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Patel ND, Wainwright MS, Moore A, Suz P, Muangman S, Vavilala MS. Establishing normal Lindegaard Ratio in healthy children 10-16 years of age. Childs Nerv Syst 2024:10.1007/s00381-024-06467-9. [PMID: 38907117 DOI: 10.1007/s00381-024-06467-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 06/23/2024]
Abstract
PURPOSE Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data to support the diagnosis. Studies have relied on expert consensus, but the definitions have not been validated in children diagnosed with angiographic evidence of vasospasm. Obtaining normative data is a prerequisite to defining pediatric cerebral vasospasm and the Lindegaard Ratio (LR). In this study, we obtained normative data and calculation of the normal LR from healthy children aged 10-16 years. METHODS TCD and carotid ultrasonography was used to measure steady state velocities of both the middle cerebral artery (VMCA) and the extracranial internal cerebral artery (VEICA) in healthy children aged 10-16 years. Demographic information, hemodynamic characteristics and the calculated LR (VMCA/VEICA) was determined for each subject using descriptive statistics. RESULTS Of the 26 healthy children, 13 were male and 13 were female. VMCA ranged between 53 and 93 cm/sec. LR ranged between 1 and 2.2 for the cohort. VMCA for both males and females were within 2 standard deviations (SD) of the normal mean flow velocity. As the VMCA velocities approached 2 SD above the mean, LR did not exceed 2.2. CONCLUSION Our results help define a threshold for LR which can be used to establish radiographic criteria for cerebral vasospasm in children. Our data suggests that using VMCA criteria alone would overestimate cerebral vasospasm and raises question of whether an LR threshold other than 3 is more appropriate for the cut off between hyperemia versus vasospasm in children.
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Affiliation(s)
- Namrata D Patel
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | - Anne Moore
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Pilar Suz
- Department of Anesthesiology, H. Lee Moffit Cancer Center, Tampa, FL, USA
| | - Saipin Muangman
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Monica S Vavilala
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
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2
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Tanikawa D, Take Y, Naito N, Teranishi A, Kurita H. Cerebral Infarction Due to Post-traumatic Cerebral Vasospasm in a 12-Year-Old Female. Cureus 2024; 16:e56275. [PMID: 38495962 PMCID: PMC10944334 DOI: 10.7759/cureus.56275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2024] [Indexed: 03/19/2024] Open
Abstract
Cerebral infarction due to post-traumatic cerebral vasospasm is rare. Although some modalities are recommended to detect post-traumatic cerebral vasospasm, its diagnosis remains controversial and challenging. Therefore, in this report, we will use a case report to highlight challenges and to delineate the characteristics of post-traumatic cerebral vasospasm in pediatric patients, including the diagnostic and treatment options. A 12-year-old female was admitted to our hospital following a motor vehicle collision. Her consciousness was severely impaired. Initial computed tomography (CT) revealed an acute subdural hematoma along the tentorium, and a focal subarachnoid hemorrhage was observed in the Sylvian fissure. The patient underwent the insertion of an intracranial pressure sensor and received therapy for increased intracranial pressure (ICP) control under sedation. On the second day, CT angiography (CTA) revealed no signs of arterial abnormality. A patient who is comatose or under sedation has masked neurological symptoms. Thus, new neurological events could only be detected via an intracranial pressure sensor. Her ICP increased on the seventh day, and a CT scan showed a new cerebral infarction in the right middle cerebral artery (MCA) region. We performed decompressive craniectomy to reduce ICP. Postoperative CTA confirmed severe vasospasm in the right MCA. The severe cerebral vasospasm induced the cerebral infarction. Our review suggests that physicians in trauma departments should frequently perform vascular evaluations by CTA, magnetic resonance angiography (MRA), transcranial Doppler ultrasound, or digital subtraction angiography (DSA), especially within two weeks from onset, to detect post-traumatic cerebral vasospasm.
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Affiliation(s)
- Daisuke Tanikawa
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Yushiro Take
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Nobuaki Naito
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Akio Teranishi
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, JPN
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3
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Vinci F, Tiseo M, Colosimo D, Calandrino A, Ramenghi LA, Biasucci DG. Point-of-care brain ultrasound and transcranial doppler or color-coded doppler in critically ill neonates and children. Eur J Pediatr 2024; 183:1059-1072. [PMID: 38112802 DOI: 10.1007/s00431-023-05388-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/21/2023]
Abstract
Point-of-care brain ultrasound and transcranial doppler or color-coded doppler is being increasingly used as an essential diagnostic and monitoring tool at the bedside of critically ill neonates and children. Brain ultrasound has already established as a cornerstone of daily practice in the management of the critically ill newborn for diagnosis and follow-up of the most common brain diseases, considering the easiness to insonate the brain through transfontanellar window. In critically ill children, doppler based techniques are used to assess cerebral hemodynamics in acute brain injury and recommended for screening patients suffering from sickle cell disease at risk for stroke. However, more evidence is needed regarding the accuracy of doppler based techniques for non-invasive estimation of cerebral perfusion pressure and intracranial pressure, as well as regarding the accuracy of brain ultrasound for diagnosis and monitoring of acute brain parenchyma alterations in children. This review is aimed at providing a comprehensive overview for clinicians of the technical, anatomical, and physiological basics for brain ultrasonography and transcranial doppler or color-coded doppler, and of the current status and future perspectives of their clinical applications in critically ill neonates and children. CONCLUSION In critically ill neonates, brain ultrasound for diagnosis and follow-up of the most common cerebral pathologies of the neonatal period may be considered the standard of care. Data are needed about the possible role of doppler techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles. In pediatric critical care, doppler based techniques should be routinely adopted to assess and monitor cerebral hemodynamics. New technologies and more evidence are needed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. WHAT IS KNOWN • In critically ill neonates, brain ultrasound for early diagnosis and follow-up of the most common cerebral and neurovascular pathologies of the neonatal period is a cornerstone of daily practice. In critically ill children, doppler-based techniques are more routinely used to assess cerebral hemodynamics and autoregulation after acute brain injury and to screen patients at risk for vasospasm or stroke (e.g., sickle cell diseases, right-to-left shunts). WHAT IS NEW • In critically ill neonates, research is currently focusing on the use of novel high frequency probes, even higher than 10 MHz, especially for extremely preterm babies. Furthermore, data are needed about the role of doppler based techniques for the assessment of cerebral perfusion and vasoreactivity of the critically ill neonate with open fontanelles, also integrated with a non-invasive assessment of brain oxygenation. In pediatric critical care, new technologies should be developed to improve the accuracy of brain ultrasound for the assessment of brain parenchyma of critically ill children with fibrous fontanelles. Furthermore, large multicenter studies are needed to clarify role and accuracy of doppler-based techniques to assess cerebral perfusion pressure and its changes after treatment interventions.
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Affiliation(s)
- Francesco Vinci
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Marco Tiseo
- Intensive Care Unit, 'Tor Vergata' University Hospital, Rome, Italy
| | - Denise Colosimo
- Pediatric Intensive Care Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Andrea Calandrino
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Luca Antonio Ramenghi
- Department of Neuroscience, Rehabilitation, Ophtalmology, Genetics, Maternal and Child Health, University of Genoa, Genoa, Italy
- Neonatal Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Daniele Guerino Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy.
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Kim M, Subah G, Cooper J, Fortunato M, Nolan B, Bowers C, Prabhakaran K, Nuoman R, Amuluru K, Soldozy S, Das AS, Regenhardt RW, Izzy S, Gandhi C, Al-Mufti F. Neuroendovascular Surgery Applications in Craniocervical Trauma. Biomedicines 2023; 11:2409. [PMID: 37760850 PMCID: PMC10525707 DOI: 10.3390/biomedicines11092409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.
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Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Michael Fortunato
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87108, USA
| | - Kartik Prabhakaran
- Department of Surgery, Division of Trauma and Acute Care Surgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children’s Hospital, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Indianapolis, IN 46032, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Alvin S. Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
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Harrar DB, Sun LR, Segal JB, Lee S, Sansevere AJ. Neuromonitoring in Children with Cerebrovascular Disorders. Neurocrit Care 2023; 38:486-503. [PMID: 36828980 DOI: 10.1007/s12028-023-01689-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 01/31/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Cerebrovascular disorders are an important cause of morbidity and mortality in children. The acute care of a child with an ischemic or hemorrhagic stroke or cerebral sinus venous thrombosis focuses on stabilizing the patient, determining the cause of the insult, and preventing secondary injury. Here, we review the use of both invasive and noninvasive neuromonitoring modalities in the care of pediatric patients with arterial ischemic stroke, nontraumatic intracranial hemorrhage, and cerebral sinus venous thrombosis. METHODS Narrative review of the literature on neuromonitoring in children with cerebrovascular disorders. RESULTS Neuroimaging, near-infrared spectroscopy, transcranial Doppler ultrasonography, continuous and quantitative electroencephalography, invasive intracranial pressure monitoring, and multimodal neuromonitoring may augment the acute care of children with cerebrovascular disorders. Neuromonitoring can play an essential role in the early identification of evolving injury in the aftermath of arterial ischemic stroke, intracranial hemorrhage, or sinus venous thrombosis, including recurrent infarction or infarct expansion, new or recurrent hemorrhage, vasospasm and delayed cerebral ischemia, status epilepticus, and intracranial hypertension, among others, and this, is turn, can facilitate real-time adjustments to treatment plans. CONCLUSIONS Our understanding of pediatric cerebrovascular disorders has increased dramatically over the past several years, in part due to advances in the neuromonitoring modalities that allow us to better understand these conditions. We are now poised, as a field, to take advantage of advances in neuromonitoring capabilities to determine how best to manage and treat acute cerebrovascular disorders in children.
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Affiliation(s)
- Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.
| | - Lisa R Sun
- Divisions of Pediatric Neurology and Vascular Neurology, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Bradley Segal
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Arnold J Sansevere
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
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6
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Cerebrovascular injuries in traumatic brain injury. Clin Neurol Neurosurg 2022; 223:107479. [DOI: 10.1016/j.clineuro.2022.107479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/22/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
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Transcranial Doppler Ultrasound, a Review for the Pediatric Intensivist. CHILDREN 2022; 9:children9050727. [PMID: 35626904 PMCID: PMC9171581 DOI: 10.3390/children9050727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 12/04/2022]
Abstract
The use of transcranial Doppler ultrasound (TCD) is increasing in frequency in the pediatric intensive care unit. This review highlights some of the pertinent TCD applications for the pediatric intensivist, including evaluation of cerebral hemodynamics, autoregulation, non-invasive cerebral perfusion pressure/intracranial pressure estimation, vasospasm screening, and cerebral emboli detection.
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8
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Vasospasm Surveillance by a Simplified Transcranial Doppler Protocol in Traumatic Brain Injury. World Neurosurg 2022; 164:e318-e325. [PMID: 35504479 DOI: 10.1016/j.wneu.2022.04.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To detect post-traumatic vasospasm in patients with traumatic brain injury (TBI), we implemented a simplified transcranial Doppler (TCD) surveillance protocol in a neurointensive care setting. In this study, we evaluate the yield of this protocol. METHODS Adult patients with TBI admitted to the neurointensive care unit were examined with TCD by 2 intensive care nurses trained in TCD examinations. Flow velocities of the middle cerebral arteries were recorded. TCD suspected vasospasm was defined as the mean flow velocity >120 cm/s, and when detected, the protocol recommended a supplementary computed tomography angiography. The rate of detection of TCD suspected vasospasm and the subsequent rate of radiological diagnosis of vasospasm were recorded. In multivariate logistic regression analysis, we evaluated age, initial Glasgow Coma Scale, craniotomy, and decompressive craniectomy as potential predictors of developing increased TCD velocity. RESULTS A total of 84 patients with TBI with a median initial Glasgow Coma Scale score of 6 were examined by TCD. TCD suspected vasospasm was found in the middle cerebral arteries of 18% of examined patients. Two-thirds of patients with TCD suspected vasospasm were investigated with a subsequent computed tomography angiography, and 80% of these patients received a radiological diagnosis of vasospasm. In logistic regression analysis, decompressive craniectomy was significantly associated with increased risk of developing TCD suspected vasospasm (odds ratio: 11.57, 95% confidence interval: 2.59-51.73, P = 0.001). CONCLUSIONS The implementation of a simplified TCD surveillance protocol in a neurointensive care setting yielded an 18% detection rate of TCD suspected vasospasm. In our cohort of patients with TBI, decompressive craniectomy was associated with increased risk of developing TCD suspected vasospasm.
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Dicpinigaitis AJ, Feldstein E, Damodara N, Cooper JB, Shapiro SD, Kamal H, Kinon MD, Pisapia J, Rosenberg J, Gandhi CD, Al-Mufti F. Development of cerebral vasospasm following traumatic intracranial hemorrhage: incidence, risk factors, and clinical outcomes. Neurosurg Focus 2022; 52:E14. [DOI: 10.3171/2021.12.focus21668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult.
METHODS
Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97–0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12–2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49–11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02–1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97–6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34–3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26–2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45–0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78–4.48; p < 0.001), but not with mortality.
CONCLUSIONS
This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.
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Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, and
| | | | | | | | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, and
| | | | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, and
| | - Jon Rosenberg
- Department of Neurology, Westchester Medical Center, Valhalla, New York
| | | | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, and
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Almojuela A, Kaderali Z, McEachern J, Kazina C, Serletis D. Vasospasm following low-velocity penetrating pediatric intracranial trauma. J Med Case Rep 2022; 16:48. [PMID: 35123564 PMCID: PMC8818220 DOI: 10.1186/s13256-022-03254-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 01/03/2022] [Indexed: 05/31/2023] Open
Abstract
Background BB guns or non-powder guns created in the modern era are able to reach exceedingly fast velocities as a result of advances in compressed-gas technology. While missile penetrating trauma has been well documented in neurosurgical literature, penetrating intracranial injury secondary to non-powder guns, along with their associated complications and treatments, is not well described, and even less so in the pediatric population.
Case presentation Here, we describe an unusual case of a 6-year-old Indigenous child who was accidentally shot with a BB gun to the head. He subsequently developed delayed acute right-sided weakness due to symptomatic vasospasm. His symptoms resolved following hypertensive therapy, balloon angioplasty intervention, and intra-arterial milrinone therapy. Conclusions This case highlights the unique complication of delayed symptomatic vasospasm in a child following a non-missile intracranial penetrating injury. Intracranial vasospasm needs to be considered in the presence of delayed neurological deficit given its potential reversibility. This case also emphasizes the importance of gun safety and education when handling and storing these potential weapons around children. Supplementary Information The online version contains supplementary material available at 10.1186/s13256-022-03254-5.
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Isola C, Evain JN, Francony G, Baud C, Millet A, Desrumaux A, Wroblewski I, Payen JF, Mortamet G. Cerebral vasospasm in children with subarachnoid hemorrhage: frequency, diagnosis, and therapeutic management. Neurocrit Care 2021; 36:868-875. [PMID: 34791595 DOI: 10.1007/s12028-021-01388-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The present study explores the frequency, diagnostic approach, and therapeutic management of cerebral vasospasm in a cohort of children with moderate-to-severe traumatic and nontraumatic subarachnoid hemorrhage (SAH). METHODS This was a single-center retrospective study performed over a 10-year period, from January 2010 to December 2019. Children aged from one month to 18 years who were admitted to the pediatric or adult intensive care unit with a diagnosis of SAH were eligible. Cerebral vasospasm could be suspected by clinical signs or transcranial Doppler (TCD) criteria (mean blood flow velocity > 120 cm/s or an increase in mean blood flow velocity by > 50 cm/s within 24 h) and then confirmed on cerebral imaging (with a reduction to less than 50% of the caliber of the cerebral artery). RESULTS Eighty patients aged 8.6 years (3.3-14.8 years, 25-75th centiles) were admitted with an initial Glasgow Coma Scale score of 8 (4-12). SAH was nontraumatic in 21 (26%) patients. A total of 14/80 patients (18%) developed cerebral vasospasm on brain imaging on day 6 (5-10) after admission, with a predominance of nontraumatic SAH (12/14). The diagnosis of cerebral vasospasm was suspected on clinical signs and/or significant temporal changes in TCD monitoring (7 patients) and then confirmed on cerebral imaging. Thirteen of 14 patients with vasospasm were successfully treated using a continuous intravenous infusion of milrinone. The Pediatric Cerebral Performance Category score at discharge from the intensive care unit was comparable between children with vasospasm (score of 2 [1-4]) vs. children without vasospasm (score of 4 [2-4]) (p = 0.09). CONCLUSIONS These findings indicate that cerebral vasospasm exists in pediatrics, particularly after nontraumatic SAH. The use of TCD and milrinone may help in the diagnostic and therapeutic management of cerebral vasospasm.
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Affiliation(s)
- Clément Isola
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Jean-Noel Evain
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France
| | - Gilles Francony
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France
| | - Caroline Baud
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Anne Millet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Amélie Desrumaux
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Isabelle Wroblewski
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France
| | - Jean-Francois Payen
- Department of Anesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Alpes University, Grenoble, 3800, France.,Grenoble Institute Neurosciences, Grenoble Alpes University, Grenoble, 3800, France
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble Alpes University, Grenoble, 3800, France. .,INSERM U1042, Grenoble-Alpes University,, Grenoble, 3800, France.
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12
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Sun LR, Ziai W, Brown P, Torriente AG, Cooper S, Gottesman RF, Felling RJ. Intrathecal chemotherapy-associated cerebral vasospasm in children with hematologic malignancies. Pediatr Res 2021; 89:858-862. [PMID: 32544924 DOI: 10.1038/s41390-020-1008-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/13/2020] [Accepted: 05/27/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Mechanisms of chemotherapy-associated neurotoxicity are poorly understood, and therefore, prevention strategies have not been developed. We hypothesized that a subgroup of children receiving intrathecal cytarabine develops subclinical vasospasm, which may contribute to long-term neurocognitive sequelae of cancer. METHODS We used transcranial Doppler ultrasound to serially evaluate cerebral blood flow velocities in participants ≤25 years old receiving intrathecal cytarabine for hematologic malignancies. RESULTS Four of 18 participants (22%) met the criteria for subclinical vasospasm within 4 days of intrathecal cytarabine administration. The distribution of oncologic diagnoses differed between the vasospasm and non-vasospasm groups (p = 0.02). Acute myeloid leukemia was identified as a potential risk factor for vasospasm. Children with vasospasm were more likely to have received intravenous cytarabine (75% versus 0%, p = 0.01) and less likely to have received steroids (25% versus 100%, p = 0.01). CONCLUSIONS A subpopulation of children with hematologic malignancies develops subclinical vasospasm after intrathecal cytarabine treatment. Future research is needed to determine the long-term clinical consequences of cerebral vasospasm in this population. IMPACT A subset of children with hematologic malignancies who receive intrathecal cytarabine experience subclinical cerebral vasospasm, as measured by transcranial Doppler ultrasound. Of children receiving intrathecal cytarabine, those who develop cerebral vasospasm are more likely to have diagnosis of acute myeloid leukemia, more likely to receive concurrent intravenous cytarabine, and less likely to receive steroids as part of their chemotherapy regimen, as compared with children without vasospasm. Future research is needed to determine if vasospasm during chemotherapy is associated with higher rates of neurocognitive dysfunction, and if so, to focus on prevention of these long-term sequelae of childhood cancer.
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Affiliation(s)
- Lisa R Sun
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Wendy Ziai
- Division of Neurocritical Care, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Patrick Brown
- Division of Pediatric Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Stacy Cooper
- Division of Pediatric Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rebecca F Gottesman
- Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ryan J Felling
- Division of Pediatric Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Division of Cerebrovascular Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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13
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Trihan JE, Perez-Martin A, Guillaumat J, Lanéelle D. Normative and pathological values of hemodynamic and Doppler ultrasound arterial findings in children. VASA 2020; 49:264-274. [PMID: 32323630 DOI: 10.1024/0301-1526/a000860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Doppler ultrasound is an effective, useful and remarkably powerful tool in pediatric imaging. If possible, its use is always favored to avoid exposure to radiation or sedatives. By waveform spectrum analysis, Doppler ultrasound reveals information on blood flow and details on normal physiology and pathological processes undiscernible from gray-scale imaging alone. However, Doppler ultrasound remains underused, largely due to the difficult interpretation of changes in Doppler waveforms during childhood. This article provides a narrative review of the literature regarding the normative values and the physiological arterial changes through childhood according to age, weight or height, as well as frequent pathological arterial findings in children, classified by arterial territory.
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Affiliation(s)
- Jean-Eudes Trihan
- Department of Vascular Medicine, Cardio-Vascular Center, University Hospital Center of Poitiers, Poitiers, France
| | | | - Jérôme Guillaumat
- University Hospital Center Côte de Nacre, UniCaen University, Caen, France
| | - Damien Lanéelle
- University Hospital Center Côte de Nacre, UniCaen University, Caen, France
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14
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Singh Y, Tissot C, Fraga MV, Yousef N, Cortes RG, Lopez J, Sanchez-de-Toledo J, Brierley J, Colunga JM, Raffaj D, Da Cruz E, Durand P, Kenderessy P, Lang HJ, Nishisaki A, Kneyber MC, Tissieres P, Conlon TW, De Luca D. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24:65. [PMID: 32093763 PMCID: PMC7041196 DOI: 10.1186/s13054-020-2787-9] [Citation(s) in RCA: 281] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
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Affiliation(s)
- Yogen Singh
- Department of Paediatrics - Neonatology and Paediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Addenbrooke's Hospital, Box 402, Cambridge, UK.
| | - Cecile Tissot
- Paediatric Cardiology, Centre de Pédiatrie, Clinique des Grangettes, Geneva, Switzerland
| | - María V Fraga
- Department of Paediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Nadya Yousef
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
| | - Rafael Gonzalez Cortes
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jorge Lopez
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - Joe Brierley
- Department of Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | - Juan Mayordomo Colunga
- Department of Paediatric Intensive Care, Hospital Universitario Central de Asturias, Oviedo. CIBER-Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid. Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Dusan Raffaj
- Department of Paediatric Intensive Care, Nottingham University Hospitals, Nottingham, UK
| | - Eduardo Da Cruz
- Department of Paediatric and Cardiac Intensive Care, Children's Hospital Colorado, Aurora, USA
| | - Philippe Durand
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Peter Kenderessy
- Department of Paediatric Anaesthesia and Intensive Care, Children's Hospital Banska Bystrica, Banska Bystrica, Slovakia
| | - Hans-Joerg Lang
- Department of Paediatrics, Medicins Sans Frontieres (Suisse), Geneva, Switzerland
| | - Akira Nishisaki
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Martin C Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pierre Tissieres
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Thomas W Conlon
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM Unit U999, South Paris Medical School, Paris Saclay University, Paris, France
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15
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Transcranial Doppler Ultrasound During Critical Illness in Children: Survey of Practices in Pediatric Neurocritical Care Centers. Pediatr Crit Care Med 2020; 21:67-74. [PMID: 31568242 DOI: 10.1097/pcc.0000000000002118] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The scope of transcranial Doppler ultrasound in the practice of pediatric neurocritical care is unknown. We have surveyed pediatric neurocritical care centers on their use of transcranial Doppler and analyzed clinical management practices. DESIGN Electronic-mail recruitment with survey of expert centers using web-based questionnaire. SETTING Survey of 43 hospitals (31 United States, 12 international) belonging to the Pediatric Neurocritical Care Research Group. PATIENTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A 67% (29/43) hospital-response rate. Of these centers, 27 reported using transcranial Doppler in the PICU; two hospitals opted out due to lack of transcranial Doppler availability/use. The most common diagnoses for using transcranial Doppler in clinical care were intracranial/subarachnoid hemorrhage (20 hospitals), arterial ischemic stroke (14 hospitals), and traumatic brain injury (10 hospitals). Clinical studies were carried out and interpreted by credentialed individuals in 93% (25/27) and 78% (21/27) of the centers, respectively. A written protocol for performance of transcranial Doppler in the PICU was available in 30% (8/27 hospitals); of these, two of eight hospitals routinely performed correlation studies to validate results. In 74% of the centers (20/27), transcranial Doppler results were used to guide clinical care: that is, when to obtain a neuroimaging study (18 hospitals); how to manipulate cerebral perfusion pressure with fluids/vasopressors (13 hospitals); and whether to perform a surgical intervention (six hospitals). Research studies were also commonly performed for a range of diagnoses. CONCLUSIONS At least 27 pediatric neurocritical care centers use transcranial Doppler during clinical care. In the majority of centers, studies are performed and interpreted by credentialed personnel, and findings are used to guide clinical management. Further studies are needed to standardize these practices.
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16
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Lovett ME, Maa T, Moore-Clingenpeel M, O’Brien NF. Transcranial Doppler ultrasound findings in children with moderate-to-severe traumatic brain injury following abusive head trauma. Childs Nerv Syst 2020; 36:993-1000. [PMID: 31781914 PMCID: PMC7224000 DOI: 10.1007/s00381-019-04431-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/01/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of fatal head injuries for children under 2 years. The objective was to evaluate, using transcranial Doppler ultrasound (TCD), whether children with AHT have a similar neurovascular response to injury compared with children without AHT. METHODS Retrospective sub-analysis of previously prospectively acquired data in a pediatric intensive care unit in a level 1 trauma hospital. TCD was performed daily until hospital day 8, discharge, or death. Neurologic outcome was assessed using the Glasgow Outcome Scale Extended (GOS-E Peds) at 1 month from initial injury. RESULTS Sixty-nine children aged 1 day to 17 years with moderate-to-severe traumatic brain injury were enrolled. Fifteen children suffered AHT and 54 had no suspicion for AHT. Fifteen children with AHT underwent 80 serial TCD examinations; 54 children without AHT underwent 308 exams. After standardization for age and gender normative values, there was no statistically significant difference in mean cerebral blood flow velocity of the middle cerebral artery (VMCA) between children with and without AHT. There was no difference in the incidence of extreme cerebral blood flow velocity (CBFV, greater or less than 2 standard deviations from normative value) between groups. Within the AHT group, there were no statistically significant differences in VMCA between children with a favorable (GOS-E Peds 1-4) versus unfavorable neurologic outcome (GOS-E Peds 5-8). CONCLUSION Children with AHT have no significant differences in VMCA or percentage of extreme CBFV in the middle cerebral artery compared to with those without AHT.
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Affiliation(s)
- Marlina E. Lovett
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Tensing Maa
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Melissa Moore-Clingenpeel
- grid.240344.50000 0004 0392 3476Biostatistics Core, Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Nicole F. O’Brien
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
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17
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Lang SS, Khanna O, Atkin NJ, Palma JE, Yuan I, Storm PB, Heuer GG, Kennedy B, Waanders AJ, Li Y, Huh JW. Perioperative near-infrared spectroscopy cerebral oxygen saturation in symptomatic pediatric hydrocephalus patients at risk for intracranial hypertension. J Neurosurg Pediatr 2019; 25:235-241. [PMID: 31783356 DOI: 10.3171/2019.9.peds19457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 09/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The lack of a continuous, noninvasive modality for monitoring intracranial pressure (ICP) is a major obstacle in the care of pediatric patients with hydrocephalus who are at risk for intracranial hypertension. Intracranial hypertension can lead to cerebral ischemia and brain tissue hypoxia. In this study, the authors evaluated the use of near-infrared spectroscopy (NIRS) to measure regional cerebral oxygen saturation (rSO2) in symptomatic pediatric patients with hydrocephalus concerning for elevated ICP. METHODS The authors evaluated the NIRS rSO2 trends in pediatric patients presenting with acute hydrocephalus and clinical symptoms of intracranial hypertension. NIRS rSO2 values were recorded hourly before and after neurosurgical intervention. To test for significance between preoperative and postoperative values, the authors constructed a linear regression model with the rSO2 values as the outcome and pre- and postsurgery cohorts as the independent variable, adjusted for age and sex, and used the generalized estimating equation method to account for within-subject correlation. RESULTS Twenty-two pediatric patients underwent NIRS rSO2 monitoring before and after CSF diversion surgery. The mean durations of NIRS rSO2 recording pre- and postoperatively were 13.95 and 26.82 hours, respectively. The mean pre- and postoperative rSO2 values were 73.84% and 80.65%, respectively, and the adjusted mean difference estimated from the regression model was 5.98% (adjusted p < 0.0001), suggestive of improved cerebral oxygenation after definitive neurosurgical CSF diversion treatment. Postoperatively, all patients returned to baseline neurological status with no clinical symptoms of elevated ICP. CONCLUSIONS Cerebral oxygenation trends measured by NIRS in symptomatic pediatric hydrocephalus patients with intracranial hypertension generally improve after CSF diversion surgery.
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Affiliation(s)
- Shih-Shan Lang
- 1Division of Neurosurgery, Children's Hospital of Philadelphia
- 2Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania
- 6Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia
| | - Omaditya Khanna
- 3Department of Neurological Surgery, Thomas Jefferson University Hospital
| | - Natalie J Atkin
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
- 5Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania
| | - Judy E Palma
- 6Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia
| | - Ian Yuan
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
- 5Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania
| | - Phillip B Storm
- 1Division of Neurosurgery, Children's Hospital of Philadelphia
- 2Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania
- 6Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia
| | - Gregory G Heuer
- 1Division of Neurosurgery, Children's Hospital of Philadelphia
- 2Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania
- 6Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia
| | - Benjamin Kennedy
- 1Division of Neurosurgery, Children's Hospital of Philadelphia
- 2Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania
- 6Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia
| | - Angela J Waanders
- 6Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia
- 10Division of Hematology, Oncology, and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yimei Li
- 7Department of Oncology, Children's Hospital of Philadelphia
- 8Department of Oncology, Perelman School of Medicine, University of Pennsylvania
- 9Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Jimmy W Huh
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia
- 5Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania
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18
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Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol 2019; 10:1261. [PMID: 32038449 PMCID: PMC6988791 DOI: 10.3389/fneur.2019.01261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/13/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Improved methods of monitoring real-time cerebral physiology are needed to better understand when secondary brain injury develops and what treatment strategies may alleviate or prevent such injury. In this review, we discuss emerging technologies that exist to better understand intracranial pressure (ICP), cerebral blood flow, metabolism, oxygenation and electrical activity. We also discuss approaches to integrating these data as part of a multimodality monitoring strategy to improve patient care.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - Brian T Burrows
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Stephen Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
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19
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Noninvasive Measures of Cerebrohemodynamics in Complicated Mild Traumatic Brain Injury. Pediatr Crit Care Med 2019; 20:389-390. [PMID: 30950994 DOI: 10.1097/pcc.0000000000001873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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20
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The TRPC6 inhibitor, larixyl acetate, is effective in protecting against traumatic brain injury-induced systemic endothelial dysfunction. J Neuroinflammation 2019; 16:21. [PMID: 30704505 PMCID: PMC6354413 DOI: 10.1186/s12974-019-1407-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 01/11/2019] [Indexed: 01/28/2023] Open
Abstract
Background The incidence of traumatic brain injuries (TBIs) is on the rise in the USA. Concussions, or mild TBIs without skull fracture, account for about 75% of all TBIs. Mild TBIs (mTBIs) lead to memory and cognitive deficits, headaches, intraocular pressure rises, axonal degeneration, neuroinflammation, and an array of cerebrovascular dysfunctions, including increased vascular permeability and decreased cerebral blood flow. It has been recently reported that besides vascular dysfunction in the cerebral circulation, mTBI may also cause a significant impairment of endothelial function in the systemic circulation, at least within mesenteric microvessels. In this study, we investigated whether mTBI affects endothelial function in aortas and determined the contribution of transient receptor potential canonical (TRPC) channels to modulating mTBI-associated endothelial dysfunction. Methods We used a model of closed-head mTBI in C57BL/6, 129S, 129S-C57BL/6-F2 mice, and 129S-TRPC1 and 129S-C57BL/6-TRPC6 knockout mice to determine the effect of mTBI on endothelial function in mouse aortas employing ex vivo isometric tension measurements. Aortic tissue was also analyzed using immunofluorescence and qRT-PCR for TRPC6 expression following mTBI. Results We show that in various strains of mice, mTBI induces a pronounced and long-lasting endothelial dysfunction in the aorta. Ablation of TRPC6 protects mice from mTBI-associated aortic endothelial dysfunction, while TRPC1 ablation does not impact brain injury-induced endothelial impairment in the aorta. Consistent with a role of TRPC6 activation following mTBI, we observed improved endothelial function in wild type control mice subjected to mTBI following 7-day in vivo treatment with larixyl acetate, an inhibitor of TRPC6 channels. Conversely, in vitro treatment with the pro-inflammatory endotoxin lipopolysaccharide, which activates endothelial TRPC6 in a Toll-like receptor type 4 (TLR4)-dependent manner, worsened aortic endothelial dysfunction in wild type mice. Lipopolysaccharide treatment in vitro failed to elicit endothelial dysfunction in TRPC6 knockout mice. No change in endothelial TRPC6 expression was observed 7 days following TBI. Conclusions These data suggest that TRPC6 activation may be critical for inducing endothelial dysfunction following closed-head mTBI and that pharmacological inhibition of the channel may be a feasible therapeutic strategy for preventing mTBI-associated systemic endothelial dysfunction.
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21
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Sanefuji M, Ichimiya Y, Kaku N, Sasazuki M, Yonemoto K, Torio M, Mizuguchi S, Motomura Y, Muraoka M, Lee S, Baba H, Ohkubo K, Sonoda Y, Ishizaki Y, Sakai Y, Ohga S. Vascular pathomechanism in acute encephalopathy with biphasic seizures and late reduced diffusion. J Neurol Sci 2018; 395:141-146. [PMID: 30317181 DOI: 10.1016/j.jns.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 09/30/2018] [Accepted: 10/02/2018] [Indexed: 10/28/2022]
Abstract
Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is a childhood-onset encephalopathy, but the precise pathophysiology remains unclear. We encountered a child with Moyamoya syndrome and AESD. He exhibited left-predominant stenosis of the middle cerebral artery (MCA), and later developed broad lesions in the left hemisphere, raising the possibility that insufficient blood supply relates to formation of the lesions. To test the hypothesis, we investigated the relationship between MCA volume and lesion extent in seven AESD children without preexisting diseases. The MCA volume and lesion extent were quantified with time of flight images for construction of magnetic resonance angiography and apparent diffusion coefficient maps, respectively. Lateralization indices ([right - left]/[right + left]) of the MCA volume and lesion extent were calculated. We found that the lateralization indices were negatively correlated (r = -0.786, p = .036), that is, when the MCA volume was smaller in one side than the other side, the lesions were likely to develop more extensively in the ipsilateral side than the contralateral side. This indicates the association of insufficient blood supply with the lesions. The present study provides the first observation to suggest the involvement of vascular mechanism in AESD and has potential implications for novel therapeutic approach.
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Affiliation(s)
- Masafumi Sanefuji
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Research Center for Environment and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Yuko Ichimiya
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Noriyuki Kaku
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Momoko Sasazuki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kosuke Yonemoto
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Michiko Torio
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Soichi Mizuguchi
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Yoshitomo Motomura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Mamoru Muraoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Emergency and Critical Care Center, Kyushu University Hospital, Fukuoka, Japan
| | - Sooyoung Lee
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Intensive Care, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Haruhisa Baba
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Pediatrics, National Fukuoka-Higashi Medical Center, Fukuoka, Japan
| | - Kazuhiro Ohkubo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuri Sonoda
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Research Center for Environment and Developmental Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yoshito Ishizaki
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasunari Sakai
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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22
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Presenting Characteristics Associated With Outcome in Children With Severe Traumatic Brain Injury: A Secondary Analysis From a Randomized, Controlled Trial of Therapeutic Hypothermia. Pediatr Crit Care Med 2018; 19:957-964. [PMID: 30067578 PMCID: PMC6170689 DOI: 10.1097/pcc.0000000000001676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To identify injury patterns and characteristics associated with severe traumatic brain injury course and outcome, within a well-characterized cohort, which may help guide new research and treatment initiatives. DESIGN A secondary analysis of a phase 3, randomized, controlled trial that compared therapeutic hypothermia versus normothermia following severe traumatic brain injury in children. SETTING Fifteen sites in the United States, Australia, and New Zealand. PATIENTS Children (< 18 yr old) with severe traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Baseline, clinical, and CT characteristics of patients (n = 77) were examined for association with mortality and outcome, as measured by the Glasgow Outcome Scale-Extended Pediatric Revision 3 months after traumatic brain injury. Data are presented as odds ratios with 95% CIs. No demographic, clinical, or CT characteristic was associated with mortality in bivariate analysis. Characteristics associated with worse Glasgow Outcome Scale-Extended Pediatric Revision in bivariate analysis were two fixed pupils (14.17 [3.38-59.37]), abdominal Abbreviated Injury Severity score (2.03 [1.19-3.49]), and subarachnoid hemorrhage (3.36 [1.30-8.70]). Forward stepwise regression demonstrated that Abbreviated Injury Severity spine (3.48 [1.14-10.58]) and midline shift on CT (8.35 [1.05-66.59]) were significantly associated with mortality. Number of fixed pupils (one fixed pupil 3.47 [0.79-15.30]; two fixed pupils 13.61 [2.89-64.07]), hypoxia (5.22 [1.02-26.67]), and subarachnoid hemorrhage (3.01 [1.01-9.01]) were independently associated with worse Glasgow Outcome Scale-Extended Pediatric Revision following forward stepwise regression. CONCLUSIONS Severe traumatic brain injury is a clinically heterogeneous disease that can be accompanied by a range of neurologic impairment and a variety of injury patterns at presentation. This secondary analysis of prospectively collected data identifies several characteristics associated with outcome among children with severe traumatic brain injury. Future, larger trials are needed to better characterize phenotypes within this population.
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Deines JJ, Chang J, Reuter-Rice K. Cerebral Blood Flow Velocities and Functional Outcomes in Pediatric Mild Traumatic Brain Injury. J Neurotrauma 2018; 36:135-141. [PMID: 30044180 PMCID: PMC6306683 DOI: 10.1089/neu.2017.5577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Outcomes can be challenging to predict in children with mild traumatic brain injury (TBI). Transcranial Doppler (TCD) ultrasound has become an increasingly useful modality in adult and pediatric TBI by measuring blood flow velocities within the circle of Willis. In children with moderate-to-severe TBI, multiple studies have correlated abnormal TCD measurements and poor outcomes. Additionally, TCD has shown value in assessing adults with mild brain injury. To date, there are no studies that correlate TCD findings and outcomes in children with mild TBI. We hypothesize that altered cerebral blood flow after mild TBI is associated with poor functional outcome using the Glasgow Outcome Scale-Extended, Pediatrics (GOS-E Peds). TCD was performed within 24 h of admission on 60 patients at a tertiary Level 1 children's hospital. A secondary analysis was performed on the subgroup of 28 mild TBI patients. GOS-E Peds was measured at the time of hospital discharge and 4-6 weeks post-discharge. Cerebral blood flow velocities did not show correlation with outcome. At discharge, the right-sided Spearman's correlation coefficient was 0.19 (p value = 0.33) and the left-sided was 0.36 (p = 0.06). At follow up the right-sided coefficient was -0.04 (p = 0.84), the left-sided was -0.25 (p = 0.24). Pulsatility index likewise showed no correlation. Right and left-sided correlation at discharge were -0.25 (p = 0.19) and 0.01 (p = 0.96), respectively. At follow up the right side showed 0.004 (p = 0.99), and the left showed 0.18 (p = 0.41). Although our data did not show correlation, it showed that the investigation could feasibly be done in pediatric patients with mild TBI. The study was limited by small sample size and infrequent outcome of interest. Future studies may help define the role of TCD in the large population of mild pediatric TBI patients.
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Affiliation(s)
- Jake J. Deines
- Department of Pediatrics, Golisano Children's Hospital/University of Rochester, Rochester, New York
| | - Jianhong Chang
- Duke University School of Nursing, Durham, North Carolina
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Al-Mufti F, Amuluru K, Lander M, Mathew M, El-Ghanem M, Nuoman R, Park S, Patel V, Singh IP, Gupta G, Gandhi CD. Low Glasgow Coma Score in Traumatic Intracranial Hemorrhage Predicts Development of Cerebral Vasospasm. World Neurosurg 2018; 120:e68-e71. [PMID: 30055364 DOI: 10.1016/j.wneu.2018.07.143] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The exact mechanism, incidence, and risk factors for cerebral vasospasm after traumatic intracranial hemorrhage (ICH) continue to be poorly characterized. The incidence of post-traumatic vasospasm (PTV) varies depending on the detection modality. OBJECTIVE We aimed to shed light on the predictors, associations, and true incidence of cerebral vasospasm after traumatic ICH using digital subtraction angiography (DSA) as the gold standard. METHODS We examined a prospectively maintained database of traumatic brain injury (TBI) patients to identify patients with ICH secondary to TBI enrolled between 2002 and 2015 at our trauma center. Patients with TBI-associated ICH and evidence of elevated velocities on transcranial Doppler and computed tomography angiograms, confirmed with DSA were included. The diagnostic cerebral angiograms were evaluated by 2 blinded neurointerventionalists for cerebral vasospasm. Statistical analyses were conducted to determine predictors of PTV. RESULTS Twenty patients with ICH secondary to TBI and evidence of vasospasm underwent DSAs. Seven patients (7/20; 35%) with traumatic ICH developed cerebral vasospasm and of those, 1 developed delayed cerebral ischemia (1/7; 14%). Of these 7 patients, 6 presented with subarachnoid hemorrhage (6/7; 85%). Vasospasm was substantially more common in patients with a Glasgow Coma Scale <9 (P = 0.017) than in all other groups. CONCLUSIONS PTV as demonstrated by DCA may be more common than previously reported. Patients who exhibit PTV were more likely to have a Glasgow Coma Scale <9. This subgroup of patients may benefit from more systematic screening for the development of PTV, and earlier monitoring for signs of delayed cerebral ischemia.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, New York, USA.
| | - Krishna Amuluru
- Department of Interventional Neuroradiology, University of Pittsburgh Medical Center-Hamot, Erie, Pennsylvania, USA
| | - Megan Lander
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Melvin Mathew
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona College of Medicine-Tucson, Tuscon, Arizona, USA
| | - Rolla Nuoman
- Department of Neurology, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Seami Park
- Department of Neurology, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Vikas Patel
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, New York, USA; Department of Neurology, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
| | - Inder Paul Singh
- Department of Neurosurgery, Neurology, and Radiology, Mount Sinai Health System, New York, New York, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Chirag D Gandhi
- Department of Neurology, Neurosurgery, and Radiology, New York Medical College, Valhalla, New York, USA; Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Neurology, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA; Department of Radiology, Rutgers University, New Jersey Medical School, Newark, New Jersey, USA
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Reuter-Rice K, Regier M, Bennett E, Laskowitz D. The Effect of the Relationship of APOE Polymorphisms and Cerebral Vasospasm on Functional Outcomes in Children With Traumatic Brain Injury. Biol Res Nurs 2018; 20:566-576. [PMID: 29996665 DOI: 10.1177/1099800418785982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pediatric traumatic brain injury (TBI) is a leading cause of death and disability. Polymorphisms in the apolipoprotein E ( APOE) gene have been linked to cerebral vasospasm (CV) and poor outcomes in adults with TBI, yet these associations remain poorly defined in children. OBJECTIVE We examined the effect of the relationship between APOE polymorphisms and CV on functional outcomes in children with a TBI. METHOD This prospective, descriptive study examined 60 children (aged 10 days to 15 years) with a TBI. Data included demographic information, genetic sampling for the APOE gene and single-nucleotide polymorphisms (SNPs; rs405509, rs429358, rs7412), and daily transcranial Doppler ultrasounds to evaluate for CV. We examined Glasgow Outcome Scale-Extended Pediatrics (GOS-E Peds) scores at the time of discharge and 4-6 weeks after discharge. RESULTS More than half (56.7%) of the 60 children ( Mage = 5.9 years) were male. Twenty-six participants (43.3%) experienced an occurrence of CV. There were significant differences in injury mechanism (unadjusted p = .048) and age (unadjusted p = .02) between those with and without CV. Also, the noncoding promoter SNP rs405509 T/T, when considered with injury severity, appeared to modify the relationship of APOE genotype to CV. The relationship between APOE and CV had no significant effect on GOS-E Peds scores. CONCLUSION Injury severity and the APOE noncoding promoter SNP rs405509 may modify the relationship between APOE and CV in children with TBI. More studies are needed to understand the role of APOE polymorphisms in outcomes in children with TBI.
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Affiliation(s)
- Karin Reuter-Rice
- 1 Division of Critical Care Medicine, Department of Pediatrics, School of Nursing, Duke University School of Medicine, Durham, NC, USA
| | - Michael Regier
- 2 Department of Biostatistics, West Virginia University, Morgantown, WV, USA
| | - Ellen Bennett
- 3 Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Daniel Laskowitz
- 3 Department of Neurology, Duke University School of Medicine, Durham, NC, USA
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Relationships between cerebral flow velocities and neurodevelopmental outcomes in children with moderate to severe traumatic brain injury. Childs Nerv Syst 2018; 34:663-672. [PMID: 29264705 DOI: 10.1007/s00381-017-3693-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 12/10/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE This study aimed to determine relationships between cerebral blood flow and neurodevelopmental outcomes in children with moderate to severe traumatic brain injury (TBI). METHODS Children with TBI, a Glasgow Coma Score of 8-12, and abnormal brain imaging were enrolled prospectively. Cerebral blood flow velocity (CBFV) was assessed within 24 h of trauma and daily thereafter through death, discharge, or hospital day 8, whichever came first. Twelve months from injury, participants completed neurodevelopmental testing. RESULTS Sixty-nine patients were enrolled. Low flow velocities (< 2 SD below age/gender normal) were found in 6% (n = 4). No patient with a single low CBFV measurement had a good neurologic outcome (Pediatric Glasgow Outcome Scale (GOS-E Peds) ≤ 4)). Normal flow velocities (± 2 SD around age/gender normal) were seen in 43% of participants (n = 30). High flow velocities (> 2 SD above age and gender normal with a Lindegaard ratio (LR) < 3) were identified in 23% of children (n = 16), and vasospasm (> 2 SD above age/gender normal with LR ≥ 3) was identified in 28% (n = 19). Children with good outcomes based on GOS-E Peds scoring were more likely to have had normal flow velocity than other flow patterns. No other differences in neurodevelopmental outcomes were noted. CONCLUSIONS Individual patient responses to TBI in terms of CBFV alterations were heterogeneous. Low flow was uniformly associated with a poor outcome. Patients with good outcomes were more likely to have normal flow. This suggests CBFV may serve as a prognostic indicator in children with TBI. Future studies are needed to determine if aberrant CBFVs are also a therapeutic target.
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Narayan V, Mohammed N, Savardekar AR, Patra DP, Notarianni C, Nanda A. Noninvasive Intracranial Pressure Monitoring for Severe Traumatic Brain Injury in Children: A Concise Update on Current Methods. World Neurosurg 2018. [PMID: 29524721 DOI: 10.1016/j.wneu.2018.02.159] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of pediatric morbidity and mortality worldwide and intracranial pressure (ICP) monitoring plays a crucial role in its management. Based on existing literature, we review the current practicing noninvasive ICP monitoring devices and their accuracy in predicting increased ICP in pediatric TBI. METHODS A thorough literature search was conducted on PubMed, Medline, and the Cochrane database, articles were selected systematically and reviewed completely, and relevant data were summarized and discussed. RESULTS A total of 27 articles pertaining to pediatric TBI were included and reviewed. We found various modalities of noninvasive ICP monitoring devices used over the last few years. The noninvasive modalities so far attempted in pediatric TBI and so reviewed here are transcranial Doppler, optic nerve sheath diameter, otoacoustic emission, near-infrared spectroscopy, contrast-enhanced ultrasonography, and quantitative pupillometry. CONCLUSIONS Invasive monitoring methods are the current gold standard for monitoring ICP; however, complications caused by their invasive nature are of concern. Of all the noninvasive methods based on the literature, we found transcranial Doppler and optic nerve sheath diameter assessment to be the best tools to monitor ICP in pediatric TBI. The promising results and developments of noninvasive ICP monitoring modalities with its ideal features of high sensitivity, diagnostic accuracy, and simple acquisition technique may make it the future of neurointensive monitoring in pediatric TBI.
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Affiliation(s)
- Vinayak Narayan
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Nasser Mohammed
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Devi Prasad Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Christina Notarianni
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Anil Nanda
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.
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Figaji AA. Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care. Front Neurol 2017; 8:685. [PMID: 29312119 PMCID: PMC5735372 DOI: 10.3389/fneur.2017.00685] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/30/2017] [Indexed: 01/08/2023] Open
Abstract
General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.
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Affiliation(s)
- Anthony A Figaji
- Neuroscience Institute, Division of Neurosurgery, University of Cape Town, Red Cross Children's Hospital, Rondebosch, Cape Town, South Africa
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Al-Mufti F, Amuluru K, Changa A, Lander M, Patel N, Wajswol E, Al-Marsoummi S, Alzubaidi B, Singh IP, Nuoman R, Gandhi C. Traumatic brain injury and intracranial hemorrhage–induced cerebral vasospasm: a systematic review. Neurosurg Focus 2017; 43:E14. [DOI: 10.3171/2017.8.focus17431] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVELittle is known regarding the natural history of posttraumatic vasospasm. The authors review the pathophysiology of posttraumatic vasospasm (PTV), its associated risk factors, the efficacy of the technologies used to detect PTV, and the management/treatment options available today.METHODSThe authors performed a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed, Google Scholar, and CENTRAL (the Cochrane Central Register of Controlled Trials). Outcome variables extracted from each study included epidemiology, pathophysiology, time course, predictors of PTV and delayed cerebral ischemia (DCI), optimal means of surveillance and evaluation of PTV, application of multimodality monitoring, modern management and treatment options, and patient outcomes after PTV. Study types were limited to retrospective chart reviews, database reviews, and prospective studies.RESULTSA total of 40 articles were included in the systematic review. In many cases of mild or moderate traumatic brain injury (TBI), imaging or ultrasonographic studies are not performed. The lack of widespread assessment makes finding the true overall incidence of PTV a difficult endeavor. The clinical consequences of PTV are important, given the morbidity that can result from it. DCI manifests as new-onset neurological deterioration that occurs beyond the timeframe of initial brain injury. While there are many techniques that attempt to diagnose cerebral vasospasm, digital subtraction angiography is the gold standard. Some predictors of PTV include SAH, intraventricular hemorrhage, low admission Glasgow Coma Scale (GCS) score (< 9), and young age (< 30 years).CONCLUSIONSGiven these results, clinicians should suspect PTV in young patients presenting with intracranial hemorrhage (ICH), especially SAH and/or intraventricular hemorrhage, who present with a GCS score less than 9. Monitoring and regulation of CNS metabolism following TBI/ICH-induced vasospasm may play an important adjunct role to the primary prevention of vasospasm.
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Affiliation(s)
- Fawaz Al-Mufti
- 1Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick
- Departments of 2Neurosurgery,
| | | | | | | | | | | | | | - Basim Alzubaidi
- 1Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick
| | - I. Paul Singh
- Departments of 2Neurosurgery,
- 4Radiology, Rutgers University, New Jersey Medical School, Newark, New Jersey; and
| | | | - Chirag Gandhi
- Departments of 2Neurosurgery,
- 4Radiology, Rutgers University, New Jersey Medical School, Newark, New Jersey; and
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Reuter-Rice K. Transcranial Doppler Ultrasound Use in Pediatric Traumatic Brain Injury. JOURNAL OF RADIOLOGY NURSING 2017; 36:3-9. [PMID: 28947894 PMCID: PMC5609698 DOI: 10.1016/j.jradnu.2016.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Transcranial Doppler ultrasound (TCD) is an inexpensive portable diagnostic tool commonly available within most healthcare systems. A team of trained individuals perform and interpret the test to inform patient care management. The benefit of TCD is well established in adult patients with traumatic brain injury. However, in children with TBI, it is still considered exploratory and its use is not a part of the standard of care. This article describes what TCD is, its use in children, and how TCD measurements apply to children and adolescents in an effort to establish criteria for the use of TCD for children with TBI. The benefit of TCD in pediatric TBI is illustrated by 2 cases of children who participated in a TBI research study. Early indications are that the use of TCD in pediatric cases of TBI may produce unexpected real-time data about the cerebral vasculature and circulation characteristics in children with TBI. Transcranial Doppler ultrasound has the potential for playing an informative diagnostic role in future pediatric TBI management. Ultimately the goal to promote best outcomes after a TBI requires insights into the multi-dynamic nature of the injury and TCD has the ability to support these efforts.
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Affiliation(s)
- Karin Reuter-Rice
- Associate Professor, Duke University, School of Nursing, School of Medicine, Dept. of Pediatrics, Duke Institute for Brain Science, 307 Trent Drive, DUMC 3322, Durham, NC, 27710
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LaRovere KL, O'Brien NF, Tasker RC. Current Opinion and Use of Transcranial Doppler Ultrasonography in Traumatic Brain Injury in the Pediatric Intensive Care Unit. J Neurotrauma 2016; 33:2105-2114. [DOI: 10.1089/neu.2015.4344] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kerri L. LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nicole F. O'Brien
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio
| | - Robert C. Tasker
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
- Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Ducharme-Crevier L, Mills MG, Mehta PM, Smith CM, Wainwright MS. Use of Transcranial Doppler for Management of Central Nervous System Infections in Critically Ill Children. Pediatr Neurol 2016; 65:52-58.e2. [PMID: 27743745 DOI: 10.1016/j.pediatrneurol.2016.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 08/26/2016] [Accepted: 08/28/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND The primary objective of this study was to characterize changes in cerebral blood flow measured using transcranial Doppler in children with central nervous system infections. We hypothesized that children with central nervous system infections have abnormal cerebral blood flow, associated with a greater frequency of complications and poor neurological outcome. METHODS We conducted a single-center, retrospective study of children admitted to the neonatal or pediatric intensive care unit with central nervous system infection and undergoing transcranial Doppler as part of routine care between March 2011 and July 2015. RESULTS A total of 20 children with central nervous system infection underwent 35 transcranial Dopplers. The mean age was 8.2 ± 6.3 years, including 12 boys and eight girls. The most common infection was meningitis (n = 11, 55%), with the remainder comprising encephalitis (15%), meningoencephalitis (20%), and abscess or empyema (10%). Bacterial (n = 10, 50%) and viral (n = 6) sources were common with only one (5%) fungal infection and three (15%) unknown but presumed viral etiology. The patients underwent transcranial Doppler 4 ± 9 days after intensive care unit admission. Mean cerebral blood flow velocities were overall increased compared with reference values for age (healthy children and critically ill children) mostly because of hyperemia (n = 21, 60%) and vasospasm (6%). Hypoperfusion (cerebral blood flow velocity <1 S.D. of normal value) in at least one vessel was associated with morbidity (intubation, vasoactive medications, neurosurgery, cardiac arrest) (P = 0.04) and mortality (P = 0.03). Two patients had increased intracranial pressure and hyperventilation was safely achieved with transcranial Doppler monitoring to avoid ischemia. Serial transcranial Dopplers were used to guide blood pressure management. CONCLUSIONS Transcranial Doppler can be used in children with central nervous system infection as a tool to assess cerebral blood flow. In this retrospective study, cerebral hypoperfusion was associated with increased morbidity and mortality. If transcranial Doppler is to guide medical therapy and management of cerebral blood flow in children with central nervous system infections, these results will need to be validated in prospective studies with a more homogenous population of children with encephalitis or meningitis.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michele G Mills
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Priya M Mehta
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig M Smith
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark S Wainwright
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Predictors of Acute Vertebrobasilar Vasospasm following Tumor Resection in the Foramen Magnum Region. PLoS One 2016; 11:e0163908. [PMID: 27682826 PMCID: PMC5040390 DOI: 10.1371/journal.pone.0163908] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 09/18/2016] [Indexed: 02/05/2023] Open
Abstract
Objective Cerebral vasospasm can occur after skull base tumor removal. Few studies concentrated on the posterior circulation vasospasm after tumor resection in the posterior fossa. We aimed to identify the risk factors associated with postoperative vertebrobasilar vasospasm after tumor resection in the foramen magnum. Methods We retrospectively reviewed the data of 62 patients with tumors in the foramen magnum at our institution from January 2010 to January 2015. The demographic data, tumor features, surgical characteristics were collected. Vertebrobasilar vasospasm was evaluated by bedside transcranial Doppler before surgery and on postoperative day 1, 3, 7. Univariate and multivariate analyses were performed to determine the predictors of postoperative vasospasm in the posterior circulation. Results Vertebrobasilar vasospasm was detected in 28 (53.8%) of the 62 patients at a mean time of 3.5 days after surgery. There were 5 (8%) patients with severe vasospasm according to the grading criteria. Age, tumor type, tumor size, vertebral artery encasement, and surgical time were significantly related to vasospasm in the univariate analysis. Further multivariate analysis demonstrated that only age and vertebral artery encasement were independent risk factors predicting the occurrence of postoperative vertebrobasilar vasospasm. Conclusions The incidence of acute vertebrobasilar vasospasm is not uncommon after foramen magnum tumor resection. Age and vertebral artery encasement are significantly correlated with postoperative vasospasm. Close monitoring of vasospasm should be given to patients with younger age and the presence of vertebral artery encasement on the preoperative imaging to facilitate early diagnosis and intervention.
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Reference values for cerebral blood flow velocities in critically ill, sedated children. Childs Nerv Syst 2015; 31:2269-76. [PMID: 26285761 DOI: 10.1007/s00381-015-2873-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/06/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Transcranial Doppler ultrasound (TCD) is increasingly being used in the pediatric intensive care unit to assess cerebral hemodynamics during critical illness. However, no normative data in this patient population have been published to date. Therefore, we aimed to describe the anterior and posterior cerebral blood flow velocities in critically ill children undergoing mechanical ventilation and sedation. DESIGN A prospective, observational cohort study was performed. Children with known or suspected acute or chronic neurologic conditions were excluded. Participants underwent TCD measurement of middle cerebral and basilar artery flow velocities. RESULTS One hundred and forty children newborn to 17 years of age were enrolled. Measured values were lower in this cohort of children than the previously published cerebral flow velocities of normal, healthy children. CONCLUSIONS Cerebral blood flow velocities of the basal cerebral arteries in critically ill, mechanically ventilated, sedated children are lower than in healthy children of the same age and gender published in previous studies. As such, the cerebral blood flow velocity (CBFV) values reported here may serve as a more accurate reference point when using TCD as a clinical tool to diagnose CBFV abnormalities and guide therapy in this patient population.
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LaRovere KL, O'Brien NF. Transcranial Doppler Sonography in Pediatric Neurocritical Care: A Review of Clinical Applications and Case Illustrations in the Pediatric Intensive Care Unit. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:2121-32. [PMID: 26573100 DOI: 10.7863/ultra.15.02016] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/31/2015] [Indexed: 05/25/2023]
Abstract
Transcranial Doppler sonography is a noninvasive, real-time physiologic monitor that can detect altered cerebral hemodynamics during catastrophic brain injury. Recent data suggest that transcranial Doppler sonography may provide important information about cerebrovascular hemodynamics in children with traumatic brain injury, intracranial hypertension, vasospasm, stroke, cerebrovascular disorders, central nervous system infections, and brain death. Information derived from transcranial Doppler sonography in these disorders may elucidate underlying pathophysiologic characteristics, predict outcomes, monitor responses to treatment, and prompt a change in management. We review emerging applications for transcranial Doppler sonography in the pediatric intensive care unit with case illustrations from our own experience.
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Affiliation(s)
- Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.).
| | - Nicole F O'Brien
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts USA (K.L.L.); and Department of Pediatrics, Division of Pediatric Critical Care Medicine, Nationwide Children's Hospital and Ohio State University, Columbus, Ohio USA (N.F.O.)
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Ducharme-Crevier L, Pettersen G, Emeriaud G. Vasospasm After Pediatric Traumatic Brain Injury: A Difficult Diagnosis. Crit Care Med 2015; 43:e467-8. [PMID: 26376271 DOI: 10.1097/ccm.0000000000001129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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38
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Digital decoding of pediatric traumatic brain injury. Crit Care Med 2015; 43:722-3. [PMID: 25700067 DOI: 10.1097/ccm.0000000000000799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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