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Sirén A, Nyman M, Syvänen J, Mattila K, Hirvonen J. Utility of brain imaging in pediatric patients with a suspected accidental spinal injury but no brain injury-related symptoms. Childs Nerv Syst 2024; 40:1435-1441. [PMID: 38279986 PMCID: PMC11026267 DOI: 10.1007/s00381-024-06298-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/20/2024] [Indexed: 01/29/2024]
Abstract
PURPOSE Imaging is the gold standard in diagnosing traumatic brain injury, but unnecessary scans should be avoided, especially in children and adolescents. Clinical decision-making rules often help to distinguish the patients who need imaging, but if spinal trauma is suspected, concomitant brain imaging is often conducted. Whether the co-occurrence of brain and spine injuries is high enough to justify head imaging in patients without symptoms suggesting brain injury is unknown. OBJECTIVE This study aims to assess the diagnostic yield of brain MRI in pediatric patients with suspected or confirmed accidental spinal trauma but no potential brain injury symptoms. METHODS We retrospectively reviewed the medical and imaging data of pediatric patients (under 18 years old) who have undergone concomitant MRI of the brain and spine because of acute spinal trauma in our emergency radiology department over a period of 8 years. We compared the brain MRI findings in patients with and without symptoms suggesting brain injury and contrasted spine and brain MRI findings. RESULTS Of 179 patients (mean age 11.7 years, range 0-17), 137 had symptoms or clinical findings suggesting brain injury, and 42 did not. None of the patients without potential brain injury symptoms had traumatic findings in brain MRI. This finding also applied to patients with high-energy trauma (n = 47) and was unrelated to spinal MRI findings. CONCLUSION Pediatric accidental trauma patients with suspected or confirmed spine trauma but no symptoms or clinical findings suggesting brain injury seem not to benefit from brain imaging.
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Affiliation(s)
- Aapo Sirén
- Department of Radiology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Mikko Nyman
- Department of Radiology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Johanna Syvänen
- Department of Pediatric Orthopedic Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, University of Turku and Turku University Hospital, Kiinamyllynkatu 4-8, 20520, Turku, Finland
- Medical Imaging Center, Department of Radiology, Tampere University and Tampere University Hospital, Tampere, Finland
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Laaksonen J, Ponkilainen V, Kuitunen I, Möttönen J, Mattila VM. Pediatric traumatic brain injury and early age multiple sclerosis in Finland: A nationwide register-based cohort study. Brain Behav 2024; 14:e3478. [PMID: 38622897 PMCID: PMC11019240 DOI: 10.1002/brb3.3478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/13/2024] [Accepted: 03/09/2024] [Indexed: 04/17/2024] Open
Abstract
OBJECTIVE Examine the link between pediatric traumatic brain injury (pTBI) and early-onset multiple sclerosis in Finland. METHODS Conducted nationwide register study (1998-2018) with 28,750 pTBI patients (< 18) and 38,399 pediatric references with extremity fractures. Multiple sclerosis diagnoses from Finnish Social Insurance Institution. Employed Kaplan-Meier and multivariable Cox regression for probability assessment, results presented with 95% CI. RESULTS Of 66 post-traumatic multiple sclerosis cases, 30 (0.10%) had pTBI, and 36 (0.09%) were in the reference group. Cumulative incidence rates (CIR) in the first 10 years were 46.5 per 100,000 (pTBI) and 33.1 per 100,000 (reference). Hazard ratio (HR) for pTBI was 1.10 (95% CI: 0.56-1.48).Stratified by gender, women's CIR was 197.9 per 100,000 (pTBI) and 167.0 per 100,000 (reference) after 15 years. For men, CIR was 44.6 per 100,000 (pTBI) and 34.7 per 100,000 (reference). In the initial 3 years, HR for female pTBI was 1.75 (95% CI: 0.05-6.32), and between years 3 and 20, it was 1.08 (95% CI: 0.51-1.67). For male patients, HR was 1.74 (95% CI: 0.69-4.39). SIGNIFICANCE We did not find evidence of an association between pTBI and early-onset multiple sclerosis 20 years post-initial trauma.
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Affiliation(s)
| | - Ville Ponkilainen
- Department of SurgeryHospital Nova of Central FinlandJyväskyläFinland
| | - Ilari Kuitunen
- Institute of Clinical Medicine and Department of PediatricsUniversity of Eastern FinlandKuopioFinland
- Department of PediatricsKuopio University HospitalKuopioFinland
| | - Julius Möttönen
- Institute of Clinical Medicine and Department of PediatricsUniversity of Eastern FinlandKuopioFinland
| | - Ville M. Mattila
- School of MedicineUniversity of TampereTampereFinland
- Department of Orthopedics and TraumatologyTampere University HospitalTampereFinland
- Coxa Hospital for Joint ReplacementTampereFinland
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Stein A, Vinh To X, Nasrallah FA, Barlow KM. Evidence of Ongoing Cerebral Microstructural Reorganization in Children With Persisting Symptoms Following Mild Traumatic Brain Injury: A NODDI DTI Analysis. J Neurotrauma 2024; 41:41-58. [PMID: 37885245 DOI: 10.1089/neu.2023.0196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
Approximately 300-550 children per 100,000 sustain a mild traumatic brain injury (mTBI) each year, of whom ∼25-30% have long-term cognitive problems. Following mTBI, free water (FW) accumulation occurs in white matter (WM) tracts. Diffusion tensor imaging (DTI) can be used to investigate structural integrity following mTBI. Compared with conventional DTI, neurite orientation dispersion and density imaging (NODDI) orientation dispersion index (ODI) and fraction of isolated free water (FISO) metrics may allow a more advanced insight into microstructural damage following pediatric mTBI. In this longitudinal study, we used NODDI to explore whole-brain and tract-specific differences in ODI and FISO in children with persistent symptoms after mTBI (n = 80) and in children displaying clinical recovery (n = 32) at 1 and 2-3 months post-mTBI compared with healthy controls (HCs) (n = 21). Two-way repeated measures analysis of variance (ANOVA) and voxelwise two-sample t tests were conducted to compare whole-brain and tract-specific diffusion across groups. All results were corrected at positive false discovery rate (pFDR) <0.05. We also examined the association between NODDI metrics and clinical outcomes, using logistical regression to investigate the value of NODDI metrics in predicting future recovery from mTBI. Whole-brain ODI was significantly increased in symptomatic participants compared with HCs at both 1 and 2 months post-injury, where the uncinate fasciculus (UF) and inferior fronto-occipital fasciculus (IFOF) were particularly implicated. Using region of interest (ROI) analysis in significant WM, bilateral IFOF and UF voxels, symptomatic participants had the highest ODI in all ROIs. ODI was lower in asymptomatic participants, and HCs had the lowest ODI in all ROIs. No changes in FISO were found across groups or over time. WM ODI was moderately correlated with a higher youth-reported post-concussion symptom inventory (PCSI) score. With 87% predictive power, ODI (1 month post-injury) and clinical predictors (age, sex, PCSI score, attention scores) were a more sensitive predictor of recovery at 2-3 months post-injury than fractional anisotropy (FA) and clinical predictors, or clinical predictors alone. FISO could not predict recovery at 2-3 months post-injury. Therefore, we found that ODI was significantly increased in symptomatic children following mTBI compared with HCs at 1 month post-injury, and progressively decreased over time alongside clinical recovery. We found no significant differences in FISO between groups or over time. WM ODI at 1 month was a more sensitive predictor of clinical recovery at 2-3 months post-injury than FA, FISO, or clinical measures alone. Our results show evidence of ongoing microstructural reorganization or neuroinflammation between 1 and 2-3 months post-injury, further supporting delayed return to play in children who remain symptomatic. We recommend future research examining the clinical utility of NODDI following mTBI to predict recovery or persistence of post-concussion symptoms and thereby inform management of mTBI.
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Affiliation(s)
- Athena Stein
- Acquired Brain Injury in Children Research Group, The University of Queensland, South Brisbane, Queensland, Australia
| | - Xuan Vinh To
- Queensland Brain Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Fatima A Nasrallah
- Queensland Brain Institute, The University of Queensland, South Brisbane, Queensland, Australia
| | - Karen M Barlow
- Acquired Brain Injury in Children Research Group, The University of Queensland, South Brisbane, Queensland, Australia
- Queensland Pediatric Rehabilitation Service, Queensland Children's Hospital, South Brisbane, Queensland, Australia
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Laaksonen J, Ponkilainen V, Kuitunen I, Möttönen J, Mattila VM. Association between pediatric traumatic brain injury and epilepsy at later ages in Finland: A nationwide register-based cohort study. Epilepsia 2023; 64:3257-3265. [PMID: 37867469 DOI: 10.1111/epi.17805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE This study was undertaken to examine how pediatric traumatic brain injury (pTBI) correlates with incidence of epilepsy at later ages in Finland. METHODS This nationwide retrospective register-based cohort study extended from 1998 to 2018. The study group consisted of 71 969 pediatric (<18 years old) patients hospitalized with TBI and a control group consisting of 64 856 pediatric patients with distal extremity fracture. Epilepsy diagnoses were gathered from the Finnish Social Insurance Institution. Kaplan-Meier and multivariable Cox regression models were conducted to analyze the probability of epilepsy with 95% confidence intervals (CIs). RESULTS Cumulative incidence rates (CIRs) for the first 2 years were .5% in the pTBI group and .1% in the control group. The corresponding rates after 15 years of follow-up were 1.5% in the pTBI group and .7% in the control group. Due to proportional hazard violations, the study population was split to the first 2 years and in subgroup analysis 4 years. During the first 2 years of surveillance, the hazard ratio (HR) for the pTBI group was 4.38 (95% CI = 3.39-5.66). However, between years 2 and 20, the HR for the pTBI group was 2.02 (95% CI = 1.71-2.38). A total of 337 patients (.47%) underwent neurosurgery, and 36 (10.7%) patients subsequently developed epilepsy. The CIR for the first year after TBI was 4.5% (95% CI = 2.3-6.7) in operatively managed patients and .3% (95% CI = .3-.4) in nonoperatively managed patients. Corresponding figures after 15 years were 12.0% (95% CI = 8.2-15.8) and 1.5% (95% CI = 1.4-1.6). During the first 4 years of surveillance, the HR for the operative pTBI group was 14.37 (95% CI = 9.29-20.80) and 3.67 (95% CI = 1.63-8.22) between years 4 and 20. SIGNIFICANCE pTBI exposes patients to a higher risk for posttraumatic epilepsy for many years after initial trauma. Children who undergo operative management for TBI have a high risk for epilepsy, and this risk was highest during the first 4 years after injury.
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Affiliation(s)
- Juho Laaksonen
- School of Medicine, University of Tampere, Tampere, Finland
| | - Ville Ponkilainen
- Department of Surgery, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Julius Möttönen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
| | - Ville M Mattila
- School of Medicine, University of Tampere, Tampere, Finland
- Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
- Coxa Hospital for Joint Replacement, Tampere, Finland
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Möttönen J, Ponkilainen VT, Iverson GL, Luoto T, Mattila VM, Kuitunen I. Incidence of acute neurosurgery for traumatic brain injury in children-a nationwide analysis from 1998 to 2018. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05628-0. [PMID: 37184636 DOI: 10.1007/s00701-023-05628-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Most of moderate and severe pTBIs are managed conservatively, but in some cases neurosurgical interventions are needed. The incidence rates of acute pTBI neurosurgery vary considerably between countries and operation types. Our goal was to assess the incidence of acute pTBI neurosurgery in Finland. METHODS We conducted a retrospective Finnish register-based cohort study from 1998 to 2018. We included all patients that were 0 to 17 years of age at the time of the TBI. The incidence rates of patients with pTBI undergoing neurosurgery and the rates for specific operation types were calculated per 100,000 person-years. We compared the annual incidences with incidence rate ratios (IRR) with 95% confidence intervals (CI). We stratified patients to three age categories: (i) 0 to 3 years of age, (ii) 4 to 12 years of age, and (iii) 13 to 17 years of age. RESULTS The total number of neurosurgeries for acute pTBI during the study period was 386, and the cumulative incidence was 1.67 operations per 100,000 person-years. The cumulative incidence during the 21-year follow-up was highest at the age of 16 (IRR 4.78, CI 3.68 to 6.11). Boys had a 2.42-time higher cumulative incidence (IRR 2.35, CI 1.27 to 3.99) than girls (IRR 0.97, CI 0.35 to 2.20). The most common neurosurgery was an evacuation of an intracranial hemorrhage (n = 171; 44.3%). CONCLUSION The incidence of neurosurgeries for pTBIs has been stable from 1998 to 2018. The incidence was highest at the age of 16, and boys had higher incidence than girls.
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Affiliation(s)
- Julius Möttönen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland.
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland.
| | | | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA, USA
- Department of Physical Medicine and Rehabilitation, Schoen Adams Research Institute at Spaulding Rehabilitation, Charlestown, MA, USA
- Sports Concussion Program, Mass General Hospital for Children, Boston, MA, USA
| | - Teemu Luoto
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
- Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Ilari Kuitunen
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics, Mikkeli Central Hospital, Mikkeli, Finland
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