Long-Term Neuropsychological Profiles and Their Role as Mediators of Adaptive Functioning after Traumatic Brain Injury in Early Childhood

The neuropsychology of early childhood and infancy

OBJECTIVES

Piaget's theory emphasizes the biological structures children utilize to make sense of their environment and based on those experiences become able to adapt. Many factors can intervene in the gradual and complex process of development, causing an array of issues both acute and chronic.

METHOD

Several studies have found that disability in the early months is a strong predictor of cognitive impairment in preschool. The presence of early functional anomalies may represent developmental delay and/or neurodevelopmental disorders.

RESULTS

Understanding the risk factors and detecting such signs early on is important to prevent or minimize later cognitive, behavioral, and psychosocial problems. The study aims to emphasize how critical the early years are to a child's future cognitive, physical, emotional, and social development as well as their overall well-being.

DISCUSSION

In addition, the fact that crucial developmental stages can be hampered or obstructed by a variety of factors is highlighted.

Exploring the link among injury severity, white matter connectivity and psychosocial outcomes in pediatric TBI: a probabilistic tractography approach

AIM

We examined associations among injury severity, white matter structural connectivity within functionally defined brain networks and psychosocial/adaptive outcomes in children with traumatic brain injury (TBI).

METHOD

Participants included 58 youths (39 male) with complicated-mild TBI (cmTBI; n = 12, age =  12.6 ± 2.0), moderate/severe TBI (msTBI; n =  16, age =  11.4 ± 2.9) and a comparison group with orthopedic injury (OI; n =  24, age =  11.7 ± 2.1), at least 1 year post-injury. Participants underwent diffusion tensor imaging and parents rated children's behavioral and adaptive function on the CBCL and ABAS-3, respectively. Probabilistic tractography quantified streamline density. Group differences were analyzed for structural connectivity and behavioral outcomes.

RESULTS

Groups differed in structural connectivity within regions of the default mode and central executive networks (ps < .05, FDR corrected). The msTBI group displayed decreased connectivity relative to cmTBI and OI, whereas the cmTBI group displayed increased connectivity relative to msTBI and OI. Similar patterns emerged in several behavioral domains. Ordinary least squares path analyses showed that structural connectivity mediated the relationship between injury severity and multiple parent-reported outcomes for msTBI.

INTERPRETATION

White matter structural connectivity may explain unique variance in long-term psychosocial and adaptive outcome in children with TBI, particularly in cases of moderate-to-severe injury.

Exposure to Sedation and Analgesia Medications: Short-term Cognitive Outcomes in Pediatric Critical Care Survivors With Acquired Brain Injury

Background/Objective: Pediatric intensive care unit (PICU) survivors risk significant cognitive morbidity, particularly those with acquired brain injury (ABI) diagnoses. Studies show sedative and analgesic medication may potentiate neurologic injury, but few studies evaluate impact on survivor outcomes. This study aimed to evaluate whether exposures to analgesic and sedative medications are associated with worse neurocognitive outcome. Methods: A retrospective cohort study was conducted of 91 patients aged 8 to 18 years, undergoing clinical neurocognitive evaluation approximately 1 to 3 months after PICU discharge. Electronic health data was queried for sedative and analgesic medication exposures, including opioids, benzodiazepines, propofol, ketamine, and dexmedetomidine. Doses were converted to class equivalents, evaluated by any exposure and cumulative dose exposure per patient weight. Cognitive outcome was derived from 8 objective cognitive assessments with an emphasis on executive function skills using Principal Components Analysis. Then, linear regression was used to control for baseline cognitive function estimates to calculate a standardized residualized neurocognitive index (rNCI) z-score. Multivariable linear regression evaluated the association between rNCI and medication exposure controlling for covariates. Significance was defined as P < .05. Results: Most (n = 80; 88%) patients received 1 or more study medications. Any exposure and higher cumulative doses of benzodiazepine and ketamine were significantly associated with worse rNCI in bivariate analyses. When controlling for Medicaid, preadmission comorbid conditions, length of stay, delirium, and receipt of other medication classes, receipt of benzodiazepine was associated with significantly worse rNCI (β-coefficient = -0.48, 95% confidence interval = -0.88, -0.08). Conclusions: Exposure to benzodiazepines was independently associated with worse acute phase cognitive outcome using objective assessments focused on executive function skills when controlling for demographic and illness characteristics. Clinician decisions regarding medication regimens in the PICU may serve as a modifiable factor to improve outcomes. Additional inquiry into associations with long-term cognitive outcome and optimal medication regimens is needed.

Differences between parent- and teacher-reported executive functioning behaviors after traumatic injuries

Deficits in executive functioning (EF) behaviors are very common following pediatric traumatic brain injury (TBI) and can linger well after acute injury recovery. Raters from multiple settings provide information that may not be appreciated otherwise. We examined differences between parent and teacher ratings of EF using data examining longitudinal outcomes following pediatric TBI in comparison to orthopedic injury (OI). We used linear mixed models to determine the association of rater type and injury type with scores on the Behavior Rating Inventory of Executive Functioning (BRIEF). After controlling for demographic variables, rater type and injury type accounted for a small but significant proportion of the variance in EF. Teachers' ratings on the BRIEF were significantly higher than parent ratings for global EF and metacognition, but not for behavior regulation, regardless of injury type, indicating greater EF concerns. All BRIEF ratings, whether from teachers or parents, were higher for children with TBI than for those with OI. Results suggest that parents and teachers provide unique information regarding EF following traumatic injuries and that obtaining ratings from persons who observe children at school as well as at home can result in a better understanding of situation-specific variability in outcomes.

Brain-Derived Neurotrophic Factor in Pediatric Acquired Brain Injury and Recovery

We review emerging preclinical and clinical evidence regarding brain-derived neurotrophic factor (BDNF) protein, genotype, and DNA methylation (DNAm) as biomarkers of outcomes in three important etiologies of pediatric acquired brain injury (ABI), traumatic brain injury, global cerebral ischemia, and stroke. We also summarize evidence suggesting that BDNF is (1) involved in the biological embedding of the psychosocial environment, (2) responsive to rehabilitative therapies, and (3) potentially modifiable. BDNF's unique potential as a biomarker of neuroplasticity and neural repair that is reflective of and responsive to both pre- and post-injury environmental influences separates it from traditional protein biomarkers of structural brain injury with exciting potential to advance pediatric ABI management by increasing the accuracy of prognostic tools and informing clinical decision making through the monitoring of therapeutic effects.

Adaptive functioning and academic achievement in pediatric survivors of acute lymphoblastic leukemia: Associations with executive functioning, socioeconomic status, and academic support

OBJECTIVES

This study examines associations of functional outcomes (adaptive functioning and academic achievement) with executive functioning (EF), socioeconomic status (SES), and academic support in pediatric acute lymphoblastic leukemia (ALL) survivors.

METHODS

Fifty survivors of B-lineage ALL treated with chemotherapy-only (42% female, 76% NHW, ages 6-19) were evaluated on performance-based EF and academic achievement, and parent-rated EF and adaptive functioning. Area deprivation and child opportunity (i.e., SES) were extracted using census blocks and tracts. Academic support data were extracted from chart review.

RESULTS

Compared to population norms, pediatric ALL survivors demonstrated significantly lower overall adaptive skills and performance in word reading and math calculation (all p ≤ .011). Frequencies of impairment were significantly elevated on all adaptive scales and in math calculation compared to the population (all p ≤ .002). Parent-rated EF significantly predicted overall adaptive skills (p < .001), while performance-based EF significantly predicted word reading and math calculation (all p < .05). Adaptive functioning was not associated with neighborhood-specific variables or academic support. However, academic support predicted word reading (p < .001), while area deprivation and academic support predicted performance-based EF (all p ≤ .02).

CONCLUSIONS

Screening of functional outcomes, targeted intervention, and neuropsychological monitoring are necessary to support pediatric ALL survivors' neurocognitive and psychosocial development.

Intelligence and executive function are associated with age at insult, time post-insult, and disability following chronic pediatric acquired brain injury

Background

Pediatric acquired brain injury (pABI) profoundly affects cognitive functions, encompassing IQ and executive functions (EFs). Particularly, young age at insult may lead to persistent and debilitating deficits, affecting daily-life functioning negatively. This study delves into the intricate interplay of age at insult, time post-insult, and their associations with IQ and EFs during chronic (>1 year) pABI. Additionally, we investigate cognitive performance across different levels of global function, recognizing the multifaceted nature of developmental factors influencing outcomes.

Methods

Drawing upon insult data and baseline information analyzing secondary outcomes from a multicenter RCT, including comprehensive medical and neuropsychological assessments of participants aged 10 to 17 years with pABI and parent-reported executive dysfunctions. The study examined associations between age at insult (early, EI; ≤7y vs. late, LI; > 7y) and time post-insult with IQ and EFs (updating, shifting, inhibition, and executive attention). Additionally, utilizing the Pediatric Glasgow Outcome Scale-Extended, we explored cognitive performance across levels of global functioning.

Results

Seventy-six participants, median 8 years at insult and 5 years post-insult, predominantly exhibiting moderate disability (n = 38), were included. Notably, participants with LI demonstrated superior IQ, executive attention, and shifting compared to EI, [adjusted mean differences with 95% Confidence Intervals (CIs); 7.9 (1.4, 14.4), 2.48 (0.71, 4.24) and 1.73 (0.03, 3.43), respectively]. Conversely, extended post-insult duration was associated with diminished performances, evident in mean differences with 95% CIs for IQ, updating, shifting, and executive attention compared to 1-2 years post-insult [-11.1 (-20.4, -1.7), -8.4 (-16.7, -0.1), -2.6 (-4.4, -0.7), -2.9 (-4.5, -1.2), -3.8 (-6.4, -1.3), -2.6 (-5.0, -0.3), and -3.2 (-5.7, -0.8)]. Global function exhibited a robust relationship with IQ and EFs.

Conclusion

Early insults and prolonged post-insult durations impose lasting tribulations in chronic pABI. While confirmation through larger studies is needed, these findings carry clinical implications, underscoring the importance of vigilance regarding early insults. Moreover, they dispel the notion that children fully recover from pABI; instead, they advocate equitable rehabilitation offerings for pABI, tailored to address cognitive functions, recognizing their pivotal role in achieving independence and participation in society. Incorporating disability screening in long-term follow-up assessments may prove beneficial.

Posttraumatic epilepsy in critically ill children with traumatic brain injury

PURPOSE

The aim of this study was to determine the clinical, laboratory, and radiological factors related with posttraumatic epilepsy (PTE).

METHODS

The study is a multicenter descriptive cross-sectional cohort study. Children who followed up for TBI in the pediatric intensive care unit between 2014 and 2021 were included. Demographic data and clinical and radiological parameters were recorded from electronic case forms. All patients who were in the 6-month posttraumatic period were evaluated by a neurologist for PTE.

RESULTS

Four hundred seventy-seven patients were included. The median age at the time of trauma was 66 (IQR 27-122) months, and 298 (62.5%) were male. Two hundred eighty (58.7%) patients had multiple traumas. The mortality rate was 11.7%. The mean duration of hospitalization, pediatric intensive care unit hospitalization and mechanical ventilation, Rotterdam score, PRISM III score, and GCS at admission were higher in patients with epilepsy (p < 0.05). The rate of epilepsy was higher in patients with severe TBI, cerebral edema on tomography and clinical findings of increased intracranial pressure, blood transfusion in the intensive care unit, multiple intracranial hemorrhages, and intubated patients (p < 0.05). In logistic regression analysis, the presence of intracranial hemorrhage in more than one compartment of the brain (OR 6.13, 95%CI 3.05-12.33) and the presence of seizures (OR 9.75, 95%CI 4.80-19.83) were independently significant in terms of the development of epilepsy (p < 0.001).

CONCLUSIONS

In this multicenter cross-sectional study, intracranial hemorrhages in more than one compartment and clinical seizures during intensive care unit admission were found to be independent risk factors for PTE development in pediatric intensive care unit patients with TBI.

Exploring the Caregiver-Reported Impact of the COVID-19 Pandemic on Children with Traumatic Brain Injury

The COVID-19 pandemic is expected to have a persistent, negative, and disproportionate impact on children with disabilities. Children with traumatic brain injury (TBI) may be expected to experience a disproportionate impact given the deficits often associated with childhood TBI (e.g., family functioning, fatigue, executive functioning, quality of life). This study aimed to explore the impact of the COVID-19 pandemic on children with TBI and their families, compared to typically developing (TD) children and their families. Thirty caregivers (TBI = 15; TD = 15) completed a series of electronic survey measures. Overall, caregivers reported no negative impact of the COVID-19 pandemic on their family's or child's functioning and association with demographic factors and domains of functioning showed no clear patterns. The findings of this exploratory study support continued longitudinal investigation with larger sample sizes of the provision of supports for all families and children in light of the COVID-19 pandemic. Additional research is needed to understand the effectiveness of targeted services for students with TBI in domains of functioning that are significantly poorer than TD children (e.g., quality of life, executive functioning, fatigue).

Trajectories of Executive Functions After Early Childhood Traumatic Brain Injury: Teacher Ratings in the Initial 81 Months Postinjury

OBJECTIVE

To explore teacher-rated trajectories of executive functioning (EF) after early childhood traumatic brain injury (TBI) and to identify injury-related, academic, and family factors associated with growth trajectories using latent class growth analysis.

PARTICIPANTS

A total of 121 children who sustained a TBI or orthopedic injury (OI) between the ages of 3 and 7 years were recruited from 3 tertiary care children's hospitals and a general hospital in Ohio, including 57 with moderate or severe TBI and 64 with OI.

DESIGN

Assessments were completed at baseline (0-3 months postinjury) and an average of 6, 12, 18, and 81 months postinjury. Changes in teacher-rated EF were modeled across time and heterogeneity in recovery and moderating factors was examined.

MEASURES

Study variables included participant demographics, teacher-rated EF (Behavior Rating Inventory of Executive Function), family functioning (McMaster Family Assessment Device), and parenting style (Parenting Practices Questionnaire).

RESULTS

Analysis of teacher-rated EF yielded 2 trajectories: Normative (64.71%) and At-Risk (35.29%). Traumatic brain injury was a weak predictor of membership in the At-Risk trajectory ( P = .05). Membership in the At-Risk trajectory (compared with Normative category) was associated with a higher incidence of Individualized Education Programs, higher baseline EF concerns, increased endorsement of authoritarian parenting, lower socioeconomic status, and non-White race.

CONCLUSION

Teacher-rated EF after pediatric TBI differs from OI. Increased EF concerns over time were associated with increased baseline EF and characteristics of the home and school environment. These findings extend previous research on recovery of EF to educational settings and outline potentially modifiable risk factors that can maximize success in the school settings for children who experience early-childhood traumatic injury.

Processing Speed in Children with Traumatic Brain Injury

Abstract: Traumatic brain injury (TBI) is a common cause of childhood morbidity and mortality. Information processing speed (IPS) is a central construct of neuropsychology and a mediator for a range of cognitive functions. In adults, the negative effects of TBI on IPS are well documented. This review qualitatively describes the impact of TBI on IPS in children and adolescents and examines various influencing factors. We included a total of 37 studies in the review that explored IPS using various clinical assessments. These clinical assessments often examine other neuropsychological functions besides IPS. In 29 of these studies, we found a negative effect of TBI on IPS. While injury severity has small but consistent effects on IPS, the effects of age at injury, time since injury, and gender were less evident. Because it is a central construct of neuropsychological functions, IPS should be assessed after TBI.

Brain-derived neurotrophic factor Val66Met and neuropsychological functioning after early childhood traumatic brain injury

OBJECTIVE

The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on neuropsychological functioning in children with traumatic brain injury (TBI) relative to orthopedic injury (OI).

METHODS

Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Children completed a battery of neuropsychological measures targeting attention, memory, and executive functions at four timepoints spanning the immediate post-acute period to 18 months post-injury. Children also completed a comparable age-appropriate battery of measures approximately 7 years post-injury. Parents rated children's dysexecutive behaviors at all timepoints.

RESULTS

Longitudinal mixed models revealed a significant allele status × injury group interaction with a medium effect size for verbal fluency. Cross-sectional models at 7 years post-injury revealed non-significant but medium effect sizes for the allele status x injury group interaction for fluid reasoning and immediate and delayed verbal memory. Post hoc stratified analyses revealed a consistent pattern of poorer neuropsychological functioning in Met carriers relative to Val/Val homozygotes in the TBI group, with small effect sizes; the opposite trend or no appreciable effect was observed in the OI group.

CONCLUSIONS

The results suggest a differential effect of the BDNF Val66Met polymorphism on verbal fluency, and possibly fluid reasoning and immediate and delayed verbal memory, in children with early TBI relative to OI. The Met allele-associated with reduced activity-dependent secretion of BDNF-may confer risk for poorer neuropsychological functioning in children with TBI.

Variability Across Caregiver and Performance-Based Measures of Executive Functioning in an Acute Pediatric Neurocritical Care Population

Youth admitted to the pediatric intensive care unit (PICU) for traumatic brain injury (TBI) commonly struggle with long-term residual effects in the domains of physical, cognitive, emotional, and psychosocial/family functioning. In the cognitive domain, executive functioning (EF) deficits are often observed. The Behavior Rating Inventory of Executive Functioning, Second Edition (BRIEF-2) is a parent/caregiver-completed measure that is regularly utilized to assess caregivers' perspectives of daily EF abilities. Using parent/caregiver-completed measures like the BRIEF-2 in isolation as outcome measures for capturing symptom presence and severity might be problematic given that caregiver ratings are vulnerable to influence from external factors. As such, this study aimed to investigate the association between the BRIEF-2 and performance-based measures of EF in youth during the acute recovery period post-PICU admission for TBI. A secondary aim was to explore associations among potential confounding factors, including family-level distress, injury severity, and the impact of pre-existing neurodevelopmental conditions. Participants included 65 youths, 8-19 years of age, admitted to the PICU for TBI, who survived hospital discharge and were referred for follow-up care. Non-significant correlations were found between BRIEF-2 outcomes and performance-based measures of EF. Measures of injury severity were strongly correlated with scores from performance-based EF measures, but not BRIEF-2. Parent/caregiver-reported measures of their own health-related quality of life were related to caregiver responses on the BRIEF-2. Results demonstrate the differences captured by performance-based versus caregiver-report measures of EF, and also highlight the importance of considering other morbidities related to PICU admission.

Back to School: Academic Functioning and Educational Needs among Youth with Acquired Brain Injury

Youth with a history of traumatic or non-traumatic acquired brain injury are at increased risk for long-lasting cognitive, emotional, behavioral, social, and physical sequelae post-injury. Such sequelae have great potential to negatively impact this population’s academic functioning. Consistently, poorer academic achievement and elevated need for educational supports have been well-documented among youth with a history of acquired brain injury. The current paper reviews the literature on neuropsychological, psychiatric, and academic outcomes of pediatric acquired brain injury. A discussion of special education law as it applies to this patient population, ongoing limitations within the field, and a proposal of solutions are also included.

Prescribing Patterns of Amantadine During Pediatric Inpatient Rehabilitation After Traumatic Brain Injury: A Multicentered Retrospective Review From the Pediatric Brain Injury Consortium

OBJECTIVES

To describe dosing practices for amantadine hydrochloride and related adverse effects among children and young adults with traumatic brain injury (TBI) admitted to pediatric inpatient rehabilitation units.

SETTING

Eight pediatric acute inpatient rehabilitation units located throughout the United States comprising the Pediatric Brain Injury Consortium.

PARTICIPANTS

Two-hundred thirty-four children and young adults aged 2 months to 21 years with TBI.

DESIGN

Retrospective data revie.

MAIN OUTCOME MEASURES

Demographic variables associated with the use of amantadine, amantadine dose, and reported adverse effects.

RESULTS

Forty-nine patients (21%) aged 0.9 to 20 years received amantadine during inpatient rehabilitation. Forty-five percent of patients admitted to inpatient rehabilitation with a disorder of consciousness (DoC) were treated with amantadine, while 14% of children admitted with higher levels of functioning received amantadine. Children with DoC who were not treated with amantadine were younger than those with DoC who received amantadine (median 3.0 vs 11.6 years, P = .008). Recorded doses of amantadine ranged from 0.7 to 13.5 mg/kg/d; the highest total daily dose was 400 mg/d. Adverse effects were reported in 8 patients (16%); nausea/abdominal discomfort and agitation were most common, each reported in 3 patients. The highest reported dose without an adverse effect was 10.1 mg/kg/d.

CONCLUSION

During pediatric inpatient rehabilitation, amantadine was prescribed to children across a range of ages and injury severity and was most commonly prescribed to older children with DoC. Dosing varied widely, with weight-based dosing for younger/smaller children at both lower and higher doses than what had been previously reported. Prospective studies are needed to characterize the safety and tolerability of higher amantadine doses and optimize amantadine dosing parameters for children with TBI.

Sleep and Executive Functioning in Pediatric Traumatic Brain Injury Survivors after Critical Care

Over 50,000 children are hospitalized annually for traumatic brain injury (TBI) and face long-term cognitive morbidity. Over 50% develop sleep/wake disturbances (SWDs) that can affect brain development and healing. We hypothesized SWDs would portend worse executive function outcomes in children aged 3−18 years with TBI 1−3 months after hospital discharge. SWDs were defined using the Sleep Disturbances Scale for Children (t-scores ≥ 60). Outcomes included the Global Executive Composite (GEC, t-score) from the Behavior Rating Inventory of Executive Function, Second and Preschool Editions, and multiple objective executive function assessments combined through Principal Components Analysis into a Neurocognitive Index (NCI, z-score). Multiple linear regression evaluated associations between SWDs and executive function outcomes, controlling for covariates. Among 131 children, 68% had clinically significant SWDs, which were associated with significantly worse median scores on the GEC (56 vs. 45) and NCI (−0.02 vs. 0.42; both p < 0.05). When controlling for baseline characteristics and injury severity in multivariable analyses, SWDs were associated with worse GEC (β-coefficient = 7.8; 95% Confidence Interval = 2.5, 13.1), and worse NCI (β-coefficient = −0.4; 95% Confidence Interval = −0.8, −0.04). SWDs in children with TBI are associated with worse executive function outcomes after hospital discharge, and may serve as modifiable targets to improve outcomes.

Neural alterations in working memory of mild-moderate TBI: An fMRI study in Malaysia

Working memory (WM) encompasses crucial cognitive processes or abilities to retain and manipulate temporary information for immediate execution of complex cognitive tasks in daily functioning such as reasoning and decision-making. The WM of individuals sustaining traumatic brain injury (TBI) was commonly compromised, especially in the domain of WM. The current study investigated the brain responses of WM in a group of participants with mild-moderate TBI compared to their healthy counterparts employing functional magnetic resonance imaging. All consented participants (healthy: n = 26 and TBI: n = 15) performed two variations of the n-back WM task with four load conditions (0-, 1-, 2-, and 3-back). The respective within-group effects showed a right hemisphere-dominance activation and slower reaction in performance for the TBI group. Random-effects analysis revealed activation difference between the two groups in the right occipital lobe in the guided n-back with cues, and in the bilateral occipital lobe, superior parietal region, and cingulate cortices in the n-back without cues. The left middle frontal gyrus was implicated in the load-dependent processing of WM in both groups. Further group analysis identified that the notable activation changes in the frontal gyri and anterior cingulate cortex are according to low and high loads. Though relatively smaller in scale, this study was eminent as it clarified the neural alterations in WM in the mild-moderate TBI group compared to healthy controls. It confirmed the robustness of the phenomenon in TBI with the reproducibility of the results in a heterogeneous non-Western sample.

Brain-Derived Neurotrophic Factor Val66Met and Behavioral Adjustment after Early Childhood Traumatic Brain Injury

The present study examined the differential effect of the brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on behavioral adjustment in children with traumatic brain injury (TBI) relative to children with orthopedic injury (OI). Participants were drawn from a prospective, longitudinal study of children who sustained a TBI (n = 69) or OI (n = 72) between 3 and 7 years of age. Parents completed the Child Behavior Checklist (CBCL) at the immediate post-acute period, 6, 12, and 18 months after injury, and an average of 3.5 and 7 years after injury. Longitudinal mixed models examined the BDNF Val66Met allele status (Met carriers vs. Val/Val homozygotes) × injury group (TBI vs. OI) interaction in association with behavioral adjustment. After adjusting for continental ancestry, socioeconomic status, time post-injury, and pre-injury functioning, the allele status × injury group interaction was statistically significant for Internalizing, Externalizing, and Total Behavior problems. Post hoc within-group analysis suggested a consistent trend of poorer behavioral adjustment in Met carriers relative to Val/Val homozygotes in the TBI group; in contrast, the opposite trend was observed in the OI group. These within-group differences, however, did not reach statistical significance. The results support a differential effect of the BDNF Val66Met polymorphism on behavioral adjustment in children with early TBI relative to OI, and suggest that the Met allele associated with reduced activity-dependent secretion of BDNF may impart risk for poorer long-term behavioral adjustment in children with TBI.

Surface-based abnormalities of the executive frontostriatial circuit in pediatric TBI

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Cortical thickness of the dorsolateral prefrontal cortex is reduced in pediatric TBI.

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Shape abnormalities of the caudate and mediodorsal nucleus of the thalamus are a feature of pediatric TBI.

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Surface-based abnormalities of the dorsolateral prefrontal loop do not appear to relate to executive functioning.

Childhood traumatic brain injury (TBI) is one of the most common causes of acquired disability and has significant implications for executive functions (EF), such as impaired attention, planning, and initiation that are predictive of everyday functioning. Evidence has suggested attentional features of executive functioning require behavioral flexibility that is dependent on frontostriatial circuitry. The purpose of this study was to evaluate surface-based deformation of a specific frontostriatial circuit in pediatric TBI and its role in EF. Regions of interest included: the dorsolateral prefrontal cortex (DLPFC), caudate nucleus, globus pallidus, and the mediodorsal nucleus of the thalamus (MD). T1-weighted magnetic resonance images were obtained in a sample of children ages 8–13 with complicated mild, moderate, or severe TBI (n = 32) and a group of comparison children with orthopedic injury (OI; n = 30). Brain regions were characterized using high-dimensional surface-based brain mapping procedures. Aspects of EF were assessed using select subtests from the Test of Everyday Attention for Children (TEA-Ch). General linear models tested group and hemisphere differences in DLPFC cortical thickness and subcortical shape of deep-brain regions; Pearson correlations tested relationships with EF. Main effects for group were found in both cortical thickness of the DLPFC (F_1,60 = 4.30, p = 0.042) and MD mean deformation (F_1,60 = 6.50, p = 0.01) all with lower values in the TBI group. Statistical surface maps revealed significant inward deformation on ventral-medial aspects of the caudate in TBI relative to OI, but null results in the globus pallidus. No significant relationships between EF and any region of interest were observed. Overall, findings revealed abnormalities in multiple aspects of a frontostriatial circuit in pediatric TBI, which may reflect broader pathophysiological mechanisms. Increased consideration for the role of deep-brain structures in pediatric TBI can aid in the clinical characterization of anticipated long-term developmental effects of these individuals.

Structural-covariance networks identify topology-based cortical-thickness changes in children with persistent executive function impairments after traumatic brain injury

Paediatric traumatic brain injury (pTBI) results in inconsistent changes to regional morphometry of the brain across studies. Structural-covariance networks represent the degree to which the morphology (typically cortical-thickness) of cortical-regions co-varies with other regions, driven by both biological and developmental factors. Understanding how heterogeneous regional changes may influence wider cortical network organization may more appropriately capture prognostic information in terms of long term outcome following a pTBI. The current study aimed to investigate the relationships between cortical organisation as measured by structural-covariance, and long-term cognitive impairment following pTBI. T1-weighted magnetic resonance imaging (MRI) from n = 83 pTBI patients and 33 typically developing controls underwent 3D-tissue segmentation using Freesurfer to estimate cortical-thickness across 68 cortical ROIs. Structural-covariance between regions was estimated using Pearson's correlations between cortical-thickness measures across 68 regions-of-interest (ROIs), generating a group-level 68 × 68 adjacency matrix for patients and controls. We grouped a subset of patients who underwent executive function testing at 2-years post-injury using a neuropsychological impairment (NPI) rule, defining impaired- and non-impaired subgroups. Despite finding no significant reductions in regional cortical-thickness between the control and pTBI groups, we found specific reductions in graph-level strength of the structural covariance graph only between controls and the pTBI group with executive function (EF) impairment. Node-level differences in strength for this group were primarily found in frontal regions. We also investigated whether the top n nodes in terms of effect-size of cortical-thickness reductions were nodes that had significantly greater strength in the typically developing brain than n randomly selected regions. We found that acute cortical-thickness reductions post-pTBI are loaded onto regions typically high in structural covariance. This association was found in those patients with persistent EF impairment at 2-years post-injury, but not in those for whom these abilities were spared. This study posits that the topography of post-injury cortical-thickness reductions in regions that are central to the typical structural-covariance topology of the brain, can explain which patients have poor EF at follow-up.

Processing Speed and Time since Diagnosis Predict Adaptive Functioning Measured with WeeFIM in Pediatric Brain Tumor Survivors

Simple Summary

Brain tumor (BT) survivors show difficulties in adaptive functioning (AF) and in acquiring independence (e.g., graduating, finding employment, building strong relationships, and being independent). The aim of our observational retrospective study is to explore the contribution of different clinical and cognitive variables in explaining and predicting the AF outcomes of BT survivors, measured with the Functional Independence Measure for Children (WeeFIM). The analysis demonstrated that processing speed and time since diagnosis are the main explanatory variables. Other clinical factors, such as age at diagnosis and hydrocephalus, differentially influence functional skills according to distinct domains (i.e., self-care, mobility, and cognition). The identification of the clinical factors influencing AF could suggest targets on which to focus attention. By successfully assessing, understanding, and managing AF, it will be possible to improve its management in pediatric BT survivors.

Abstract

(1) Background: Brain tumor (BT) survivors show difficulties in the acquisition of developmental milestones, related to academic achievement, vocational employment, social relationships, and autonomy. The skills underlying adaptive functioning (AF) are usually damaged in BT survivors due to the presence of the brain tumor, treatment-related factors, and other neurological sequelae. In this study, we aimed to explore the contribution of different cognitive factors in children with BT to AF, considering diagnosis-related variables. (2) Methods: Standardized cognitive assessment was undertaken and clinical information was collected from a retrospective cohort of 78 children with a BT, aged between 6 and 18 year old at the time of the assessment. Regression models were computed to investigate the influence of the selected variables on daily functional skills as measured by the Functional Independence Measure for Children (WeeFIM). (3) Results: The analyses showed that the main explanatory variables are processing speed and time since diagnosis. Other clinical variables, such as age at diagnosis and hydrocephalus, differentially influence functional skills according to distinct domains (i.e., self-care, mobility, and cognition). (4) Conclusions: The main explanatory variables of AF that emerged in our models point to a potential target of improving AF management in pediatric BT survivors.

Brain Magnetic Resonance Imaging Volumetric Measures of Functional Outcome after Severe Traumatic Brain Injury in Adolescents

Adolescent traumatic brain injury (TBI) is a major public health concern, resulting in >35,000 hospitalizations in the United States each year. Although neuroimaging is a primary diagnostic tool in the clinical assessment of TBI, our understanding of how specific neuroimaging findings relate to outcome remains limited. Our study aims to identify imaging biomarkers of long-term neurocognitive outcome after severe adolescent TBI. Twenty-four adolescents with severe TBI (Glasgow Coma Scale ≤8) enrolled in the ADAPT (Approaches and Decisions after Pediatric TBI) study were recruited for magnetic resonance imaging (MRI) scanning 1-2 years post-injury at 13 participating sites. Subjects underwent outcome assessments ∼1-year post-injury, including the Wechsler Abbreviated Scale of Intelligence (IQ) and the Pediatric Glasgow Outcome Scale-Extended (GOSE-Peds). A typically developing control cohort of 38 age-matched adolescents also underwent scanning and neurocognitive assessment. Brain-image segmentation was performed on T1-weighted images using Freesurfer. Brain and ventricular cerebrospinal fluid volumes were used to compute a ventricle-to-brain ratio (VBR) for each subject, and the corpus callosum cross-sectional area was determined in the midline for each subject. The TBI group demonstrated higher VBR and lower corpus callosum area compared to the control cohort. After adjusting for age and sex, VBR was significantly related with GOSE-Peds score in the TBI group (n = 24, p = 0.01, cumulative odds ratio = 2.18). After adjusting for age, sex, intracranial volume, and brain volume, corpus callosum cross-sectional area correlated significantly with IQ score in the TBI group (partial cor = 0.68, n = 18, p = 0.007) and with PSI (partial cor = 0.33, p = 0.02). No association was found between VBR and IQ or between corpus callosum and GOSE-Peds. After severe adolescent TBI, quantitative MRI measures of VBR and corpus callosum cross-sectional area are associated with global functional outcome and neurocognitive outcomes, respectively.

Recent Advances in Fluorescence Imaging of Traumatic Brain Injury in Animal Models

Traumatic brain injury (TBI) is one of the top three specific neurological disorders, requiring reliable, rapid, and sensitive imaging of brain vessels, tissues, and cells for effective diagnosis and treatment. Although the use of medical imaging such as computed tomography (CT) and magnetic resonance imaging (MRI) for the TBI detection is well established, the exploration of novel TBI imaging techniques is of great interest. In this review, recent advances in fluorescence imaging for the diagnosis and evaluation of TBI are summarized and discussed in three sections: imaging of cerebral vessels, imaging of brain tissues and cells, and imaging of TBI-related biomarkers. Design strategies for probes and labels used in TBI fluorescence imaging are also described in detail to inspire broader applications. Moreover, the multimodal TBI imaging platforms combining MRI and fluorescence imaging are also briefly introduced. It is hoped that this review will promote more studies on TBI fluorescence imaging, and enable its use for clinical diagnosis as early as possible, helping TBI patients get better treatment and rehabilitation.

Long-Term Outcome of PICU Patients Discharged With New, Functional Status Morbidity

OBJECTIVES

To determine the long-term (> 6 mo) functional status of PICU patients with significant new functional morbidities at hospital discharge.

DESIGN

Longitudinal cohort followed-up using structured chart reviews of electronic health records.

SETTING

Electronic health records of former PICU patients at seven sites.

PATIENTS

Randomly selected patients from the Trichotomous Outcome Prediction in Critical Care study discharged from the hospital with new functional status morbidity who had sufficient electronic health record data to determine functional status.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Long-term functional status was measured with the Functional Status Scale and categorized by comparison to hospital discharge Functional Status Scale. Improvement or new morbidity was based on a change in Functional Status Scale of greater than or equal to 2 in a single domain. Overall, 56% (n = 71) improved, 15% (n = 19) did not change, 9% (n = 11) developed a new morbidity, and 21% (n = 26) died. The shortest median follow-up time from PICU discharge was 1.4 years for those who died and the longest was 4.0 years for those improved. Functional status at baseline (pre-acute illness) was different among the outcome groups with those that improved having the highest frequency of baseline normal status or only mild dysfunction. Of the long-term survivors with improvement, 82% (n = 58) improved to normal status or mild dysfunction, 11% (n = 8) improved to moderate dysfunction, and 7% (n = 5) improved to severe dysfunction. Trauma patients improved and cancer patients died more frequently than other diagnoses. The long-term outcome groups were not associated with hospital discharge functional status.

CONCLUSIONS

A majority of PICU survivors discharged with significant new functional morbidity with follow-up after 6 or more months improved, many to normal status or only mild dysfunction, while 29% died or developed new morbidity. Of the long-term survivors, 70% had significant improvement after a median follow-up time of 4.0 years.

Oral processing speed as a key mechanism in the relationship between neurological risk and adaptive functioning in survivors of pediatric brain tumors

PURPOSE

Brain tumor (BT) survivors are at risk for difficulties with adaptive functioning (AF). Recent work has associated neurological risk with poorer AF outcomes using the Neurological Predictor Scale (NPS), a quantification of neurological risk factors. Survivors also have poorer attention, processing speed, and working memory, which are all important for AF. The current study examined whether these cognitive constructs explain the relationship between the NPS and AF in survivors.

METHODS

Ninety-five adult BT survivors and 135 healthy controls were recruited from the Atlanta area. The Oral Symbol Digits Modalities test was used to measure processing speed, Digit Span Backward assessed working memory, and Digit Span Forward measured attention. Informants completed the Scales of Independent Behavior (SIB-R) to measure AF. Group differences and correlations were assessed, and the PROCESS macro for SPSS tested indirect effects.

RESULTS

Survivors were significantly lower on AF and cognitive measures compared with controls. Attention span and processing speed had significant indirect effects in relationship between NPS and AF individually, but processing speed was the only variable with a significant indirect effect when all cognitive variables were included in the model. The NPS and processing speed together account for approximately 39% of variance in AF outcomes.

CONCLUSIONS

BT survivors in our sample have lower AF than controls, and processing speed appears to be particularly important in explaining the relationship between neurological risk and AF. In the future, the development of interventions aimed at increasing young adult independence should target both cognitive processing speed and AF skills.

Early Brain Injury and Adaptive Functioning in Middle Childhood: The Mediating Role of Pragmatic Language

OBJECTIVE

Traumatic brain injuries (TBIs) often adversely affect adaptive functioning (AF). However, the cognitive mechanisms by which AF is disrupted are not well understood in young children who sustain TBI. This study examined pragmatic language (PL) and executive functioning (EF) as potential mechanisms for AF disruption in children with early, predominantly mild-complicated, TBI.

METHOD

The sample consisted of 76 children between the ages of 6 and 10 years old who sustained a TBI (n = 36) or orthopedic injury (OI; n = 40) before 6 years of age and at least 1 year prior to testing (M = 4.86 years, SD = 1.59). Children's performance on a PL and an expressive vocabulary task (which served as a control task), and parent report of child's EF and AF were examined at two time points 1 year apart (i.e., at age 8 and at age 9 years).

RESULTS

Injury type (TBI vs. OI) significantly predicted child's social and conceptual, but not practical, AF. Results indicated that PL, and not expressive vocabulary or EF at time 1, mediated the relationship between injury type and both social and conceptual AF at time 2.

CONCLUSIONS

A TBI during early childhood appears to subtly, but uniquely, disrupt complex language skills (i.e., PL), which in turn may disrupt subsequent social and conceptual AF in middle childhood. Additional longitudinal research that examines different aspects of PL and adaptive outcomes into adolescence is warranted.

Cumulative Influence of Inflammatory Response Genetic Variation on Long-Term Neurobehavioral Outcomes after Pediatric Traumatic Brain Injury Relative to Orthopedic Injury: An Exploratory Polygenic Risk Score

The addition of genetic factors to prognostic models of neurobehavioral recovery following pediatric traumatic brain injury (TBI) may account for unexplained heterogeneity in outcomes. The present study examined the cumulative influence of candidate genes involved in the inflammatory response on long-term neurobehavioral recovery in children with early childhood TBI relative to children with orthopedic injuries (OI). Participants were drawn from a prospective, longitudinal study evaluating outcomes of children who sustained TBI (n = 67) or OI (n = 68) between the ages of 3 and 7 years. Parents completed ratings of child executive function and behavior at an average of 6.8 years after injury. Exploratory unweighted and weighted polygenic risk scores (PRS) were constructed from single nucleotide polymorphisms (SNPs) across candidate inflammatory response genes (i.e., angiotensin converting enzyme [ACE], brain-derived neurotrophic factor [BDNF], interleukin-1 receptor antagonist [IL1RN], and 5'-ectonucleotidase [NT5E]) that showed nominal (p ≤ 0.20) associations with outcomes in the TBI group. Linear regression models tested the PRS × injury group (TBI vs. OI) interaction term and post-hoc analyses examined the effect of PRS within each injury group. Higher inflammatory response PRS were associated with more executive dysfunction and behavior problems in children with TBI but not in children with OI. The cumulative influence of inflammatory response genes as measured by PRS explained additional variance in long-term neurobehavioral outcomes, over and above well-established predictors and single candidate SNPs tested individually. The results suggest that some of the unexplained heterogeneity in long-term neurobehavioral outcomes following pediatric TBI may be attributable to a child's genetic predisposition to a greater or lesser inflammatory response to TBI.

Epigenetic Effects on Pediatric Traumatic Brain Injury Recovery (EETR): An Observational, Prospective, Longitudinal Concurrent Cohort Study Protocol

Introduction: Unexplained heterogeneity in outcomes following pediatric traumatic brain injury (TBI) is one of the most critical barriers to the development of effective prognostic tools and therapeutics. The addition of personal biological factors to our prediction models may account for a significant portion of unexplained variance and advance the field toward precision rehabilitation medicine. The overarching goal of the Epigenetic Effects on Pediatric Traumatic Brain Injury Recovery (EETR) study is to investigate an epigenetic biomarker involved in both childhood adversity and postinjury neuroplasticity to better understand heterogeneity in neurobehavioral outcomes following pediatric TBI. Our primary hypothesis is that childhood adversity will be associated with worse neurobehavioral recovery in part through an epigenetically mediated reduction in brain-derived neurotrophic factor (BDNF) expression in response to TBI. Methods and analysis: EETR is an observational, prospective, longitudinal concurrent cohort study of children aged 3-18 years with either TBI (n = 200) or orthopedic injury (n = 100), recruited from the UPMC Children's Hospital of Pittsburgh. Participants complete study visits acutely and at 6 and 12 months postinjury. Blood and saliva biosamples are collected at all time points-and cerebrospinal fluid (CSF) when available acutely-for epigenetic and proteomic analysis of BDNF. Additional measures assess injury characteristics, pre- and postinjury child neurobehavioral functioning, childhood adversity, and potential covariates/confounders. Recruitment began in July 2017 and will occur for ~6 years, with data collection complete by mid-2023. Analyses will characterize BDNF DNA methylation and protein levels over the recovery period and investigate this novel biomarker as a potential biological mechanism underlying the known association between childhood adversity and worse neurobehavioral outcomes following pediatric TBI. Ethics and dissemination: The study received ethics approval from the University of Pittsburgh Institutional Review Board. Participants and their parents provide informed consent/assent. Research findings will be disseminated via local and international conference presentations and manuscripts submitted to peer-reviewed journals. Trial Registration: The study is registered with clinicaltrials.org (ClinicalTrials.gov Identifier: NCT04186429).

Progesterone treatment following traumatic brain injury in the 11-day-old rat attenuates cognitive deficits and neuronal hyperexcitability in adolescence

Traumatic brain injury (TBI) in children younger than 4 years old results in cognitive and psychosocial deficits in adolescence and adulthood. At 4 weeks following closed head injury on postnatal day 11, male and female rats exhibited impairment in novel object recognition memory (NOR) along with an increase in open arm time in the elevated plus maze (EPM), suggestive of risk-taking behaviors. This was accompanied by an increase in intrinsic excitability and frequency of spontaneous excitatory post-synaptic currents (EPSCs), and a decrease in the frequency of spontaneous inhibitory post-synaptic currents in layer 2/3 neurons within the medial prefrontal cortex (PFC), a region that is implicated in both object recognition and risk-taking behaviors. Treatment with progesterone for the first week after brain injury improved NOR memory at the 4-week time point in both sham and brain-injured rats and additionally attenuated the injury-induced increase in the excitability of neurons and the frequency of spontaneous EPSCs. The effect of progesterone on cellular excitability changes after injury may be related to its ability to decrease the mRNA expression of the β3 subunit of the voltage-gated sodium channel and increase the expression of the neuronal excitatory amino acid transporter 3 in the medial PFC in sham- and brain-injured animals and also increase glutamic acid decarboxylase mRNA expression in sham- but not brain-injured animals. Progesterone treatment did not affect injury-induced changes in the EPM test. These results demonstrate that administration of progesterone immediately after TBI in 11-day-old rats reduces cognitive deficits in adolescence, which may be mediated by progesterone-mediated regulation of excitatory signaling mechanisms within the medial PFC.

Functional outcome after severe childhood traumatic brain injury: Results of the TGE prospective longitudinal study

BACKGROUND

Childhood severe traumatic brain injury (TBI) is a leading cause of long-lasting acquired disability, but little is known about functional outcome.

OBJECTIVE

We aimed to 1) study clinical recovery and functional outcome over 24 months after severe childhood TBI, 2) identify early sociodemographic and severity factors influencing outcome, and 3) examine the clinical utility of the Pediatric Injury Functional Outcome Scale (PIFOS) to assess functional outcome.

METHODS

Children (0-15 years) consecutively admitted in a trauma centre after accidental severe TBI over 3 years were included in a prospective longitudinal study (Traumatisme Grave de l'Enfant cohort). We measured clinical/neurological recovery, functional status (Pediatric Injury Functional Outcome Scale, [PIFOS]), overall disability (pediatric Glasgow Outcome Scale [GOS-Peds]) as well as intellectual ability (Wechsler scales) and educational outcome (mainstream school vs special education) of survivors at 1, 3, 12 and 24 months post-injury.

RESULTS

For 45 children (aged 3 to 15 years at injury), functional impairments were severe within the first 3 months. Despite the initial rapid clinical recovery and significant improvement over the first year, substantial alterations persisted for most children at 12 months post-TBI, with no significant improvement up to 2 years. Up to 80% of children still had moderate or severe overall disability (GOS-Peds) at 24 months. The severity of functional impairments (PIFOS) at 12 and 24 months was mostly related to socio-emotional, cognitive and physical impairments, and was significantly correlated with clinical/neurological deficits and cognitive (intellectual, executive) and behavioural disorders. Initial TBI severity was the main prognostic factor associated with functional status over the first 2 years post-injury.

CONCLUSIONS

Our results confirm the significant impact of severe childhood TBI on short- and medium-term functional outcomes and overall disability. All patients should benefit from systematic follow-up. The PIFOS appeared to be an accurate and reliable tool to assess functional impairment evolution and clinically meaningful outcomes over the first 2 years post-injury.

Cognitive mediators of adaptive functioning outcomes in survivors of pediatric brain tumors treated with proton radiotherapy

BACKGROUND

Cranial radiotherapy (RT) is associated with risk for cognitive and adaptive dysfunction. Proton RT (PRT) is a technique hypothesized to spare cognition by reducing exposure to nontarget brain tissue. However, little is known regarding functional outcomes in survivors of pediatric brain tumor (BT) treated with PRT. The present study examined the relationship between cognitive and adaptive outcomes in pediatric BT survivors post-PRT.

METHODS

Survivors treated with either focal (n = 33) or craniospinal irradiation (CSI; n = 37) PRT completed neurocognitive evaluations approximately 5 years post-treatment. Results of intelligence testing and ratings of adaptive functioning are reported. Mediation models examined the relationship among radiation field, cognition, and adaptive functioning.

RESULTS

The PRT CSI group demonstrated worse cognitive outcomes than the PRT Focal group across each cognitive index (Cohen's d = 0.56-0.70). Parent ratings of adaptive functioning were also worse in the PRT CSI group than the PRT Focal group (Global Adaptive Composite, d = 0.53; conceptual skills, d = 0.67). Cognitive performance fully mediated the relationship between radiation field and adaptive outcomes, while controlling for group differences in tumor histology and RT dose.

CONCLUSIONS

Focal PRT survivors demonstrated generally positive outcomes with weaknesses in processing speed and aspects of adaptive functioning. CSI exposure was associated with more consistently poor cognitive and adaptive outcomes. The increased risk for adaptive dysfunction in the PRT CSI group appeared due to the effects of CSI on cognition. Efforts to reduce the volume of tissue exposure to RT remain important.

Recovery Trajectories of Child and Family Outcomes Following Online Family Problem-Solving Therapy for Children and Adolescents after Traumatic Brain Injury

OBJECTIVES

We conducted joint analyses from five randomized clinical trials (RCTs) of online family problem-solving therapy (OFPST) for children with traumatic brain injury (TBI) to identify child and parent outcomes most sensitive to OFPST and trajectories of recovery over time.

METHODS

We examined data from 359 children with complicated mild to severe TBI, aged 5-18, randomized to OFPST or a control condition. Using profile analyses, we examined group differences on parent-reported child (internalizing and externalizing behavior problems, executive function behaviors, social competence) and family outcomes (parental depression, psychological distress, family functioning, parent-child conflict).

RESULTS

We found a main effect for measure for both child and family outcomes [F(3, 731) = 7.35, p < .001; F(3, 532) = 4.79, p = .003, respectively], reflecting differing degrees of improvement across measures for both groups. Significant group-by-time interactions indicated that children and families in the OFPST group had fewer problems than controls at both 6 and 18 months post baseline [t(731) = -5.15, p < .001, and t(731) = -3.90, p = .002, respectively, for child outcomes; t(532) = -4.81, p < .001, and t(532) = -3.80, p < .001, respectively, for family outcomes].

CONCLUSIONS

The results suggest limited differences in the measures' responsiveness to treatment while highlighting OFPST's utility in improving both child behavior problems and parent/family functioning. Group differences were greatest at treatment completion and after extended time post treatment.

Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study

Traumatic brain injury (TBI) is a significant cause of mortality and disability in the pediatric population. Non-accidental trauma (NAT) has specifically been reported to result in more severe injury as compared to accidental mechanisms of injury. We aim to investigate the long-term neurological outcomes in children with moderate to severe traumatic brain injury. Our secondary aim is to evaluate the difference in outcomes between children presenting with NAT and non-NAT, in our study population. We performed a retrospective study in a tertiary pediatric hospital between January 2008 to October 2017 of all patients with TBI <16 years old with a Glasgow Coma Scale (GCS) ≤13. The dual primary outcomes were mortality and Paediatric Functional Independence Measure (WeeFIM) scores, recorded at the start of rehabilitation, discharge, 3 months and 6 months post-injury. The secondary outcome was the development of post-traumatic epilepsy. There were 68 patients with a median age of 4.5 [interquartile range (IQR) 1.0-9.0] years old. The most common presenting symptom was vomiting for children <2 years (11/20, 55.0%) while confusion and disorientation were common for those ≥2 years (27/48, 56.3%). WeeFIM scores at the start of rehabilitation [median 122.0, IQR 33.8-126.0] improved at 6 months post-injury (median 126.0, IQR 98.5-126.0). There was a greater incidence of post-traumatic epilepsy in age <2 years (6/20, 30.0%) compared to age ≥2 years (1/48, 2.1%) (p = .002). When comparing NAT versus non-NAT survivors, cognition WeeFIM scores were significantly different at the start of rehabilitation (p = .017) and at 3 months post-injury (p = .025). NAT predicts for poorer long-term outcomes, specifically in cognition, as measured by WeeFIM scores. Younger children <2 years had a higher incidence of post-traumatic epilepsy compared to older children.

Genetic Influences on Behavioral Outcomes After Childhood TBI: A Novel Systems Biology-Informed Approach

Objectives: To test whether genetic associations with behavioral outcomes after early childhood traumatic brain injury (TBI) are enriched for biologic pathways underpinning neurocognitive and behavioral networks.

Design: Cross-sectional evaluation of the association of genetic factors with early (~ 6 months) and long-term (~ 7 years) post-TBI behavioral outcomes. We combined systems biology and genetic association testing methodologies to identify biologic pathways associated with neurocognitive and behavior outcomes after TBI. We then evaluated whether genes/single nucleotide polymorphism (SNPs) associated with these biologic pathways were more likely to demonstrate a relationship (i.e., enrichment) with short and long-term behavioral outcomes after early childhood TBI compared to genes/SNPs not associated with these biologic pathways.

Setting: Outpatient research setting.

Participants:140 children, ages 3–6:11 years at time of injury, admitted for a TBI or orthopedic injury (OI).

Interventions: Not Applicable.

Main Outcome Measures: Child behavior checklist total problems T score.

Results: Systems biology methodology identified neuronal systems and neurotransmitter signaling (Glutamate receptor, dopamine, serotonin, and calcium signaling), inflammatory response, cell death, immune systems, and brain development as important biologic pathways to neurocognitive and behavioral outcomes after TBI. At 6 months post injury, the group (TBI versus OI) by polymorphism interaction was significant when the aggregate signal from the highest ranked 40% of case gene associations was compared to the control set of genes. At ~ 7 years post injury, the selected polymorphisms had a significant main effect after controlling for injury type when the aggregate signal from the highest ranked 10% of the case genes were compared to the control set of genes

Conclusions: Findings demonstrate the promise of applying a genomics approach, informed by systems biology, to understanding behavioral recovery after pediatric TBI. A mixture of biologic pathways and processes are associated with behavioral recovery, specifically genes associated with cell death, inflammatory response, neurotransmitter signaling, and brain development. These results provide insights into the complex biology of TBI recovery.

Is diffuse axonal injury on susceptibility weighted imaging a biomarker for executive functioning in adolescents with traumatic brain injury?

Traumatic brain injury (TBI) is a heterogeneous disorder in which diffuse axonal injury (DAI) is an important component contributing to executive dysfunction. During adolescence, developing brain networks are especially vulnerable to acceleration-deceleration forces. We aimed to examine the correlation between DAI (number and localization) and executive functioning in adolescents with TBI. We recruited 18 adolescents with a mean age of 15y8m (SD = 1y7m), averaging 2.5 years after sustaining a moderate-to-severe TBI with documented DAI. Susceptibility Weighted Imaging sequence was administered to localize the DAI lesions. The adolescents performed a neurocognitive test-battery, addressing different aspects of executive functioning (working memory, attention, processing speed, planning ability) and their parents completed the Behavior Rating Inventory of Executive Function (BRIEF) - questionnaire. Executive performance of the TBI-group was compared with an age and gender matched control group of typically developing peers. Based on these results we focused on the Stockings of Cambridge test and the BRIEF to correlate with the total number and location of DAI. Results revealed that the anatomical distribution of DAI, especially in the corpus callosum and the deep brain nuclei, may have more implications for executive functioning than the total amount of DAI in adolescents. Results of this study may help guide targeted rehabilitation to redirect the disturbed development of executive function in adolescents with TBI.

Exploration of gray matter correlates of cognitive training benefit in adolescents with chronic traumatic brain injury

Sustaining a traumatic brain injury (TBI) during adolescence has a profound effect on brain development and can result in persistent executive functioning deficits in daily life. Cognitive recovery from pediatric-TBI relies on the potential of neuroplasticity, which can be fostered by restorative training-programs. However the structural mechanisms underlying cognitive recovery in the immature brain are poorly understood. This study investigated gray matter plasticity following 2 months of cognitive training in young patients with TBI. Sixteen adolescents in the chronic stage of moderate-severe-TBI (9 male, mean age = 15y8m ± 1y7m) were enrolled in a cognitive computerized training program for 8 weeks (5 times/week, 40 min/session). Pre-and post-intervention, and 6 months after completion of the training, participants underwent a comprehensive neurocognitive test-battery and anatomical Magnetic Resonance Imaging scans. We selected 9 cortical-subcortical Regions-Of-Interest associated with Executive Functioning (EF-ROIs) and 3 control regions from the Desikan-Killiany atlas. Baseline analyses showed significant decreased gray matter density in the superior frontal gyri p = 0.033, superior parietal gyri p = 0.015 and thalamus p = 0.006 in adolescents with TBI compared to age and gender matched controls. Linear mixed model analyses of longitudinal volumetric data of the EF-ROI revealed no strong evidence of training-related changes in the group with TBI. However, compared to the change over time in the control regions between post-intervention and 6 months follow-up, the change in the EF-ROIs showed a significant difference. Exploratory analyses revealed a negative correlation between the change on the Digit Symbol Substitution test and the change in volume of the putamen (r = -0.596, p = 0.015). This preliminary study contributes to the insights of training-related plasticity mechanisms after pediatric-TBI.

Participation seven years after severe childhood traumatic brain injury. Disabil Rehabil 2019;42:2402-2411. [PMID: 30950661 DOI: 10.1080/09638288.2019.1594398]

Purpose: Participation in home, school and community activities is considered as the ultimate aim of rehabilitation. The aims of this study were to examine participation seven years post-severe childhood traumatic brain injury and factors associated with participation.Materials and methods: Participants were enrolled in the Traumatisme Grave de l'Enfant (Severe Childhood Injury) cohort study following severe accidental childhood traumatic brain injury. Participation seven years post-injury, was examined using parent- and self-report forms of the Child and Adolescent Scale of Participation among 37 patients [62% males, mean age 15.4 years (SD = 4.4), mean length of coma 6.68 days (SD = 4.96)] and 33 matched controls.Results: Parent reports indicated significantly lower participation among patients compared to controls, but the self-reports did not. In the traumatic brain injury group, parent-reported participation was variable, with 22% of the patients clearly showing greater restrictions than controls. Participation restrictions were significantly associated with injury severity, poor functional outcome one-year post-injury, executive and behavioral difficulties and higher fatigue levels seven years post-injury, but not with pre-injury nor family factors.Conclusions: Several years after severe childhood traumatic brain injury, participation appears to depend more on injury-related factors than on environmental factors. In self-reports assessments of participation, it could be difficult for children and adolescents to distinguish capacity from performance.Implications for rehabilitationParticipation outcomes were highly variable in a sample of patients who sustained severe childhood traumatic brain injury.Participation should be assessed systematically following severe traumatic brain injury, both initially but also in the long-term, ideally using a combination of self- and proxy-report measures.Among patients with severe injuries, the influence of initial brain injury severity markers on participation seems much stronger than that of social/family environment factors.Children's and adolescents' self-reported participation assessed with the Child and Adolescent Scale of Participation may be difficult to interpret.

Developmental trajectories of adaptive functioning following early mild traumatic brain injury

Adaptive behavior impairments have been reported in children with severe traumatic brain injury (TBI) but are not typically found following mild TBI. It is possible that mild TBI induces subtle changes in adaptive functioning that are not captured in conventional group comparisons. This study aimed to explore time course changes in adaptive functioning following early mild TBI. Parents of 63 children with mild TBI and 53 children with orthopedic injuries aged between 1.5 and 5 years at the time of injury completed the Adaptive Behavior Assessment System-II at three time points: retrospectively to assess pre-injury functioning, then at 6 and 18 months post-injury. Developmental trajectories of adaptive functioning domains (practical, conceptual, and social) reported by parents were modeled using linear mixed-model analyses. Findings suggest that mild TBI may disrupt the expected developmental progression of children's social adaptive behavior, but does not appear to alter practical and conceptual domains.

Neuroimaging of the Injured Pediatric Brain: Methods and New Lessons

Traumatic brain injury (TBI) is a significant public health problem in the United States, especially for children and adolescents. Current epidemiological data estimate over 600,000 patients younger than 20 years are treated for TBI in emergency rooms annually. While many patients experience a full recovery, for others there can be long-lasting cognitive, neurological, psychological, and behavioral disruptions. TBI in youth can disrupt ongoing brain development and create added family stress during a formative period. The neuroimaging methods used to assess brain injury improve each year, providing researchers a more detailed characterization of the injury and recovery process. In this review, we cover current imaging methods used to quantify brain disruption post-injury, including structural magnetic resonance imaging (MRI), diffusion MRI, functional MRI, resting state fMRI, and magnetic resonance spectroscopy (MRS), with brief coverage of other methods, including electroencephalography (EEG), single-photon emission computed tomography (SPECT), and positron emission tomography (PET). We include studies focusing on pediatric moderate-severe TBI from 2 months post-injury and beyond. While the morbidity of pediatric TBI is considerable, continuing advances in imaging methods have the potential to identify new treatment targets that can lead to significant improvements in outcome.

Long-term classroom functioning and its association with neuropsychological and academic performance following traumatic brain injury during early childhood

OBJECTIVE

The present study utilized ecobehavioral assessment to examine classroom functioning several years following early childhood traumatic brain injury (TBI) or orthopedic injury (OI) and its association with injury factors, neuropsychological abilities, and academic performance.

METHOD

Participants included 39 children with moderate to severe TBI and 51 children with OI sustained between ages 3 and 7 years. At 7.2 (± 1.3) years post injury, ecobehavioral assessment was used to examine classroom functioning. Additional outcomes included neuropsychological tests, parent and teacher ratings of dysexecutive behavior, and teacher ratings of academic performance. Groups were compared on measures controlling for demographic characteristics, and associations among outcomes were examined using linear regression.

RESULTS

Children with TBI showed lower academic engagement relative to children with OI, as well as more frequent individual teacher attention for children with more severe injuries. For children with TBI, difficulties in classroom functioning were associated with lower cognitive flexibility and higher parent and teacher ratings of dysexecutive behavior. Lower scores on a test of fluid reasoning and a greater frequency of individual teacher attention were also associated with lower academic performance in children with TBI.

CONCLUSIONS

Difficulties in classroom functioning are evident several years after early childhood TBI and were associated with greater injury severity, neuropsychological weaknesses, and poorer academic performance. Children with impaired cognitive flexibility and fluid reasoning skills were at greatest risk for these difficulties and associated weaknesses in academic performance. Instructional interactions may be a potential target for intervention to promote academic progress in at-risk children. (PsycINFO Database Record

In Vivo Photoacoustic Imaging of Brain Injury and Rehabilitation by High-Efficient Near-Infrared Dye Labeled Mesenchymal Stem Cells with Enhanced Brain Barrier Permeability

Stem cell migration and interaction with pathology are critical to understand the complexity and status of disease recovery progress. However, the dynamic visualization still remains a great challenge due to imaging technical limitation, cell labeling difficulty, or blood-brain barrier (BBB). Herein, fast photoacoustic tomography (PAT) with optical molecular probes is applied to noninvasively monitor traumatic brain injury (TBI) and its rehabilitation. The vascular distribution and TBI hemorrhage are clearly imaged, longitudinally monitored, and quantified. Bone mesenchymal stem cells (BMSCs) labeled with modified Prussian blue particles (PBPs), excellent near-infrared dyes and photoacoustic contrasts, are intravenously injected to the mice for improved observation and efficient therapy. BMSCs are demonstrated to be capable of overcoming BBB with enhanced delivery of PBPs to the brain parenchyma. Notably, the versatile BMSCs are observed by PAT to home to the damage region and repair the ruptured vasculature. Moreover, the wound treated by BMSCs exhibits much faster recovery speed than that without treatment. These findings can potentially provide a new noninvasive and high-resolution approach to image TBI, monitor recovery process, and especially trace BMSCs. This study will stimulate extensive researches on brain diseases and provide promising strategies of dye labeled BMSCs in regenerative medicine.

A retrospective review of paediatric head injuries in Asia - a Pan Asian Trauma Outcomes Study (PATOS) collaboration

OBJECTIVE

We aim to examine the mechanisms of head-injured children presenting to participating centres in the Pan Asian Trauma Outcomes Study (PATOS) and to evaluate the association between mechanism of injury and severe outcomes.

DESIGN AND SETTING

We performed a retrospective review of medical records among emergency departments (EDs) of eight PATOS centres, from September 2014 - August 2015.

PARTICIPANTS

We included children <16 years old who presented within 24 hours of head injury and were admitted for observation or required a computed tomography (CT) of the brain from the ED. We excluded children with known coagulopathies, neurological co-morbidities or prior neurosurgery. We reviewed the mechanism, intent, location and object involved in each injury, and the patients' physical findings on presentation.

OUTCOMES

Primary outcomes were death, endotracheal intubation or neurosurgical intervention. Secondary outcomes included hospital and ED length of stay.

RESULTS

1438 children were analysed. 953 children (66.3%) were male and the median age was 5.0 years (IQR 1.0-10.0). Falls predominated especially among children younger than 2 years (82.9%), while road traffic injuries were more likely to occur among children 2 years and above compared with younger children (25.8% vs 11.1%). Centres from upper and lower middle-income countries were more likely to receive head injured children from road traffic collisions compared with those from high-income countries (51.4% and 40.9%, vs 10.9%, p<0.0001) and attended to a greater proportion of children with severe outcomes (58.2% and 28.4%, vs 3.6%, p<0.0001). After adjusting for age, gender, intent of injury and gross national income, traffic injuries (adjusted OR 2.183, 95% CI 1.448 to 3.293) were associated with severe outcomes, as compared with falls.

CONCLUSIONS

Among children with head injuries, traffic injuries are independently associated with death, endotracheal intubation and neurosurgery. This collaboration among Asian centres holds potential for future prospective childhood injury surveillance.

Influence of Dopamine-Related Genes on Neurobehavioral Recovery after Traumatic Brain Injury during Early Childhood

The present study examined the association of dopamine-related genes with short- and long-term neurobehavioral recovery, as well as neurobehavioral recovery trajectories over time, in children who had sustained early childhood traumatic brain injuries (TBI) relative to children who had sustained orthopedic injuries (OI). Participants were recruited from a prospective, longitudinal study evaluating outcomes of children who sustained a TBI (n = 68) or OI (n = 72) between the ages of 3 and 7 years. Parents completed ratings of child executive function and behavior at the immediate post-acute period (0-3 months after injury); 6, 12, and 18 months after injury; and an average of 3.5 and 7 years after injury. Thirty-two single nucleotide polymorphisms (SNPs) in dopamine-related genes (dopamine receptor D2 [DRD2], solute carrier family 6 member 3 [SLC6A3], solute carrier family 18 member A2 [SLC18A2], catechol-o-methyltransferase [COMT], and ankyrin repeat and kinase domain containing 1 [ANKK1]) were examined in association with short- and long-term executive function and behavioral adjustment, as well as their trajectories over time. After controlling for premorbid child functioning, genetic variation within the SLC6A3 (rs464049 and rs460000) gene was differentially associated with neurobehavioral recovery trajectories over time following TBI relative to OI, with rs464049 surviving multiple testing corrections. In addition, genetic variation within the ANKK1 (rs1800497 and rs2734849) and SLC6A3 (rs464049, rs460000, and rs1042098) genes was differentially associated with short- and long-term neurobehavioral recovery following TBI, with rs460000 and rs464049 surviving multiple testing corrections. The findings provide preliminary evidence that genetic variation in genes involved in DRD2 expression and density (ANKK1) and dopamine transport (SLC6A3) plays a role in neurobehavioral recovery following pediatric TBI.