Mild traumatic brain injury in children

[Prehospital care of pediatric traumatic brain injury]

BACKGROUND

Traumatic brain injury (TBI) in children and adolescents is associated with significant morbidity and, in severe TBI, mortality. The aim of this article is to provide an overview of the spectrum of TBI, its pathophysiology, and current treatment recommendations for prehospital management of children and adolescents with TBI.

MATERIALS AND METHODS

The current literature was reviewed for studies on the management of TBI in children and adolescents.

RESULTS

In recent years, a large number of scientific studies have been published that have resulted in evidence-based guidelines for primary care of children with TBI. The primary aim is to minimize secondary brain damage following TBI, for which immediate assessment of the severity of TBI at the scene based on clinical findings and the accident mechanism and initiation of specific treatment measures to prevent hypoxia, hypotension, and hypothermia are critical. Not only prehospital management, but also the rapid transfer of children with severe TBI to centers with high neurosurgical, pediatric surgical, and pediatric intensive care expertise is of particular importance to improve survival and neurological outcome after severe TBI.

CONCLUSION

Structured prehospital management may help reduce secondary brain injury after TBI and lead to improved clinical outcomes.

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.

Short-Term Outcomes of Ethnic and Racial Minority Pediatric Patients Following Traumatic Brain Injury in the State of Texas

Background Pediatric traumatic brain injury represents a significant cause of morbidity and mortality. Broadly healthcare disparities exist for ethnic and racial minorities in the United States but it has not previously be evaluated how these disparities might influence outcomes in pediatric traumatic brain injury. Methods We sought all hospital admissions between the years 2006 and 2011 for patients aged 0-17 years admitted with traumatic brain injuries as identified by the International Classification of Diseases, 9th Revision (ICD-9) code, from a statewide database of all civilian hospital admissions. Demographic information including race, ethnicity, insurance status and illness severity as calculated by All Patient Refined-Diagnosis Related Group (APR-DRG) were analysed versus the disposition at discharge. Results 14,087 pediatric traumatic brain injury patients were admitted between 2006 and 2011. Pediatric traumatic brain injury patients of ethnic or racial minority had higher rates of in-hospital mortality as compared to whites (4.2% versus 3.3%, p = 0.009) and were less likely to be discharged to inpatient rehabilitation (2.9% versus 4%, p < 0.001). These disparities persisted even when controlling for insurance status and illness severity. Conclusion Ethnic and racial minority children from the U.S. state of Texas suffer worse short-term outcomes following traumatic brain injury than their white counterparts. Strategies are needed for addressing this disparity.

Head impact exposure in youth football: elementary school ages 7-8 years and the effect of returning players

OBJECTIVE

To provide data describing the head impact exposure of 7- to 8-year-old football players.

DESIGN

Head impact data were collected from 19 players over the course of 2 seasons using helmet-mounted accelerometer arrays.

SETTING

Data were collected from 2 youth football teams in Blacksburg, VA, spanning 2 seasons.

PARTICIPANTS

A total of 19 youth football players aged 7-8 years.

INDEPENDENT VARIABLES

Type of session (practice or game) and the player's experience.

MAIN OUTCOME MEASURES

Head impact frequency, acceleration magnitude, and impact location for games, practices, and the season as a whole were measured.

RESULTS

The average instrumented player sustained 9 ± 6 impacts per practice, 11 ± 11 impacts per game, and 161 ± 111 impacts per season. The average instrumented player had a median impact of 16 ± 2 g and 686 ± 169 rad/s and a 95th percentile impact of 38 ± 13 g and 2052 ± 664 rad/s throughout a season. Impacts of 40 g or greater tended to occur more frequently in practices than in games, and practices had a significantly higher 95th percentile impact magnitude than games (P = 0.023). Returning players had significantly more impacts than first time players (P = 0.007).

CONCLUSIONS

These data are a further step toward developing effective strategies to reduce the incidence of concussion in youth football and have applications toward youth-specific football helmet designs.

A modified controlled cortical impact technique to model mild traumatic brain injury mechanics in mice

For the past 25 years, controlled cortical impact (CCI) has been a useful tool in traumatic brain injury (TBI) research, creating injury patterns that includes primary contusion, neuronal loss, and traumatic axonal damage. However, when CCI was first developed, very little was known on the underlying biomechanics of mild TBI. This paper uses information generated from recent computational models of mild TBI in humans to alter CCI and better reflect the biomechanical conditions of mild TBI. Using a finite element model of CCI in the mouse, we adjusted three primary features of CCI: the speed of the impact to achieve strain rates within the range associated with mild TBI, the shape, and material of the impounder to minimize strain concentrations in the brain, and the impact depth to control the peak deformation that occurred in the cortex and hippocampus. For these modified cortical impact conditions, we observed peak strains and strain rates throughout the brain were significantly reduced and consistent with estimated strains and strain rates observed in human mild TBI. We saw breakdown of the blood–brain barrier but no primary hemorrhage. Moreover, neuronal degeneration, axonal injury, and both astrocytic and microglia reactivity were observed up to 8 days after injury. Significant deficits in rotarod performance appeared early after injury, but we observed no impairment in spatial object recognition or contextual fear conditioning response 5 and 8 days after injury, respectively. Together, these data show that simulating the biomechanical conditions of mild TBI with a modified cortical impact technique produces regions of cellular reactivity and neuronal loss that coincide with only a transient behavioral impairment.

Parent-reported mild head injury history and behavioural performance in children at 6 years

OBJECTIVE

Mild head and brain injuries have gained increasing attention from health professionals and researchers. Little is known about mild injuries, which may not always be diagnosed or brought to medical attention. This study examines the associations between parent-reported history of mild head injury and behavioural problems in a large community-based sample of Chinese children.

METHOD

Subjects included 725 children from China. Parents reported on children's head injury history and behaviour at age 6 years using the Chinese version of the Child Behavior Checklist. Mild head injury was defined as injury without loss of consciousness or hospitalization. Standardized T-scores were compared for each of the seven clinical sub-scales and three summary behavioural measures, adjusting for confounders. Logistic models were used to calculate odds ratios (ORs) between head injury and behavioural problems.

RESULTS

Parents reported that 97 children (14%) had a single injury and 70 (10%) had multiple injuries. Compared to the controls, head-injured children had worse behavioural outcomes and a higher prevalence of behavioural problems. Multiple injuries were associated with higher risk of certain internalizing and externalizing problems.

CONCLUSION

Mild head injuries, especially incurred repeatedly, may still be a significant risk for adverse behaviours in children.

Effects of brain contusion on mild traumatic brain-injured patients

Traumatic brain injury (TBI) is an important health issue with high prevalence. The most common type of TBI is mild TBI (MTBI). MTBI is known as a condition with self-limited symptoms; however, it could cause some structural abnormalities of brain and become complicated. Visible structural brain damage could have an important effect on recovery after MTBI, but the outcome is not fully understood. This study investigated the clinical course of MTBI patients with the existence of contusion in computed tomography (CT) imaging. Fifty patients with MTBI and simultaneous brain contusion in CT scan were enrolled according to specific exclusion criteria in 14 month. Patients were followed up for two weeks after their first arrival for neurosurgical interventions, decreased level of consciousness, and other neurological complications. Presence of neurological symptoms increased duration of hospital stay and number of CT scans. Forty-two percent of MTBI patients with contusion did not have any objective neurological signs. Fifty percent returned to the hospital with neurologic symptoms and signs. Leading causes were headache followed by seizure and dizziness. Rehospitalization was increased in the patients with altered level of consciousness. The size of brain contusion increased in two patients without further need for neurosurgical intervention. Contusion alone did not worsen the prognosis of patients in short-term follow-up and did not cause neurosurgical interventions.

An FMRI study of auditory orienting and inhibition of return in pediatric mild traumatic brain injury

Studies in adult mild traumatic brain injury (mTBI) have shown that two key measures of attention, spatial reorienting and inhibition of return (IOR), are impaired during the first few weeks of injury. However, it is currently unknown whether similar deficits exist following pediatric mTBI. The current study used functional magnetic resonance imaging (fMRI) to investigate the effects of semi-acute mTBI (<3 weeks post-injury) on auditory orienting in 14 pediatric mTBI patients (age 13.50±1.83 years; education: 6.86±1.88 years), and 14 healthy controls (age 13.29±2.09 years; education: 7.21±2.08 years), matched for age and years of education. The results indicated that patients with mTBI showed subtle (i.e., moderate effect sizes) but non-significant deficits on formal neuropsychological testing and during IOR. In contrast, functional imaging results indicated that patients with mTBI demonstrated significantly decreased activation within the bilateral posterior cingulate gyrus, thalamus, basal ganglia, midbrain nuclei, and cerebellum. The spatial topography of hypoactivation was very similar to our previous study in adults, suggesting that subcortical structures may be particularly affected by the initial biomechanical forces in mTBI. Current results also suggest that fMRI may be a more sensitive tool for identifying semi-acute effects of mTBI than the procedures currently used in clinical practice, such as neuropsychological testing and structural scans. fMRI findings could potentially serve as a biomarker for measuring the subtle injury caused by mTBI, and documenting the course of recovery.

The unique features of traumatic brain injury in children. Review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications and their imaging findings--part 1

Traumatic head/brain injury (TBI) is a leading cause of death and life-long disability in children. The biomechanical properties of the child's brain and skull, the size of the child, the age-specific activity pattern, and higher degree of brain plasticity result in a unique distribution, degree, and quality of TBI compared to adult TBI. A detailed knowledge about the various types of primary and secondary pediatric head injuries is essential to better identify and understand pediatric TBI. The goals of this review article are (1) to discuss the unique epidemiology, mechanisms, and characteristics of TBI in children, and (2) to review the anatomical and functional imaging techniques that can be used to study common and rare pediatric traumatic brain injuries and their complications.

A subacute epidural haematoma extending over the occipital region and posterior cranial fossa due to a laceration in the transverse sinus

A 6-year-old male was found dead on his stomach with massive reddish vomiting from his mouth and nose. Postmortem cranial CT revealed an epidural haematoma in the left occipital region, but the cause and origin of the haematoma were unclear. An autopsy revealed that the epidural haematoma expanded over the left temporal region and the left side of the occipital region and posterior cranial fossa, and its origin was a laceration in the left transverse sinus induced by diastases in the left lambdoidal and occipitomastoid sutures. A pathohistological examination revealed that one portion of the haematoma was an early-stage hemorrhage, while the other portion extended approximately 1 week after the hemorrhage. Moreover, approximately 1 week elapsed after the laceration of the transverse sinus. Thus, we believe that the primary haematoma was induced by the laceration in the transverse sinus approximately 1 week before death, but the haematoma ceased to enlarge due to hemostasis. However, later, the size of the haematoma rapidly increased again due to rebleeding from the laceration, which led to intracranial hypertension. Consequently, we diagnosed the direct cause of death as choking due to vomit aspiration that resulted from intracranial hypertension induced by a subacute epidural haematoma.