuum or other aspiration systems was applied in 30%, spontaneous resolution occurred in 40%; in 4 patients percutaneous microscrew elevation was applied. Overall, in 96.4% of patients the outcome was favorable since we found no significant increase in the incidence of post-traumatic seizures or neurologic sequelae with no significant differences between treated patients and spontaneous elevation. Statistical analysis showed no significant differences among the different treatment methods (P=0.53). Our results suggest that simple compound PPFs without brain compression, hematomas or dural tears could benefit from conservative management. In cases of non-spontaneous resolution after 6 months, operative strategies should be performed, considering that there is no evidence of differences between vacuum elevation and surgical elevation.

Prediction of Early Mortality Among Children With Moderate or Severe Traumatic Brain Injury Based on a Nomogram Integrating Radiological and Inflammation-Based Biomarkers

Inflammation-based scores have been increasingly used for prognosis prediction in neurological diseases. This study aimed to investigate the predictive value of inflammation-based scores combined with radiological characteristics in children with moderate or severe traumatic brain injury (MS-TBI). A total of 104 pediatric patients with MS-TBI were retrospectively enrolled and randomly divided into training and validation cohorts at a 7:3 ratio. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of prognosis in pediatric patients with MS-TBI. A prognostic nomogram was constructed, and its predictive performance was validated in both the training and validation cohorts. Sex, admission platelet-to-lymphocyte ratio, and basal cistern status from initial CT findings were identified as independent prognostic predictors for children with MS-TBI in multivariate logistic analysis. Based on these findings, a nomogram was then developed and its concordance index values were 0.918 [95% confidence interval (CI): 0.837-0.999] in the training cohort and 0.86 (95% CI: 0.70-1.00) in the validation cohort, which significantly outperformed those of the Rotterdam, Marshall, and Helsinki CT scores. The proposed nomogram, based on routine complete blood count and initial CT scan findings, can contribute to individualized prognosis prediction and clinical decision-making in children with MS-TBI.

Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey

Background

Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals.

Methods

This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0–17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020–March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable.

Results

71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006.

Conclusions

TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-022-01022-4.

Construction and Evaluation of Prognosis Prediction Model for Patients with Brain Contusion and Laceration Based on Machine Learning

Objective

Finding valuable risk factors for the prognosis of brain contusion and laceration can help patients understand the condition and improve the prognosis. This study is aimed at analyzing the risk factors of poor prognosis in patients with brain contusion after the operation.

Methods

A total of 136 patients with cerebral contusion and laceration combined with cerebral hernia treated by neurosurgical craniotomy in our hospital were retrospectively selected and divided into a training set (n = 95) and a test set (n = 41) by the 10-fold crossover method. Logistic regression and back-propagation neural network prediction models were established to predict poor prognosis factors. The receiver operating characteristic curve (ROC) and the calibration curve were used to verify the differentiation and consistency of the prediction model.

Results

Based on logistic regression and back-propagation neural network prediction models, GCS score ≤ 8 on admission, blood loss ≥ 30 ml, mannitol ≥ 2 weeks, anticoagulants before admission, and surgical treatment are the risk factors that affect the poor prognosis of patients with a cerebral contusion after the operation. The area under the ROC was 0.816 (95% CI 0.705~0.926) and 0.819 (95% CI 0.708~0.931), respectively.

Conclusion

The prediction model based on the risk factors that affect the poor prognosis of patients with brain contusion and laceration has good discrimination and accuracy.

The Effect of Cerebrolysin on Anxiety, Depression, and Cognition in Moderate and Severe Traumatic Brain Injury Patients: A CAPTAIN II Retrospective Trial Analysis

Background and Objectives: Traumatic brain injuries represent an important source of disease burden requiring emergency inpatient care and continuous outpatient tailored rehabilitation. Although most TBIs are mild, patients are still developing post-TBI depression, anxiety, and cognitive impairments. Our secondary retrospective trial analysis aimed to (1) analyze correlations between HADS-Anxiety/HADS-Depression and scales that measure cognitive and motor processes in patients treated with Cerebrolysin compared to the placebo group and (2) compare anxiety and depression scores among the two treatment groups. Materials and Methods: Our secondary retrospective analysis focused on TBI patients with moderate and severe disability divided into two groups: Cerebrolysin (treatment) and saline solution (procedural placebo). We analyzed data from 125 patients. We computed descriptive statistics for nominal and continuous variables. We used Spearman's correlation to find associations between HADS and other neuropsychological scales and the Mann-Whitney U test to compare HADS-Anxiety and HADS-Depression scores among the two study arms. Results: Our sample consisted of patients with a mean age of 45.3, primarily men, and with a 24 h GCS (Glasgow Coma Scale) mean of 12.67. We obtained statistically significant differences for HADS-Anxiety during the second and third visits for patients treated with Cerebrolysin. Our results show that Cerebrolysin has a large effect size (0.73) on anxiety levels. In addition, there are positive and negative correlations between HADS-Anxiety and Depression subscales and other neuropsychological scales. Conclusions: Our secondary database analysis supports the existing body of evidence on the positive effect of Cerebrolysin on post-TBI mental health status. Future confirmatory trials are necessary to clarify the link between the intervention and measured outcomes.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury

OBJECTIVES

Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level.

METHODS

The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis.

RESULTS

The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001).

CONCLUSIONS

In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Pediatric Traumatic Brain Injury : The Epidemiology in Korea

Traumatic brain injury (TBI) is one of the leading causes of death in the pediatric population in Korea. In addition, it can cause disability in children and adolescents, with physical and mental consequences. This causes a substantial burden on the health care system and occurs globally and not just in Korea. We searched and reviewed current data on the epidemiologic characteristics of pediatric TBI in Korea. Our review provides the recent epidemiological trend mainly focusing on incidence and mortality along with worldwide reported data. This review will be helpful to understand the global epidemiology of pediatric TBI and its differences between countries.

Pediatric Severe Traumatic Brain Injury : Updated Management

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Survivors of severe TBI are more susceptible to functional deficits, resulting in disability, poor quality of life, cognitive decline, and mental health problems. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Internationally, efforts are being made to expand knowledge of pathophysiology and develop practical clinical treatment recommendations to improve outcomes. Here we discuss recently updated evidence and management of severe pediatric TBI.

HDAC1 expression is positively correlated with NADPH oxidase 4-mediated oxidative stress in a mouse model of traumatic brain injury

Accumulating evidence has demonstrated that histone deacetylase 1 (HDAC1) expression is statistically correlated with the severity of traumatic brain injury (TBI). However, the specific role of HDAC1 in the occurrence and development of TBI remains unclear. The Lateral Fluid Percussion Injury (LFPI) was used to conduct TBI mouse model in C57BL/6J and C57BL/6J-Hdac1^em1cyagen mice. Western blot and qRT-PCR were performed to estimate the expression of HADC1 and nicotinamide adenine dinucleotide phosphate oxidase 4 (NOX4) in brain tissues. Modified Neurological Severity Score (mNSS) and brain water content were performed to detect the neurological deficit. Malondialdehyde (MDA), superoxide dismutase (SOD) and glutathione (GSH) were used to detect the oxidative stress. Oxidative stresses, HDAC1 and NOX4 expression were upregulated in the lesioned cortices tissues after TBI. HDAC1 protein expression was positively correlated with the NOX4 in TBI mouse. Hdac1 knockout attenuated brain edema and neurological dysfunction caused by TBI in mice. Hdac1 knockout inhibited the expressions of NOX4 induced by TBI and attenuated TBI induced oxidative stress. HDAC1 expression is positively correlated with to NOX4-mediated oxidative stress in a TBI mouse model.

Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit

Background

Traumatic brain injury (TBI) is a common cause of paediatric morbidity and mortality, with higher TBI rates in low- and middle-income countries. Non-contrast brain CT is the gold standard for diagnosing intracranial injuries; however, it exposes patients to ionising radiation. The Paediatric Emergency Care Applied Research Network (PECARN) clinical decision rule (CDR) aids clinicians in their decision-making processes whilst deciding whether a patient at very low risk of a clinically important TBI (ciTBI) requires a CT scan.

Objectives

To establish whether the introduction of the PECARN CDR would affect CT utilisation rates for paediatric patients presenting with minor blunt head injuries to an academic hospital in Gauteng, South Africa.

Method

This was an audit of paediatric patients who presented with minor blunt head injuries and were referred for CT imaging at an academic hospital in Gauteng, compared with PECARN CDR recommendations, over a 1-year period.

Results

A total of 100 patients were referred for CT imaging. Twenty patients were classified as very low risk, none of whom had any CT findings of a TBI or ciTBI (p < 0.01). A total of 61 patients were classified as intermediate risk and 19 as high risk. In all, 23% of the intermediate and 47% of the high-risk patients had CT features of a TBI, whilst 8% and 37% had a ciTBI, respectively.

Conclusion

Computed tomography brain imaging may be omitted in patients classified as very low risk without missing a clinically important TBI. Implementing the PECARN CDR in appropriate patients would reduce CT utilisation rates.