Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery

Age predicts likelihood for surgery for pediatric tbi: an analysis of 1745 hospitlizations from a Chinese Children's Hospital

PURPOSE

We tested the role of age and sex in surgery following pediatric TBI hospitalization.

METHODS

Records of 1745 children hospitalized at a pediatric neurotrauma center in China included age, sex, cause of injury, diagnosis of injury, days of hospitalization, in-house rehabilitation, Glasgow Coma Scale score, mortality, 6-month post-discharge Glasgow Outcome Scale score, and surgery intervention. The children were 0-13 years (M= 3.56 years; SD = 3.06), with 47.4% 0-2 years of age.

RESULTS

The mortality rate was 1.49%. Logistic regression on 1027 children with epidural hematoma, subdural hematoma, intracerebral hemorrhage, and intraventricular hemorrhage showed that controlling for other variables, the odds for younger children to receive surgery was statistically lower for epidural hematomas (OR = 0.75; 95% CI = 0.68-0.82), subdural hematomas (OR = 0.59; 95% CI = 0.47-0.74), and intraventricular hemorrhage (OR = 0.52; 95% CI = 0.28-0.98).

CONCLUSIONS

While severity of TBI and type of TBI were expected predictors for surgery, a younger age also predicted a significantly lower likelihood of surgery in our sample. Sex of the child was unrelated to surgical intervention.

Decompressive Craniectomy for Pediatric Traumatic Brain Injury in Low-and-Middle Income and High Income Countries

Traumatic brain injury is one of the leading causes of mortality and morbidity in children worldwide. In severe cases, high intracranial pressure is the most frequent cause of death. When first-line medical management fails, the neurosurgical procedure of decompressive craniectomy (DC) has been proposed for controlling intracranial pressure and improving the long-term outcomes for children with severe traumatic brain injury. However, the use of this procedure is controversial. The evidence from clinical trials shows some promise for the use of DC as an effective second-line treatment. However, it is limited by conflicting trial results, a lack of trials, and a high risk of bias. Furthermore, most research comes from retrospective observational studies and case series. This narrative review considers the strength of evidence for the use of DC in both a high income country and low-and-middle income country setting and examine how we can improve study design to better assess the efficacy of this procedure and increase the clinical translatability of results to centers worldwide. Specifically, we argue for a need for further studies with higher pediatric participant numbers, multicenter collaboration, and the use of a more consistent methodology to enable comparability of results among settings.

Management of Severe Traumatic Brain Injury in Pediatric Patients

The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.

Long-Term Outcome Following Decompressive Craniectomy in Pediatric Penetrating Blast Brain Injury; a Prospective Study

Background: Brain penetrating blast injury is a leading cause of early death due to excessively elevated intracranial pressure (ICP), culminating in trans-tentorial herniation. The role of craniectomy to decrease ICP and secondary injuries has been controversial particularly in pediatric patients. Three cases of pediatric penetrating blast injuries undergoing decompressive craniectomy are reported in Methods: The current study was a prospective series, including fifteen cases of pediatric blast-related brain injury referred to the emergency ward during a period of two years. Three survived patients had a Glasgow Coma Scale (GCS) of four along with anisocoric pupillary light reflex (PLR). Decompressive craniectomy and ventriculostomy (EVD) were performed. The patients underwent ICP monitoring for two weeks. Results: Early postoperative GCS (5 days) was 7/15 in all three patients. Two weeks and one month’s GCS were 9 and 14, respectively. After three months, cranioplasty was performed. Long-term follow-up detected no major motor deficits after one year and was associated with excellent school performance. Neuroplasticity resulted in contralateral dominancy and handedness in one case. Conclusions: Survivors of pediatric blast brain injury had a favorable outcome after decompressive craniectomy in the current paper. However, there was a limited number of patients, and the results could not be generalized. Further research in this regard with larger sample size is recommended.

Bone Flap Resorption in Pediatric Patients Following Autologous Cranioplasty

Following a decompressive craniectomy, the autologous bone flap is generally considered the reconstructive material of choice in pediatric patients. Replacement of the original bone flap takes advantage of its natural biocompatibility and the associated low risk of rejection, as well as the potential to reintegrate with the adjacent bone and subsequently grow with the patient. However, despite these advantages and unlike adult patients, the replaced calvarial bone is more likely to undergo delayed bone resorption in pediatric patients, ultimately requiring revision surgery. In this review, we describe the materials that are currently available for pediatric cranioplasty, the advantages and disadvantages of autologous calvarial replacement, the incidence and classification of bone resorption, and the clinical risk factors for bone flap resorption that have been identified to date.

Decompressive craniectomy in pediatric non-traumatic intracranial hypertension: a single center experience

Purpose: To study the clinical profile and predictors of outcome in children undergoing decompressive craniectomy (DC) for non-traumatic intracranial hypertension (ICH).Materials and methods: Mixed observational study of children, aged 1 month-12 years, who underwent DC for non-traumatic ICH in a tertiary care pediatric intensive care unit from 2012 to 2017. Data on clinical profile and outcome were retrieved retrospectively and survivors were assessed prospectively. The primary outcome was neurological outcome using Glasgow Outcome Scale-Extended (GOS-E) at minimum 6 months' post-discharge. GOS-E of 1-4 were classified as a poor and 5-8 as a good outcome.Results: Thirty children, median (IQR) age of 6.5 (2, 50) months, underwent DC; of which 26 (86.7%) were boys. Altered sensorium (n = 26, 86.7%), seizures (n = 25, 83.3%), pallor (n = 19, 63.3%) and anisocoria (n = 14, 46.7%) were common signs and symptoms. Median (IQR) Glasgow Coma Scale at admission was 9 (6,11). Commonest etiology was intracranial bleed (n = 24; 80%). Median (IQR) time to DC was 24 (24,72) h. Eight (26.7%) children died; 2 during PICU stay and 6 during follow-up. Neurological sequelae at discharge (n = 28) were seizures (n = 25; 89.2%) and hemiparesis (n = 16; 57.1%). Twenty-one children were followed-up at median (IQR) duration of 12 (6,54) months. Good neurological outcome was seen in 14/29 (48.2%) and hemiparesis in 10/21 (47.6%) patients. On regression analysis, anisocoria at admission was an independent predictor of poor outcome [OR 7.33; 95%CI: 1.38-38.87; p = 0.019].Conclusions: DC is beneficial in children with non-traumatic ICH due to a focal pathology and midline shift. Evidence on indications and timing of DC in NTC is still evolving.

Exploratory, cognitive, and depressive-like behaviors in adult and pediatric mice exposed to controlled cortical impact

Objective

Sequelae of behavioral impairments associated with human traumatic brain injury (TBI) include neurobehavioral problems. We compared exploratory, cognitive, and depressive-like behaviors in pediatric and adult male mice exposed to controlled cortical impact (CCI).

Methods

Pediatric (21 to 25 days old) and adult (8 to 12 weeks old) male C57Bl/6 mice underwent CCI at a 2-mm depth of deflection. Hematoxylin and eosin staining was performed 3 to 7 days after recovery from CCI, and injury volume was analyzed using ImageJ. Neurobehavioral characterization after CCI was performed using the Barnes maze test (BMT), passive avoidance test, open-field test, light/dark test, tail suspension test, and rotarod test. Acutely and subacutely (3 and 7 days after CCI, respectively), CCI mice showed graded injury compared to sham mice for all analyzed deflection depths.

Results

Time-dependent differences in injury volume were noted between 3 and 7 days following 2-mm TBI in adult mice. In the BMT, 2-mm TBI adults showed spatial memory deficits compared to sham adults (P<0.05). However, no difference in spatial learning and memory was found between sham and 2-mm CCI groups among pediatric mice. The open-field test, light/dark test, and tail suspension test did not reveal differences in anxiety-like behaviors in both age groups.

Conclusion

Our findings revealed a graded injury response in both age groups. The BMT was an efficient cognitive test for assessing spatial/non-spatial learning following CCI in adult mice; however, spatial learning impairments in pediatric mice could not be assessed.

Ruptured intracranial aneurysm in a patient with autosomal recessive polycystic kidney disease

Aneurysmal rupture can result in devastating neurological consequences and can be complicated by comorbid disease processes. Patients with autosomal recessive polycystic kidney disease (ARPKD) have a low rate of reported aneurysms, but this may be due to the relative high rate of end-stage illnesses early in childhood. Authors here report the case of a 10-year-old boy with ARPKD who presented with a Hunt and Hess grade V subarachnoid hemorrhage requiring emergency ventriculostomy, embolization, and decompressive craniectomy. Despite initial improvements in his neurological status, the patient succumbed to hepatic failure. Given the catastrophic outcomes of subarachnoid hemorrhage in young patients, early radiographic screening in those with ARPKD may be warranted.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

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.

Hydroxyapatite ceramic implants for cranioplasty in children: a single-center experience

PURPOSE

The use of hydroxyapatite ceramic (HAC) implants for the treatment of skull defects in pediatric patients started 2010 at our institution. Ceramic implants facilitate osteoblast migration and therefore optimize osteointegration with the host bone. The purpose of this study is to report a single-center experience with this treatment modality.

METHODS

A retrospective review of all patients from July 2010 through June 2014 undergoing a cranioplasty using hydroxyapatite ceramic implant and managed at a single institution was performed. Indication for cranioplasty, the hospital course, and follow-up were reviewed. Bone density was measured in Hounsfield Units (HU) and osteointegration was calculated using Mimics Software® (Mimics Innovation Suite v17.0 Medical, Materialize, Leuven, Belgium).

RESULTS

Over the 4-year period, six patients met criteria for the study. Five patients had an osteointegration of nearly 100%. One patient had an incomplete osteointegration with a total bone-implant contact area of 69%. The mean bone density was 2800 HU (2300-3000 HU). Bone density alone is estimated to have a Hounsfield value between 400 and 2000 HU depending on the body region and bone quality. There were no major complications, and the patients were highly satisfied with the esthetical result.

CONCLUSION

Hydroxyapatite ceramic implants for cranioplasty in pediatric patients are a good choice for different indications. The implants show excellent osteointegration and esthetical results.

The role of decompressive craniectomy in children with severe traumatic brain injury

OBJECTIVE

Severe traumatic brain injury (TBI) remains the leading cause of death in children. The present study analyses the outcome of children after severe TBI treated by decompressive craniectomy (DC) due to elevated intracranial pressure (ICP) in a single centre.

METHODS

Fifty-six consecutive children (age < 16 years) were treated for severe TBI at our institution between 2001 and 2011. For study purposes, children with severe generalized traumatic brain swelling without concomitant mass lesion were further analysed. Descriptive statistics were used to report clinical conditions as well as outcome measurements after conservative treatment only in comparison to secondary decompressive craniectomy.

RESULTS

Of 56 children, a total of eight children presented with generalized and progressive traumatic brain swelling and impending brain herniation. Four children were treated conservatively following standardized local protocol for anti-oedematous management, with ICP amenable to intensified therapy. Four children required decompressive surgery due to progressive oedema refractory to intensified conservative management. Children receiving secondary DC had a longer stay in the intensive care unit as well as a longer average time of assisted ventilation compared to children treated conservatively. Concomitant injuries were more severe in the DC subgroup. Yet, Glasgow Outcome Scale was equally distributed in both groups.

CONCLUSION

In children with refractory ICP conditions due to severe TBI, decompressive surgery might lead to a similar favourable outcome compared to children in whom ICP can be controlled only by conservative management. Timing of surgery depends on the neurological deterioration of the patients and a continuous ICP monitoring.

Intraoperative blood loss during decompressive craniectomy for intractable intracranial hypertension after severe traumatic brain injury in children

PURPOSE

There are no data available on the risk of intraoperative bleeding during decompressive craniectomy (DC) after traumatic brain injury (TBI) in children. The objectives of this study were to assess the risk of intraoperative bleeding during DC for intractable intracranial hypertension after TBI, to identify potential factors associated with the risk of bleeding during DC, and to assess the impact of DC on systemic and cerebral hemodynamics and on coagulation.

METHODS

Twelve children were identified as having undergone DC after TBI from April 2009 to June 2013 in our center. Subjects were allocated into two groups according to the percentage of blood loss (IBL) during the intraoperative period (<or ≥50 % of the estimated blood volume (EBV)).

RESULTS

The median IBL during DC was 49 [17-349] % of the EBV. Children with an IBL ≥ 50 % of EBV had higher preoperative intracranial pressure (ICP) (p = 0.03) and international normalized ratio (INR) (p = 0.02) than those with an IBL < 50 % of EBV. DC induced significant decreases in ICP (p = 0.0005), mean arterial pressure (p = 0.01), and a significant increase in norepinephrine flow rate (p = 0.04) between the immediate pre- and postoperative periods.

CONCLUSIONS

DC allows a significant decrease in ICP after severe pediatric TBI but is a surgical procedure at a high risk of bleeding. High ICP and INR during the immediate preoperative period are the main factors associated with increased IBL during DC. Further studies are needed to confirm our results and to assess the impact of the amount of IBL on the postoperative survival and functional outcome.

Performance analysis of the protective effects of bicycle helmets during impact and crush tests in pediatric skull models

OBJECT

Bicycle accidents are a very important cause of clinically important traumatic brain injury (TBI) in children. One factor that has been shown to mitigate the severity of lesions associated with TBI in such scenarios is the proper use of a helmet. The object of this study was to test and evaluate the protection afforded by a children's bicycle helmet to human cadaver skulls with a child's anthropometry in both "impact" and "crushing" situations.

METHODS

The authors tested human skulls with and without bicycle helmets in drop tests in a monorail-guided free-fall impact apparatus from heights of 6 to 48 in onto a flat steel anvil. Unhelmeted skulls were dropped at 6 in, with progressive height increases until failure (fracture). The maximum resultant acceleration rates experienced by helmeted and unhelmeted skulls on impact were recorded by an accelerometer attached to the skulls. In addition, compressive forces were applied to both helmeted and unhelmeted skulls in progressive amounts. The tolerance in each circumstance was recorded and compared between the two groups.

RESULTS

Helmets conferred up to an 87% reduction in so-called mean maximum resultant acceleration over unhelmeted skulls. In compression testing, helmeted skulls were unable to be crushed in the compression fixture up to 470 pound-force (approximately 230 kgf), whereas both skull and helmet alone failed in testing.

CONCLUSIONS

Children's bicycle helmets provide measurable protection in terms of attenuating the acceleration experienced by a skull on the introduction of an impact force. Moreover, such helmets have the durability to mitigate the effects of a more rare but catastrophic direct compressive force. Therefore, the use of bicycle helmets is an important preventive tool to reduce the incidence of severe associated TBI in children as well as to minimize the morbidity of its neurological consequences.

Decompressive craniectomy with massive intractable intraoperative cerebral edema: utilization of silicone sheet for temporary scalp closure

The authors present a case of extreme brain herniation encountered during decompressive craniectomy in a 21-month-old boy who suffered a trauma event that necessitated temporary scalp closure in which a sterile silicone sheet was placed. Although the clinical situation is usually expected to lead to brain death or severe disability, the patient's 3-year follow-up examination revealed a highly functional child with a good quality of life. The authors discuss the feasibility and advantages of temporary scalp expansion as a treatment option when extreme brain herniation is encountered during craniotomy.