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Rahmani F, Batson RD, Zimmerman A, Reddigari S, Bigler ED, Lanning SC, Ilasa E, Grafman JH, Lu H, Lin AP, Raji CA. Rate of abnormalities in quantitative MR neuroimaging of persons with chronic traumatic brain injury. BMC Neurol 2024; 24:235. [PMID: 38969967 PMCID: PMC11225195 DOI: 10.1186/s12883-024-03745-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 06/26/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Mild traumatic brain injury (mTBI) can result in lasting brain damage that is often too subtle to detect by qualitative visual inspection on conventional MR imaging. Although a number of FDA-cleared MR neuroimaging tools have demonstrated changes associated with mTBI, they are still under-utilized in clinical practice. METHODS We investigated a group of 65 individuals with predominantly mTBI (60 mTBI, 48 due to motor-vehicle collision, mean age 47 ± 13 years, 27 men and 38 women) with MR neuroimaging performed in a median of 37 months post-injury. We evaluated abnormalities in brain volumetry including analysis of left-right asymmetry by quantitative volumetric analysis, cerebral perfusion by pseudo-continuous arterial spin labeling (PCASL), white matter microstructure by diffusion tensor imaging (DTI), and neurometabolites via magnetic resonance spectroscopy (MRS). RESULTS All participants demonstrated atrophy in at least one lobar structure or increased lateral ventricular volume. The globus pallidi and cerebellar grey matter were most likely to demonstrate atrophy and asymmetry. Perfusion imaging revealed significant reductions of cerebral blood flow in both occipital and right frontoparietal regions. Diffusion abnormalities were relatively less common though a subset analysis of participants with higher resolution DTI demonstrated additional abnormalities. All participants showed abnormal levels on at least one brain metabolite, most commonly in choline and N-acetylaspartate. CONCLUSION We demonstrate the presence of coup-contrecoup perfusion injury patterns, widespread atrophy, regional brain volume asymmetry, and metabolic aberrations as sensitive markers of chronic mTBI sequelae. Our findings expand the historic focus on quantitative imaging of mTBI with DTI by highlighting the complementary importance of volumetry, arterial spin labeling perfusion and magnetic resonance spectroscopy neurometabolite analyses in the evaluation of chronic mTBI.
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Affiliation(s)
- Farzaneh Rahmani
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Richard D Batson
- Endocrine & Brain Injury Research Alliance, Neurevolution Medicine, PLLC, NUNM Helfgott Research Institute, Portland, Oregon, USA
| | | | | | - Erin D Bigler
- Department of Neurology, Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
| | | | | | - Jordan H Grafman
- Departments of Physical Medicine & Rehabilitation, Neurology, Cognitive Neurology and Alzheimer's Center, Department of Psychiatry, Feinberg School of Medicine, Department of Psychology, Weinberg College of Arts and Sciences, Northwestern University, Chicago, IL, USA
| | - Hanzhang Lu
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alexander P Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Cyrus A Raji
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO, USA.
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO, USA.
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Lyons TW, Mannix R, Monuteaux MC, Schutzman SA. Emergency Department Evaluation of Young Infants With Head Injury. Pediatrics 2024; 153:e2023065037. [PMID: 38813646 DOI: 10.1542/peds.2023-065037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/14/2024] [Accepted: 02/14/2024] [Indexed: 05/31/2024] Open
Abstract
OBJECTIVES We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children. METHODS Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old. RESULTS We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%). CONCLUSIONS The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population.
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Affiliation(s)
- Todd W Lyons
- Departments of Pediatrics and Emergency Medicine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Rebekah Mannix
- Departments of Pediatrics and Emergency Medicine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Sara A Schutzman
- Departments of Pediatrics and Emergency Medicine
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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3
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Raut A, Pierce MC. Cranial Imaging in the Youngest Infants: Worth the Risk. Pediatrics 2024; 153:e2023065511. [PMID: 38813619 DOI: 10.1542/peds.2023-065511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 05/31/2024] Open
Affiliation(s)
- Audrey Raut
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Mary Clyde Pierce
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois
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4
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Altmann S, Abello Mercado MA, Brockstedt L, Kronfeld A, Clifford B, Feiweier T, Uphaus T, Groppa S, Brockmann MA, Othman AE. Ultrafast Brain MRI Protocol at 1.5 T Using Deep Learning and Multi-shot EPI. Acad Radiol 2023; 30:2988-2998. [PMID: 37211480 DOI: 10.1016/j.acra.2023.04.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/23/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate clinical feasibility and image quality of a comprehensive ultrafast brain MRI protocol with multi-shot echo planar imaging and deep learning-enhanced reconstruction at 1.5T. MATERIALS AND METHODS Thirty consecutive patients who underwent clinically indicated MRI at a 1.5 T scanner were prospectively included. A conventional MRI (c-MRI) protocol, including T1-, T2-, T2*-, T2-FLAIR, and diffusion-weighted images (DWI)-weighted sequences were acquired. In addition, ultrafast brain imaging with deep learning-enhanced reconstruction and multi-shot EPI (DLe-MRI) was performed. Subjective image quality was evaluated by three readers using a 4-point Likert scale. To assess interrater agreement, Fleiss' kappa (ϰ) was determined. For objective image analysis, relative signal intensity levels for grey matter, white matter, and cerebrospinal fluid were calculated. RESULTS Time of acquisition (TA) of c-MRI protocols added up to 13:55 minutes, whereas the TA of DLe-MRI-based protocol added up to 3:04 minutes, resulting in a time reduction of 78%. All DLe-MRI acquisitions yielded diagnostic image quality with good absolute values for subjective image quality. C-MRI demonstrated slight advantages for DWI in overall subjective image quality (c-MRI: 3.93 [+/- 0.25] vs DLe-MRI: 3.87 [+/- 0.37], P = .04) and diagnostic confidence (c-MRI: 3.93 [+/- 0.25] vs DLe-MRI: 3.83 [+/- 3.83], P = .01). For most evaluated quality scores, moderate interobserver agreement was found. Objective image evaluation revealed comparable results for both techniques. CONCLUSION DLe-MRI is feasible and allows for highly accelerated comprehensive brain MRI within 3minutes at 1.5 T with good image quality. This technique may potentially strengthen the role of MRI in neurological emergencies.
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Affiliation(s)
- Sebastian Altmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckst. 1, 55131 Mainz, Germany (S.A., M.A.M., L.B., A.K., M.A.B., A.E.O.).
| | - Mario Alberto Abello Mercado
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckst. 1, 55131 Mainz, Germany (S.A., M.A.M., L.B., A.K., M.A.B., A.E.O.)
| | - Lavinia Brockstedt
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckst. 1, 55131 Mainz, Germany (S.A., M.A.M., L.B., A.K., M.A.B., A.E.O.)
| | - Andrea Kronfeld
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckst. 1, 55131 Mainz, Germany (S.A., M.A.M., L.B., A.K., M.A.B., A.E.O.)
| | - Bryan Clifford
- Siemens Medical Solutions USA, Boston, Massachusetts (B.C.)
| | | | - Timo Uphaus
- Department of Neurology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany (T.U., S.G.)
| | - Sergiu Groppa
- Department of Neurology, University Medical Center Mainz, Johannes Gutenberg University, Mainz, Germany (T.U., S.G.)
| | - Marc A Brockmann
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckst. 1, 55131 Mainz, Germany (S.A., M.A.M., L.B., A.K., M.A.B., A.E.O.)
| | - Ahmed E Othman
- Department of Neuroradiology, University Medical Center Mainz, Johannes Gutenberg University, Langenbeckst. 1, 55131 Mainz, Germany (S.A., M.A.M., L.B., A.K., M.A.B., A.E.O.)
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Suri I, Suri M, Hu J, Dedhia SK, Yaeger K. Case Volume Justification of 3D-Navigated Spinal Procedures: A Cost-Benefit Analysis. J Med Syst 2023; 47:114. [PMID: 37938464 DOI: 10.1007/s10916-023-02000-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/28/2023] [Indexed: 11/09/2023]
Abstract
3D image-guidance platforms have transformed spinal surgery by enhancing visualization, increasing precision, and improving patient outcomes. However, with high procurement, operational, and maintenance costs relative to the standard of care, the benefits of acquiring these platforms must be thoroughly assessed. This study aims to develop a model that weighs the cost of a typical 3D navigation platform against its clinical benefits to determine the facility case volume required to justify its purchase. Using Medtronic's StealthStation and O-Arm as a market example, we calculated the break-even case volume by dividing the cost of the platform by the difference in gross margins between 3D navigation and the standard of care. Total gross margins earned from first-time and revision surgeries were calculated based on each payer's reimbursement rate and covered case volume, as well as each technology's revision rate. Values reported in literature and by Centers for Medicare and Medicaid Services databases were plugged into the model to calculate variables. At a 0% reimbursement rate from private payers for revision surgeries, an annual case volume of 158 spinal surgeries would be required to justify the per-year 3D navigation cost; at 100% private payer reimbursement, 352 surgeries would be required. Given these volumes, 61% of all US inpatient facilities cannot justify 3D navigation at 0% reimbursement, and 86% cannot justify it at 100% reimbursement. Accordingly, greater pricing flexibility, such as per-procedure models, is required for 3D navigation systems to standardize clinical outcomes across medical centers.
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Affiliation(s)
- Ikaasa Suri
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA.
- Illuminant Surgical, Inc., Cambridge, MA, USA.
| | - Mehr Suri
- Stern School of Business, New York University, New York, NY, USA
| | - James Hu
- Illuminant Surgical, Inc., Cambridge, MA, USA
| | - Siddarth Ketan Dedhia
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kurt Yaeger
- Department of Neurosurgery, Houston Methodist Hospital, Houston, TX, USA
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Wang CB, Wang H, Zhao JS, Wu ZJ, Liu HD, Wang CJ, Li AR, Wang D, Hu J. Right-to-Left Displacement of an Airgun Lead Bullet after Transorbital Entry into the Skull Complicated by Posttraumatic Epilepsy : A Case Report. J Korean Neurosurg Soc 2023; 66:598-604. [PMID: 37337741 PMCID: PMC10483155 DOI: 10.3340/jkns.2022.0234] [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: 11/03/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 06/21/2023] Open
Abstract
Penetrating head injury is a serious open cranial injury. In civilians, it is often caused by non-missile, low velocity flying objects that penetrate the skull through a weak cranial structure, forming intracranial foreign bodies. The intracranial foreign body can be displaced due to its special quality, shape, and location. In this paper, we report a rare case of right-to-left displacement of an airgun lead bullet after transorbital entry into the skull complicated by posttraumatic epilepsy, as a reminder to colleagues that intracranial metal foreign bodies maybe displaced intraoperatively. In addition, we have found that the presence of intracranial metallic foreign bodies may be a factor for the posttraumatic epilepsy, and their timely removal appears to be beneficial for epilepsy control.
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Affiliation(s)
- Chao-bin Wang
- Department of Neurosurgery, Taihe Hospital, Jinzhou Medical University Union Training Base, Shiyan, China
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hui Wang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jun-shuang Zhao
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Ze-jun Wu
- Department of Neurosurgery, Taihe Hospital, Jinzhou Medical University Union Training Base, Shiyan, China
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Hao-dong Liu
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao-jia Wang
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - An-rong Li
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Dawei Wang
- Department of Ultrasonography, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Juntao Hu
- Department of Neurosurgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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Volumetric MRI Findings in Mild Traumatic Brain Injury (mTBI) and Neuropsychological Outcome. Neuropsychol Rev 2023; 33:5-41. [PMID: 33656702 DOI: 10.1007/s11065-020-09474-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Region of interest (ROI) volumetric assessment has become a standard technique in quantitative neuroimaging. ROI volume is thought to represent a coarse proxy for making inferences about the structural integrity of a brain region when compared to normative values representative of a healthy sample, adjusted for age and various demographic factors. This review focuses on structural volumetric analyses that have been performed in the study of neuropathological effects from mild traumatic brain injury (mTBI) in relation to neuropsychological outcome. From a ROI perspective, the probable candidate structures that are most likely affected in mTBI represent the target regions covered in this review. These include the corpus callosum, cingulate, thalamus, pituitary-hypothalamic area, basal ganglia, amygdala, and hippocampus and associated structures including the fornix and mammillary bodies, as well as whole brain and cerebral cortex along with the cerebellum. Ventricular volumetrics are also reviewed as an indirect assessment of parenchymal change in response to injury. This review demonstrates the potential role and limitations of examining structural changes in the ROIs mentioned above in relation to neuropsychological outcome. There is also discussion and review of the role that post-traumatic stress disorder (PTSD) may play in structural outcome in mTBI. As emphasized in the conclusions, structural volumetric findings in mTBI are likely just a single facet of what should be a multimodality approach to image analysis in mTBI, with an emphasis on how the injury damages or disrupts neural network integrity. The review provides an historical context to quantitative neuroimaging in neuropsychology along with commentary about future directions for volumetric neuroimaging research in mTBI.
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Kabakus IM, Spampinato MV, Knipfing M, Cervantes G, Patel A, Eskandari R, Yazdani M. Fast Brain Magnetic Resonance Imaging With Half-Fourier Acquisition With Single-Shot Turbo Spin Echo Sequence in Detection of Intracranial Hemorrhage and Skull Fracture in General Pediatric Patients: Preliminary Results. Pediatr Emerg Care 2021; 37:e1168-e1172. [PMID: 31804431 DOI: 10.1097/pec.0000000000001949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the accuracy of fast brain magnetic resonance imaging (MRI) in the detection of intra- and extra-axial intracranial hemorrhage compared with standard-of-care computed tomography (CT) or MRI in pediatric patients. Unlike previous studies, we did not focus exclusively on patients with head trauma. We evaluated the fast brain MRI findings in a general pediatric population referred for indications other than evaluation of ventricular size. METHODS We retrospectively reviewed 48 pediatric patients with indications other than hydrocephalus and shunt follow-up, who underwent a standard head CT or standard MRI within 15 days of the fast brain MRI. All fast brain MRI scans included half-Fourier acquisition with single-shot turbo spin echo (HASTE) sequences in the axial, coronal, and sagittal plane. Two neuroradiologists blinded to patient information and study indications reviewed the fast brain MRI studies independently and then concurrently. RESULTS A total of 48 patients met the inclusion and exclusion criteria. The median and mean time interval between the standard and fast imaging were 2 and 3.9 days, respectively. The sensitivity and specificity of fast brain MRI to detect intraparenchymal hemorrhage were 100% and 97%, respectively. The sensitivity and specificity of fast brain MRI in the detection of extra-axial hemorrhage (subdural and/or epidural) were 86% and 96%, respectively. The sensitivity and specificity of fast brain MRI were, respectively, 10% and 100% for subarachnoid hemorrhage, 50% and 100% for intraventricular hemorrhage, and 47% and 97% for skull fracture, respectively. CONCLUSIONS Our results show that fast brain MRI with HASTE sequence is as sensitive as CT and standard MRI in the detection of intra-axial hemorrhage and has moderate sensitivity in the detection of extra-axial hemorrhage. Our preliminary results show that T2-weighted HASTE imaging may be suitable for the follow-up of intraparenchymal and extra-axial (subdural and/or epidural) hemorrhages.
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Affiliation(s)
| | | | | | | | | | - Ramin Eskandari
- Neurosurgery, Medical University of South Carolina, Charleston, SC
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Janas AM, Qin F, Hamilton S, Jiang B, Baier N, Wintermark M, Threlkeld Z, Lee S. Diffuse Axonal Injury Grade on Early MRI is Associated with Worse Outcome in Children with Moderate-Severe Traumatic Brain Injury. Neurocrit Care 2021; 36:492-503. [PMID: 34462880 PMCID: PMC8405042 DOI: 10.1007/s12028-021-01336-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/16/2021] [Indexed: 01/15/2023]
Abstract
Background Traumatic brain injury (TBI) is the leading cause of death and disability in children, but effective tools for predicting outcome remain elusive. Although many pediatric patients receive early magnetic resonance imaging (MRI), data on its utility in prognostication are lacking. Diffuse axonal injury (DAI) is a hallmark of TBI detected on early MRI and was shown previously to improve prognostication in adult patients with TBI. In this exploratory study, we investigated whether DAI grade correlates with functional outcome and improves prognostic accuracy when combined with core clinical variables and computed tomography (CT) biomarkers in pediatric patients with moderate-severe TBI (msTBI). Methods Pediatric patients (≤ 19 years) who were admitted to two regional level one trauma centers with a diagnosis of msTBI (Glasgow Coma Scale [GCS] score < 13) between 2011 and 2019 were identified through retrospective chart review. Patients who underwent brain MRI within 30 days of injury and had documented clinical follow-up after discharge were included. Age, pupil reactivity, and initial motor GCS score were collected as part of the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. Imaging was reviewed to calculate the Rotterdam score (CT) and DAI grade (MRI) and to evaluate for presence of hypoxic-ischemic injury (MRI). The primary outcome measure was the Pediatric Cerebral Performance Category Scale (PCPCS) score at 6 months after TBI, with favorable outcome defined as PCPCS scores 1–3 and unfavorable outcome defined as PCPCS scores 4–6. The secondary outcome measure was discharge disposition to home versus to an inpatient rehabilitation facility. Result Of 55 patients included in the study, 45 (82%) had severe TBI. The most common mechanism of injury was motor vehicle collision (71%). Initial head CT scans showed acute hemorrhage in 84% of patients. MRI was acquired a median of 5 days after injury, and hemorrhagic DAI lesions were detected in 87% of patients. Each 1-point increase in DAI grade increased the odds of unfavorable functional outcome by 2.4-fold. When controlling for core IMPACT clinical variables, neither the DAI grade nor the Rotterdam score was independently correlated with outcome and neither significantly improved outcome prediction over the IMPACT model alone. Conclusions A higher DAI grade on early MRI is associated with worse 6-month functional outcome and with discharge to inpatient rehabilitation in children with acute msTBI in a univariate analysis but does not independently correlate with outcome when controlling for the GCS score. Addition of the DAI grade to the core IMPACT model does not significantly improve prediction of poor neurological outcome. Further study is needed to elucidate the utility of early MRI in children with msTBI. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01336-8.
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Affiliation(s)
- Anna M Janas
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA. .,Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - FeiFei Qin
- Quantitative Science Unit, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Scott Hamilton
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Bin Jiang
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Nicole Baier
- Department of Pediatrics, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Max Wintermark
- Department of Radiology, Stanford University, Stanford, CA, USA
| | - Zachary Threlkeld
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
| | - Sarah Lee
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA
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10
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Bussolin L, Falconi M, Leo MC, Parri N, DE Masi S, Rosati A, Cecchi C, Spacca B, Grandoni M, Bettiol A, Lucenteforte E, Lubrano R, Falsaperla R, Melosi F, Agostiniani R, Mangiantini F, Talamonti G, Calderini E, Mancino A, DE Luca M, Conti G, Petrini F. The management of pediatric severe traumatic brain injury: Italian Guidelines. Minerva Anestesiol 2021; 87:567-579. [PMID: 33432789 DOI: 10.23736/s0375-9393.20.14122-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of the work was to update the "Guidelines for the Management of Severe Traumatic Brain Injury" published in 2012, to reflect the new available evidence, and develop the Italian national guideline for the management of severe pediatric head injuries to reduce variation in practice and ensure optimal care to patients. EVIDENCE ACQUISITION MEDLINE and EMBASE were searched from January 2009 to October 2017. Inclusion criteria were English language, pediatric populations (0-18 years) or mixed populations (pediatric/adult) with available age subgroup analyses. The guideline development process was started by the Promoting Group that composed a multidisciplinary panel of experts, with the representatives of the Scientific Societies, the independent expert specialists and a representative of the Patient Associations. The panel selected the clinical questions, discussed the evidence and formulated the text of the recommendations. The documentarists of the University of Florence oversaw the bibliographic research strategy. A group of literature reviewers evaluated the selected literature and compiled the table of evidence for each clinical question. EVIDENCE SYNTHESIS The search strategies identified 4254 articles. We selected 3227 abstract (first screening) and, finally included 67 articles (second screening) to update the guideline. This Italian update includes 25 evidence-based recommendations and 5 research recommendations. CONCLUSIONS In recent years, progress has been made on the understanding of severe pediatric brain injury, as well as on that concerning all major traumatic pathology. This has led to a progressive improvement in the clinical outcome, although the quantity and quality of evidence remains particularly low.
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Affiliation(s)
- Leonardo Bussolin
- Neuroanesthesiology, Intensive Care and Trauma Center, A. Meyer University Hospital, Florence, Italy
| | - Martina Falconi
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Maria C Leo
- Techical-Scientific Secretary, Pediatric Regional and Ethical Committee, A. Meyer University Hospital, Florence, Italy
| | - Niccolò Parri
- Emergency Department and Trauma Center, A. Meyer University Hospital, Florence, Italy -
| | - Salvatore DE Masi
- Clinical Trial Office, A. Meyer University Hospital, Florence, Italy
| | - Anna Rosati
- Neurosciences Excellence Center, A. Meyer University Hospital, Florence, Italy
| | - Costanza Cecchi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy
| | - Barbara Spacca
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | - Manuela Grandoni
- Unit of Neurosurgery, A. Meyer University Hospital, Florence, Italy
| | | | | | - Riccardo Lubrano
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics Unit, Pediatric Emergency Department, Neonatology and Neonatal Intensive Care, "Rodolico-San Marco" University Hospital, Catania, Italy
| | - Raffaele Falsaperla
- Società Italiana di Medicina Emergenza Urgenza Pediatrica (SIMEUP), Milan, Italy.,Pediatrics and Neonatology Unit, Department of Maternal and Urological Sciences, Sapienza University, Latina, Rome, Italy
| | - Francesca Melosi
- Anestesiology and Intensive Care Unit, A. Meyer University Hospital, Florence, Italy.,Società Italiana di Neurosonologia ed Emodinamica Cerebrale (SINSEC), Bologna, Italy
| | | | | | | | - Edoardo Calderini
- Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva (SIAARTI), Rome, Italy
| | - Aldo Mancino
- Società di Anestesia e Rianimazione Neonatale e Pediatrica Italiana (S.A.R.N.eP.I), Rome, Italy
| | - Marco DE Luca
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy
| | - Giorgio Conti
- Accademia Medica ed Infermieristica di Emergenza e Terapia Intensiva Pediatrica (AMIETIP), Bologna, Italy.,IRCCS A. Gemelli, Catholic University, Rome, Italy
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King DJ, Novak J, Shephard AJ, Beare R, Anderson VA, Wood AG. Lesion Induced Error on Automated Measures of Brain Volume: Data From a Pediatric Traumatic Brain Injury Cohort. Front Neurosci 2020; 14:491478. [PMID: 33424529 PMCID: PMC7793828 DOI: 10.3389/fnins.2020.491478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/06/2020] [Indexed: 11/13/2022] Open
Abstract
Structural segmentation of T1-weighted (T1w) MRI has shown morphometric differences, both compared to controls and longitudinally, following a traumatic brain injury (TBI). While many patients with TBI present with abnormalities on structural MRI images, most neuroimaging software packages have not been systematically evaluated for accuracy in the presence of these pathology-related MRI abnormalities. The current study aimed to assess whether acute MRI lesions (MRI acquired 7–71 days post-injury) cause error in the estimates of brain volume produced by the semi-automated segmentation tool, Freesurfer. More specifically, to investigate whether this error was global, the presence of lesion-induced error in the contralesional hemisphere, where no abnormal signal was present, was measured. A dataset of 176 simulated lesion cases was generated using actual lesions from 16 pediatric TBI (pTBI) cases recruited from the emergency department and 11 typically-developing controls. Simulated lesion cases were compared to the “ground truth” of the non-lesion control-case T1w images. Using linear mixed-effects models, results showed that hemispheric measures of cortex volume were significantly lower in the contralesional-hemisphere compared to the ground truth. Interestingly, however, cortex volume (and cerebral white matter volume) were not significantly different in the lesioned hemisphere. However, percent volume difference (PVD) between the simulated lesion and ground truth showed that the magnitude of difference of cortex volume in the contralesional-hemisphere (mean PVD = 0.37%) was significantly smaller than that in the lesioned hemisphere (mean PVD = 0.47%), suggesting a small, but systematic lesion-induced error. Lesion characteristics that could explain variance in the PVD for each hemisphere were investigated. Taken together, these results suggest that the lesion-induced error caused by simulated lesions was not focal, but globally distributed. Previous post-processing approaches to adjust for lesions in structural analyses address the focal region where the lesion was located however, our results suggest that focal correction approaches are insufficient for the global error in morphometric measures of the injured brain.
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Affiliation(s)
- Daniel J King
- College of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom
| | - Jan Novak
- College of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom
| | - Adam J Shephard
- College of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom
| | - Richard Beare
- Developmental Imaging, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Medicine, Peninsula Clinical School, Monash University, Melbourne, VIC, Australia
| | - Vicki A Anderson
- Brain and Mind Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Psychology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Amanda G Wood
- College of Health and Life Sciences, Aston Institute of Health and Neurodevelopment, Aston University, Birmingham, United Kingdom.,Faculty of Health, School of Psychology, Deakin University Melbourne Burwood Campus, Geelong, VIC, Australia
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12
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Meysami S, Raji CA, Merrill DA, Porter VR, Mendez MF. MRI Volumetric Quantification in Persons with a History of Traumatic Brain Injury and Cognitive Impairment. J Alzheimers Dis 2020; 72:293-300. [PMID: 31561375 DOI: 10.3233/jad-190708] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND While traumatic brain injury (TBI) is recognized as a risk factor for dementia, there is lack of clinical tools to identify brain changes that may confer such vulnerability. Brain MRI volumetric quantification can sensitively identify brain atrophy. OBJECTIVE To characterize regional brain volume loss in persons with TBI presenting with cognitive impairment. METHODS IRB approved review of medical records in patients with cognitive decline focused on those who had documented TBI histories and brain MRI scans after TBI (n = 40, 67.7±14.5 years) with volumetric quantification by applying an FDA cleared software program. TBI documentation included head trauma mechanism. Brain volumes were compared to a normative database to determine the extent of atrophy. Correlations between these regions and global tests of cognition (MMSE in n = 17, MoCA in n = 27, n = 14 in both) were performed. RESULTS Multiple regions demonstrated volume loss in TBI, particularly ventral diencephalon, putamen, and pallidum with smaller magnitude of atrophy in temporal lobes and brainstem. Lobar structures showed strongest correlations between atrophy and lower scores on MMSE and MoCA. The hippocampus, while correlated to tests of cognitive function, was the least atrophic region as a function of TBI history. CONCLUSION Persons with TBI history exhibit show regional brain atrophy. Several of these areas, such as thalamus and temporal lobes, also correlate with cognitive function. Alzheimer's disease atrophy was less likely given relative sparing of the hippocampi. Volumetric quantification of brain MRI in TBI warrants further investigation to further determine its clinical potential in TBI and differentiating causes of cognitive impairment.
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Affiliation(s)
- Somayeh Meysami
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Cyrus A Raji
- Mallinckrodt Institute of Radiology, Division of Neuroradiology, Washington University, St. Louis, MO, USA
| | - David A Merrill
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,The John Wayne Cancer Institute and Pacific Neuroscience Institute, Providence and St. Johns Health Center, Santa Monica, CA, USA
| | - Verna R Porter
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,The John Wayne Cancer Institute and Pacific Neuroscience Institute, Providence and St. Johns Health Center, Santa Monica, CA, USA
| | - Mario F Mendez
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,V.A. Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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13
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Connectome mapping with edge density imaging differentiates pediatric mild traumatic brain injury from typically developing controls: proof of concept. Pediatr Radiol 2020; 50:1594-1601. [PMID: 32607611 PMCID: PMC7501221 DOI: 10.1007/s00247-020-04743-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/26/2020] [Accepted: 05/24/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although acute neurologic impairment might be transient, other long-term effects can be observed with mild traumatic brain injury. However, when pediatric patients with mild traumatic brain injury present for medical care, conventional imaging with CT and MR imaging often does not reveal abnormalities. OBJECTIVE To determine whether edge density imaging can separate pediatric mild traumatic brain injury from typically developing controls. MATERIALS AND METHODS Subjects were recruited as part of the "Therapeutic Resources for Attention Improvement using Neuroimaging in Traumatic Brain Injury" (TRAIN-TBI) study. We included 24 adolescents (χ=14.1 years of age, σ=1.6 years, range 10-16 years), 14 with mild traumatic brain injury (TBI) and 10 typically developing controls. Neurocognitive assessments included the pediatric version of the California Verbal Learning Test (CVLT) and the Attention Network Task (ANT). Diffusion MR imaging was acquired on a 3-tesla (T) scanner. Edge density images were computed utilizing fiber tractography. Principal component analysis (PCA) and support vector machines (SVM) were used in an exploratory analysis to separate mild TBI and control groups. The diagnostic accuracy of edge density imaging, neurocognitive tests, and fractional anisotropy (FA) from diffusion tensor imaging (DTI) was computed with two-sample t-tests and receiver operating characteristic (ROC) metrics. RESULTS Support vector machine-principal component analysis of edge density imaging maps identified three white matter regions distinguishing pediatric mild TBI from controls. The bilateral tapetum, sagittal stratum, and callosal splenium identified mild TBI subjects with sensitivity of 79% and specificity of 100%. Accuracy from the area under the ROC curve (AUC) was 94%. Neurocognitive testing provided an AUC of 61% (CVLT) and 71% (ANT). Fractional anisotropy yielded an AUC of 48%. CONCLUSION In this proof-of-concept study, we show that edge density imaging is a new form of connectome mapping that provides better diagnostic delineation between pediatric mild TBI and healthy controls than DTI or neurocognitive assessments of memory or attention.
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14
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Appelbaum R, Hoover T, Azari S, Dunstan M, Li PM, Sandhu R, Browne M. Development and Implementation of a Pilot Radiation Reduction Protocol for Pediatric Head Injury. J Surg Res 2020; 255:111-117. [PMID: 32543375 DOI: 10.1016/j.jss.2020.05.051] [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] [Received: 02/21/2020] [Revised: 04/16/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Traumatic brain injury is the leading cause of morbidity and mortality for children in the United States. The aim of this study was to develop and implement a guideline to reduce radiation exposure in the pediatric head injury patient by identifying the patient population where repeat imaging is necessary and to establish rapid brain protocol magnetic resonance imaging as the first-line modality. METHODS A retrospective chart review of trauma patients between 0 and 14 y of age admitted at a pediatric level 2 trauma center was performed between January 2013 and June 2019. The guideline established the appropriateness of repeat scans for patients with Glasgow Coma Scale >13 with clinical neurological deterioration or patients with Glasgow Coma Scale ≤13 and intracranial hemorrhagic lesion on initial head computed tomography (CT). RESULTS Our trauma registry included 592 patients during the study period, 415 before implementation and 161 after implementation. A total of 132 patients met inclusion criteria, 116 pre-guideline and 16 post-guideline. The number of patients receiving repeat head CTs significantly decreased from 34.5% to 6.3% (P < 0.02). There was also a significant decrease in the mean number of head CT/patient pre-guideline 1.63 (range 1-7) compared with post-guideline 1.06 (range 1-2) (P < 0.02). CONCLUSIONS CT head imaging is invaluable in the initial trauma evaluation of pediatric patients. However, it can be overused, and the radiation may lead to long-term deleterious effects. Establishing a head imaging guideline which limits use with clinical criteria can be effective in reducing radiation exposure without missing injuries.
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Affiliation(s)
| | - Travis Hoover
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Sarah Azari
- Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Michele Dunstan
- Division of Bariatric and Trauma Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - P Mark Li
- Division of Neurosurgery, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Rovinder Sandhu
- Division of Bariatric and Trauma Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania
| | - Marybeth Browne
- Division of Pediatric Surgical Specialties, Lehigh Valley Reilly Children's Hospital, Lehigh Valley Health Network, Allentown, Pennsylvania.
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15
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Maksoud S, Lawson McLean A, Bauer J, Schwarz F, Waschke A. Penetrating traumatic brain injury resulting from a cockerel attack: case report and literature review. Childs Nerv Syst 2020; 36:1067-1070. [PMID: 31784819 DOI: 10.1007/s00381-019-04441-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/08/2019] [Indexed: 11/25/2022]
Abstract
Traumatic brain injury is common in children and can lead to death or considerable, long-lasting morbidity. We present the case of a 10-month-old female child who presented after being attacked by a cockerel in a chicken coop. Following a seizure, an MRI scan revealed an intracerebral haemorrhage underlying a stab-type wound inflicted by the bird. Animal bite injuries are common worldwide but they rarely cause intracranial injuries. Domestic hens are rarely dangerous but can become defensive or aggressive during breeding periods or when protecting their territory. To date, only a handful of articles have reported on wounds inflicted by chicken beaks. Those reported were largely facial or ocular injuries. Infectious complications have also been encountered post-injury. This is to our knowledge the first report of a bird attack resulting in significant penetrating traumatic brain injury. Children should be cautioned by guardians to avoid unsupervised contact with chickens, particularly during breeding. Attacks to the neurocranium when they occur must be taken seriously and not treated as humorous or insignificant. Imaging appropriate to the child's clinical condition should be pursued and appropriate intervention and antibiotic treatment should be implemented.
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Affiliation(s)
- Salah Maksoud
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Aaron Lawson McLean
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany.
| | - Johannes Bauer
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Falko Schwarz
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Albrecht Waschke
- Department of Neurosurgery, Jena University Hospital - Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
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16
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Figueira Rodrigues Vieira G, Guedes Correa JF. Early computed tomography for acute post-traumatic diffuse axonal injury: a systematic review. Neuroradiology 2020; 62:653-660. [PMID: 32130462 PMCID: PMC7222974 DOI: 10.1007/s00234-020-02383-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/17/2020] [Indexed: 11/30/2022]
Abstract
Purpose Diffuse axonal injury (DAI) is the rupture of multiple axons due to acceleration and deceleration forces during a closed head injury. Most traumatic brain injuries (TBI) have some degree of DAI, especially severe TBI. Computed tomography (CT) remains the first imaging test performed in the acute phase of TBI, but has low sensitivity for detecting DAI, since DAI is a cellular lesion. The aim of this study is to search in the literature for CT signs, in the first 24 h after TBI, that may help to differentiate patients in groups with a better versus worst prognosis. Methods We searched for primary scientific articles in the PubMed database, in English, indexed since January 1st, 2000. Results Five articles were selected for review. In the DAI group, traffic accidents accounted 70% of the cases, 79% were male, and the mean age was 41 years. There was an association between DAI and intraventricular hemorrhage (IVH) and traumatic subarachnoid hemorrhage (tSAH); an association between the IVH grade and number of corpus callosum lesions; and an association between blood in the interpeduncular cisterns (IPC) and brainstem lesions. Conclusion In closed TBI with no tSAH, severe DAI is unlikely. Similarly, in the absence of IVH, any DAI is unlikely. If there is IVH, patients generally are clinically worse; and the more ventricles affected, the worse the prognosis.
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Affiliation(s)
- Giovana Figueira Rodrigues Vieira
- Department of Neurosurgery, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State, 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil.
| | - José Fernando Guedes Correa
- Department of Neurosurgery, Gaffrée e Guinle University Hospital, School of Medicine, Federal University of Rio de Janeiro State, 775 Mariz e Barros Street, Rio de Janeiro, RJ, Brazil
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17
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Warnock A, Toomey LM, Wright AJ, Fisher K, Won Y, Anyaegbu C, Fitzgerald M. Damage Mechanisms to Oligodendrocytes and White Matter in Central Nervous System Injury: The Australian Context. J Neurotrauma 2020; 37:739-769. [DOI: 10.1089/neu.2019.6890] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrew Warnock
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Lillian M. Toomey
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Alexander J. Wright
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Katherine Fisher
- School of Human Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Yerim Won
- School of Human Sciences, The University of Western Australia, Perth, Western Australia, Australia
| | - Chidozie Anyaegbu
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
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18
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Management of epidural hematomas in pediatric patients presenting with a GCS of 14 or better. J Clin Neurosci 2019; 70:118-122. [DOI: 10.1016/j.jocn.2019.08.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/06/2019] [Indexed: 11/18/2022]
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19
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Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas. Childs Nerv Syst 2019; 35:2195-2203. [PMID: 31177323 DOI: 10.1007/s00381-019-04236-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making. METHODS A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon. RESULTS Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline. CONCLUSION Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.
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20
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Morrison TR, Kulkarni P, Cai X, Iriah S, Aggarwal D, Lu SF, Simon NG, Madularu D, Ferris CF. Treating head injury using a novel vasopressin 1a receptor antagonist. Neurosci Lett 2019; 714:134565. [PMID: 31639422 DOI: 10.1016/j.neulet.2019.134565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 10/14/2019] [Indexed: 01/10/2023]
Abstract
Arginine vasopressin (AVP) is a chemical signal in the brain that influences cerebral vascular resistance and brain water permeability. Increases in AVP contribute to the pathophysiology of brain edema following traumatic brain injury (TBI). These effects are mediated through AVP V1a receptors that are expressed in cortical and subcortical brain areas. This exploratory study characterizes the effects of a novel, V1a receptor antagonist, AVN576, on behavioral and magnetic resonance imaging (MRI) measures after severe TBI. Male Sprague Dawley rats were impacted twice producing contusions in the forebrain, putative cerebral edema, and cognitive deficits. Rats were treated with AVN576 after initial impact for 5 days and then tested for changes in cognition. MRI was used to assess brain injury, enlargement of the ventricles, and resting state functional connectivity. Vehicle treated rats had significant deficits in learning and memory, enlarged ventricular volumes, and hypoconnectivity in hippocampal circuitry. AVN576 treatment eliminated the enlargement of the lateral ventricles and deficits in cognitive function while increasing connectivity in hippocampal circuitry. These data corroborate the extensive literature that drugs selectively targeting the AVP V1a receptor could be used to treat TBI in the clinic.
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Affiliation(s)
- Thomas R Morrison
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States
| | - Praveen Kulkarni
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States
| | - Xuezhu Cai
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States
| | - Sade Iriah
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States
| | - Dipak Aggarwal
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States
| | - Shi-Fang Lu
- Azevan Pharmaceuticals, Bethlehem, PA, United States; Dept. of Biological Sciences, Lehigh University, Bethlehem, PA, United States
| | - Neal G Simon
- Azevan Pharmaceuticals, Bethlehem, PA, United States; Dept. of Biological Sciences, Lehigh University, Bethlehem, PA, United States
| | - Dan Madularu
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States
| | - Craig F Ferris
- Northeastern University, Center for Translational NeuroImaging, Boston, MA, United States; Dept of Psychology and Pharmaceutical Sciences, Boston, MA, United States.
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Abstract
Conventional imaging in the acute setting of brain trauma, relevant pathophysiology of injury, and advanced imaging techniques that may provide value in understanding the immediate management and long-term sequela of traumatic brain injury are reviewed. Key imaging findings that can guide clinical management related to such injuries as concussions, hematomas, dissections, dural atrioventricular fistula, and diffuse axonal injury are discussed. The role and accuracy of computed tomography, dual-energy computed tomography, computed tomography angiography, and magnetic resonance angiography in the acute setting are evaluated. In addition, caveats related to imaging the elderly and pediatric population are addressed.
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Affiliation(s)
- Mariza O Clement
- Department of Radiology, Boston Medical Center of Boston University, 820 Harrison Avenue FGH3, Boston, MA 02118, USA.
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22
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Darwazeh R, Darwazeh M, Sbeih I, Yan Y, Wang J, Sun X. Traumatic Brain Injury Caused by Missile Wounds in the North of Palestine: A Single Institution's Experience with 520 Consecutive Civilian Patients. World Neurosurg 2018; 116:e329-e339. [DOI: 10.1016/j.wneu.2018.04.202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/15/2022]
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MRI in mild pediatric traumatic brain injury: diagnostic overkill or useful tool? Childs Nerv Syst 2018; 34:1345-1352. [PMID: 29556697 DOI: 10.1007/s00381-018-3771-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 03/01/2018] [Indexed: 01/14/2023]
Abstract
PURPOSE Magnetic resonance imaging (MRI) is a sensitive imaging tool which lacks the burden of ionizing radiation. It is not established as primary diagnostic tool in traumatic brain injury (TBI). The purpose of this study was to evaluate the usefulness of MRI as initial imaging modality in the emergency management of mild pediatric TBI. METHODS Children (0-18 years, sub-divided in four age-groups) with mild TBI who received MRI in the emergency department were identified. Clinical characteristics and trauma mechanisms were evaluated retrospectively. Univariate and multivariate logistic regression analyses were used to identify clinical factors that might be indicative for trauma sequelae on MRI scans. RESULTS An institutional case series of 569 patients (322 male/247 female; age < 18years; (GCS ≥ 13), who received MRI for mild TBI, was analyzed. Multi-sequence imaging (including T2, T2*, FLAIR, and diffusion-weighted sequences) was feasible without sedation in 96.8% of cases (sedation, 1.8%; general anesthesia, 1.4%). MRI revealed trauma-associated findings in 13% of all cases; incidental findings were detected in 4.7%. In our cohort, GCS deterioration, scalp hematoma, clinical signs of skull base fractures, and horseback riding accidents were related to structural trauma sequelae on MRI. CONCLUSIONS MRI is a practical primary imaging tool for evaluating children with mild TBI in the emergency department. The presented analyses demonstrated that in our institution, MRI imaging is performed frequently in the emergency department. It resulted mostly in normal findings. This may reflect uneasiness of when to perform imaging in mild TBI and appears retrospectively as an "overdo." There are clinical factors that are more likely associated with MRI-positive findings. Their reliability has to be evaluated in prospective studies in order to formulate further decision rules of when to perform MRI imaging or not.
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Khan NR, Fraser BD, Nguyen V, Moore K, Boop S, Vaughn BN, Klimo P. Pediatric abusive head trauma and stroke. J Neurosurg Pediatr 2017; 20:183-190. [PMID: 28574318 DOI: 10.3171/2017.4.peds16650] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite established risk factors, abusive head trauma (AHT) continues to plague our communities. Cerebrovascular accident (CVA), depicted as areas of hypodensity on CT scans or diffusion restriction on MR images, is a well-known consequence of AHT, but its etiology remains elusive. The authors hypothesize that a CVA, in isolation or in conjunction with other intracranial injuries, compounds the severity of a child's injury, which in turn leads to greater health care utilization, including surgical services, and an increased risk of death. METHODS The authors conducted a retrospective observational study to evaluate data obtained in all children with AHT who presented to Le Bonheur Children's Hospital (LBCH) from January 2009 through August 2016. Demographic, hospital course, radiological, cost, and readmission information was collected. Children with one or more CVA were compared with those without a CVA. RESULTS The authors identified 282 children with AHT, of whom 79 (28%) had one or more CVA. Compared with individuals without a CVA, children with a stroke were of similar overall age (6 months), sex (61% male), and race (56% African-American) and had similar insurance status (81% public). Just under half of all children with a stroke (38/79, 48%) were between 1-6 months of age. Thirty-five stroke patients (44%) had a Grade II injury, and 44 (56%) had a Grade III injury. The majority of stroke cases were bilateral (78%), multifocal (85%), associated with an overlying subdural hematoma (86%), and were watershed/hypoperfusion in morphology (73%). Thirty-six children (46%) had a hemispheric stroke. There were a total of 48 neurosurgical procedures performed on 28 stroke patients. Overall median hospital length of stay (11 vs 3 days), total hospital charges ($13.8 vs $6.6 million), and mean charges per patient ($174,700 vs $32,500) were significantly higher in the stroke cohort as a whole, as well as by injury grade (II and III). Twenty children in the stroke cohort (25%) died as a direct result of their AHT, whereas only 2 children in the nonstroke cohort died (1%). There was a 30% readmission rate within the first 180-day postinjury period for patients in the stroke cohort, and of these, approximately 50% required additional neurosurgical intervention(s). CONCLUSIONS One or more strokes in a child with AHT indicate a particularly severe injury. These children have longer hospital stays, greater hospital charges, and a greater likelihood of needing a neurosurgical intervention (i.e., bedside procedure or surgery). Stroke is such an important predictor of health care utilization and outcome that it warrants a subcategory for both Grade II and Grade III injuries. It should be noted that the word "stroke" or "CVA" should not automatically imply arterial compromise in this population.
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Affiliation(s)
| | - Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | | | - Scott Boop
- University of Arkansas for Medical Sciences, College of Medicine, Little Rock, Arkansas
| | - Brandy N Vaughn
- Department of Neurosurgery, Le Bonheur Children's Hospital; and
| | - Paul Klimo
- Department of Neurosurgery and.,Department of Neurosurgery, Le Bonheur Children's Hospital; and.,Semmes Murphey Clinic, Memphis, Tennessee
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25
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Abstract
Pediatric neurocritical care is a growing subspecialty of pediatric intensive care that focuses on the management of acute neurological diseases in children. A brief history of the field of pediatric neurocritical care is provided. Neuromonitoring strategies for children are reviewed. Management of major categories of acute childhood central neurologic diseases are reviewed, including treatment of diseases associated with intracranial hypertension, seizures and status epilepticus, stroke, central nervous system infection and inflammation, and hypoxic-ischemic injury.
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Affiliation(s)
- Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Haifa Mtaweh
- Department of Pediatrics, Toronto Sick Children’s Hospital, Toronto, CA
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
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Abstract
PURPOSE OF REVIEW This review addresses some of the more salient articles in the field of child maltreatment published in 2015, with a goal of helping the general practitioner understand the evolution of research in the field of child abuse pediatrics (a board-certified specialty since 2009). RECENT FINDINGS Researchers continue to refine the database for child abuse pediatrics. Several articles focus on the inconsistencies in approach to the evaluation of possible physical child abuse between hospitals and practitioners. Multiple researchers aim to develop a protocol that standardizes the response to findings of a sentinel injury, such as a rib fracture, abdominal trauma, or unexplained bruising in a nonambulatory infant. Professionals are also working to improve our understanding about the impact of trauma on children and how best to ameliorate its effects. SUMMARY With solid, evidence-based literature published on various topics in the field of child abuse pediatrics, experts work to refine and unify the clinician's approach to the evaluation of possible physical abuse.
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Young JY, Duhaime AC, Caruso PA, Rincon SP. Comparison of non-sedated brain MRI and CT for the detection of acute traumatic injury in children 6 years of age or less. Emerg Radiol 2016; 23:325-31. [DOI: 10.1007/s10140-016-1392-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 03/18/2016] [Indexed: 11/25/2022]
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28
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Rapid MRI evaluation of acute intracranial hemorrhage in pediatric head trauma. Neuroradiology 2016; 58:793-9. [DOI: 10.1007/s00234-016-1686-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 04/04/2016] [Indexed: 11/24/2022]
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