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Miklus V, Trout L, Even K. Levetiracetam Dosing Based on Glasgow Coma Scale Scores in Pediatric Traumatic Brain Injury Patients. Neuropediatrics 2024; 55:224-231. [PMID: 38740070 DOI: 10.1055/s-0044-1786796] [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] [Indexed: 05/16/2024]
Abstract
INTRODUCTION Severe traumatic brain injury (TBI) increases the risk of early posttraumatic seizures (EPTS). Guidelines suggest the use of prophylactic antiseizure agents, including levetiracetam. This study aims to evaluate the feasibility of using levetiracetam dosing based on Glasgow Comas Scale (GCS) scores with higher doses used for more severe TBI. METHODS Patients 6 months to 18 years old admitted to Penn State Hershey Children's Hospital (PSHCH) with a TBI who received levetiracetam for EPTS prophylaxis with at least one documented GCS score were included. Patients were divided into two cohorts: before and after implementation of the pediatric TBI Cerner PowerPlan at PSHCH which standardized levetiracetam dosing based on GCS scores. Primary outcome was appropriate dosing of levetiracetam based on GCS. Secondary outcomes included seizure occurrence and adverse effects. RESULTS Eighty-five patients were included: 42 in the pre-PowerPlan group and 43 in the post-PowerPlan group. Overall, 46 (54%) patients received the appropriate levetiracetam dose based on GCS (pre-PowerPlan, n = 19 [45%] vs. post-PowerPlan n = 27 [63%], p = 0.104). Sixty-four percent of severe TBI patients received appropriate levetiracetam dosing after implantation of the PowerPlan compared with 28% prior to the PowerPlan (p = 0.039). Three patients in each group experienced a seizure while on levetiracetam. Two patients experienced agitation and somnolence attributed to levetiracetam. CONCLUSION Levetiracetam dosing based on GCS scores in pediatric TBI patients is a novel approach, and dosing accuracy may be increased with use of a PowerPlan. Additional large-scale studies are needed to evaluate efficacy and safety of this approach prior to widespread implementation.
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Affiliation(s)
- Victoria Miklus
- Department of Pharmacy, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, United States
| | - Lindsay Trout
- Department of Pharmacy, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, United States
| | - Katelyn Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, United States
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Ulgen Tekerek N, Dursun O, Asilioglu Yener N, Yildizdas D, Anıl AB, Kendirli T, Koker A, Karalok S, Aksoy A, Kinik Kaya E, Ekinci F, Incecik F, Olgac Dundar N, Durak F, Botan E, Havan M, Sahin S, Duman O, Haspolat S. Posttraumatic epilepsy in critically ill children with traumatic brain injury. Childs Nerv Syst 2023; 39:3207-3214. [PMID: 37480521 DOI: 10.1007/s00381-023-06087-9] [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: 06/05/2023] [Accepted: 07/17/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE The aim of this study was to determine the clinical, laboratory, and radiological factors related with posttraumatic epilepsy (PTE). METHODS The study is a multicenter descriptive cross-sectional cohort study. Children who followed up for TBI in the pediatric intensive care unit between 2014 and 2021 were included. Demographic data and clinical and radiological parameters were recorded from electronic case forms. All patients who were in the 6-month posttraumatic period were evaluated by a neurologist for PTE. RESULTS Four hundred seventy-seven patients were included. The median age at the time of trauma was 66 (IQR 27-122) months, and 298 (62.5%) were male. Two hundred eighty (58.7%) patients had multiple traumas. The mortality rate was 11.7%. The mean duration of hospitalization, pediatric intensive care unit hospitalization and mechanical ventilation, Rotterdam score, PRISM III score, and GCS at admission were higher in patients with epilepsy (p < 0.05). The rate of epilepsy was higher in patients with severe TBI, cerebral edema on tomography and clinical findings of increased intracranial pressure, blood transfusion in the intensive care unit, multiple intracranial hemorrhages, and intubated patients (p < 0.05). In logistic regression analysis, the presence of intracranial hemorrhage in more than one compartment of the brain (OR 6.13, 95%CI 3.05-12.33) and the presence of seizures (OR 9.75, 95%CI 4.80-19.83) were independently significant in terms of the development of epilepsy (p < 0.001). CONCLUSIONS In this multicenter cross-sectional study, intracranial hemorrhages in more than one compartment and clinical seizures during intensive care unit admission were found to be independent risk factors for PTE development in pediatric intensive care unit patients with TBI.
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Affiliation(s)
- Nazan Ulgen Tekerek
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey.
- Akdeniz University Hospital, Dumlupınar Boulevard, Konyaalti, Antalya, 07059, Turkey.
| | - Oguz Dursun
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Nazik Asilioglu Yener
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Dincer Yildizdas
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Ayşe Berna Anıl
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Katip Celebi University, İzmir, Turkey
| | - Tanil Kendirli
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Alper Koker
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Selen Karalok
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Ayşe Aksoy
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Elif Kinik Kaya
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Faruk Ekinci
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Faruk Incecik
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Nihal Olgac Dundar
- Division of Pediatric Neurology, Department of Pediatrics, Katip Celebi Faculty of Medicine, İzmir, Turkey
| | - Fatih Durak
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Katip Celebi University, İzmir, Turkey
| | - Edin Botan
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Merve Havan
- Division of Pediatric Intensive Care, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Suleyman Sahin
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Ozgur Duman
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Senay Haspolat
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Omar S, Nixon S, Colantonio A. Integrated Care Pathways for Black Persons With Traumatic Brain Injury: A Critical Transdisciplinary Scoping Review of the Clinical Care Journey. TRAUMA, VIOLENCE & ABUSE 2023; 24:1254-1281. [PMID: 34915772 DOI: 10.1177/15248380211062221] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Objectives: This novel critical transdisciplinary scoping review examined the literature on integrated care pathways that consider Black people living with traumatic brain injury (TBI). The objectives were to (a) summarize the extent, nature, and range of literature on care pathways that consider Black populations, (b) summarize how Blackness, race, and racism are conceptualized in the literature, (c) determine how Black people come to access care pathways, and (d) identify how care pathways in research consider the mechanism of injury and implications for human occupation. Methods: Six databases were searched systematically identifying 178 articles after removing duplicates. In total, 43 articles on integrated care within the context of Black persons with TBI were included. Narrative synthesis was conducted to analyze the data and was presented as descriptive statistics and as a narrative to tell a story. Findings: All studies were based in the United States where 81% reported racial and ethnic disparities across the care continuum primarily using race as a biological construct. Sex, gender, and race are used as demographic variables where statistical data were stratified in only 9% of studies. Black patients are primarily denied access to care, experience lower rates of protocol treatments, poor quality of care, and lack access to rehabilitation. Racial health disparities are disconnected from racism and are displayed as symptoms of a problem that remains unnamed. Conclusion: The findings illustrate how racism becomes institutionalized in research on TBI care pathways, demonstrating the need to incorporate the voices of Black people, transcend disciplinary boundaries, and adopt an anti-racist lens to research.
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Affiliation(s)
- Samira Omar
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Stephanie Nixon
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Angela Colantonio
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, ON, Canada
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Borland ML, Dalziel SR, Phillips N, Dalton S, Lyttle MD, Bressan S, Oakley E, Kochar A, Furyk J, Cheek JA, Neutze J, Eapen N, Hearps SJC, Rausa VC, Babl FE. Incidence of traumatic brain injuries in head-injured children with seizures. Emerg Med Australas 2023; 35:289-296. [PMID: 36323396 PMCID: PMC10947265 DOI: 10.1111/1742-6723.14112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 09/01/2022] [Accepted: 10/05/2022] [Indexed: 03/20/2023]
Abstract
OBJECTIVE Incidence and short-term outcomes of clinically important traumatic brain injury (ciTBI) in head-injured children presenting to ED with post-traumatic seizure (PTS) is not described in current literature. METHODS Planned secondary analysis of a prospective observational study undertaken in 10 Australasian Paediatric Research in Emergency Departments International Collaborative (PREDICT) network EDs between 2011 and 2014 of head-injured children <18 years with and without PTS. Clinical predictors and outcomes were analysed by attributable risk (AR), risk ratios (RR) and 95% confidence interval (CI), including the association with Glasgow Coma Scale (GCS) scores. RESULTS Of 20 137 head injuries, 336 (1.7%) had PTS with median age of 4.8 years. Initial GCS was 15 in 268/336 (79.8%, AR -16.1 [95% CI -20.4 to -11.8]), 14 in 24/336 (7.1%, AR 4.4 [95% CI 1.6-7.2]) and ≤13 in 44/336 (13.1%, AR 11.7 [95% CI 8.1-15.3]) in comparison with those without PTS, respectively. The ciTBI rate was 34 (10.1%) with PTS versus 219 (1.1%) without PTS (AR 9.0 [95% CI 5.8-12.2]) with 5/268 (1.9%), 6/24 (25.0%) and 23/44 (52.3%) with GCS 15, 14 and ≤13, respectively. In PTS, rates of admission ≥2 nights (34 [10.1%] AR 9.0 [95% CI 5.8-12.3]), intubation >24 h (9 [2.7%] AR 2.5 [95% CI 0.8-4.2]) and neurosurgery (8 [2.4%] AR 2.0 [95% CI 0.4-3.7]), were higher than those without PTS. Children with PTS and GCS 15 or 14 had no neurosurgery, intubations or death, with two deaths in children with PTS and GCS ≤13. CONCLUSIONS PTS was uncommon in head-injured children presenting to the ED but associated with an increased risk of ciTBI in those with reduced GCS on arrival.
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Affiliation(s)
- Meredith L Borland
- Emergency DepartmentPerth Children's HospitalPerthWestern AustraliaAustralia
- Divisions of Paediatrics and Emergency Medicine, School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Stuart R Dalziel
- Children's Emergency DepartmentStarship Children's HospitalAucklandNew Zealand
- Departments of Surgery and Paediatrics: Child and Youth HealthThe University of AucklandAucklandNew Zealand
| | - Natalie Phillips
- Emergency DepartmentQueensland Children's HospitalBrisbaneQueenslandAustralia
- Child Health Research Centre, School of MedicineThe University of QueenslandBrisbaneQueenslandAustralia
| | - Sarah Dalton
- Emergency DepartmentThe Children's Hospital at WestmeadSydneyNew South WalesAustralia
| | - Mark D Lyttle
- Emergency DepartmentBristol Royal Hospital for ChildrenBristolUK
- Academic Department of Emergency CareUniversity of the West of EnglandBristolUK
| | - Silvia Bressan
- Department of Women's and Children's HealthUniversity of PadovaPadovaItaly
| | - Ed Oakley
- Emergency DepartmentThe Royal Children's HospitalMelbourneVictoriaAustralia
- Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health SciencesThe University of MelbourneMelbourneVictoriaAustralia
| | - Amit Kochar
- Emergency DepartmentWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Jeremy Furyk
- Emergency DepartmentThe Townsville HospitalTownsvilleQueenslandAustralia
- School of MedicineDeakin UniversityMelbourneVictoriaAustralia
- University Hospital GeelongGeelongVictoriaAustralia
| | - John A Cheek
- Emergency DepartmentThe Royal Children's HospitalMelbourneVictoriaAustralia
- Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health SciencesThe University of MelbourneMelbourneVictoriaAustralia
| | - Jocelyn Neutze
- Emergency DepartmentKidz First Children's HospitalAucklandNew Zealand
| | - Nitaa Eapen
- Murdoch Children's Research InstituteMelbourneVictoriaAustralia
| | | | - Vanessa C Rausa
- Murdoch Children's Research InstituteMelbourneVictoriaAustralia
| | - Franz E Babl
- Emergency DepartmentThe Royal Children's HospitalMelbourneVictoriaAustralia
- Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health SciencesThe University of MelbourneMelbourneVictoriaAustralia
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Balogun JA, Koko AM, Adebayo A, Aniaku I, Lasseini A, Balogun FM, Uche EO. Fall-related traumatic brain injury in a Nigerian pediatric population. J Clin Neurosci 2023; 109:26-31. [PMID: 36642033 DOI: 10.1016/j.jocn.2023.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 12/05/2022] [Accepted: 01/10/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Accidental falls are a common cause of disability and trauma-related death in the pediatric population, accounting for a large number of pediatric emergency hospital admissions. This multicenter study assesses the clinical characteristics, management outcomes of pediatric falls-related traumatic brain injury and associated factors in Nigeria. METHODS A retrospective study of pediatric patients (age less than 18-years) with falls over a 2-year period. Data was extracted from clinical records and neurosurgical data sheets from three major centres in Nigeria, and was analyzed using descriptive statistics, Chi square test and multinomial regression with significance set at p < 0.05. RESULTS 128 children presented with fall-related TBI, with a median age of 96 months (age range of 5-216 months) and M:F was 6:1. 40.6 % had moderate head injury and 55.5 % of the falls were building related. There were 52(42.6 %) children with skull fractures. Older children more commonly fell from trees and had more cases of severe head injury (14.1 %) compared with those who fell from buildings (5.5 %). Children who fell from buildings presented early (64.1 %). The 10 % mortality was mainly in children older than 5-years. Children aged 0-5 years were three times likely to fall inside/outside a building (OR: 3.3, CI: 3.06 to 243.44). Also, those who fell from trees were 6 times more likely to have a long bone fracture (OR: 6.1, CI: 1.2 to 32.6). CONCLUSIONS In the Nigerian population Traumatic Brain Injury from falls is common among children, with older children falling more from trees and associated with high mortality.
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Affiliation(s)
- James A Balogun
- Division of Neurosurgery, Department of Surgery, College of Medicine, University of Ibadan, Nigeria; Department of Neurosurgery, University College Hospital, Ibadan, Nigeria.
| | - Aliyu M Koko
- Department of Neurosurgery, Regional Centre for Neurosurgery, Usmanu Danfodiyo University, Teaching Hospital, Nigeria
| | - Adegboyega Adebayo
- Department of Neurosurgery, University College Hospital, Ibadan, Nigeria
| | - Ikechukwu Aniaku
- Neurosurgery Unit, Department of Surgery, University of Nigeria Ituku/Ozalla Campus, Enugu, Nigeria
| | - Ali Lasseini
- Department of Neurosurgery, Regional Centre for Neurosurgery, Usmanu Danfodiyo University, Teaching Hospital, Nigeria
| | - Folusho M Balogun
- Adolescent Health Unit, Institute of Child Health, College of Medicine University of Ibadan, Nigeria
| | - Enoch O Uche
- Adolescent Health Unit, Institute of Child Health, College of Medicine University of Ibadan, Nigeria
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Samara QA, Ifraitekh AS, Al Jayyousi O, Sawan S, Hazaimeh E, Jbarah OF. Use of antiepileptic drugs as prophylaxis against posttraumatic seizures in the pediatric population: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:49. [PMID: 36746821 DOI: 10.1007/s10143-023-01963-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 02/01/2023] [Accepted: 02/02/2023] [Indexed: 02/08/2023]
Abstract
We aim to assess the effect of anti-epileptic drug (AED) prophylaxis for early or late posttraumatic seizures, targeting the pediatric population with traumatic brain injury (TBI). We systematically searched for studies reporting the incidence of posttraumatic seizures in pediatric patients who suffered from TBI and received AEDs prophylactically following their TBI incident. Studies that included adult patients, adult and pediatric patients but did not report results for the pediatric population separately, and patients who did not suffer from a TBI were excluded. Studies that did not indicate the use of antiepileptic drugs prophylactically following TBI were excluded. A total of 10 studies were included involving 4621 posttraumatic brain injury patients of the pediatric age population (<18). Five studies assessed the effect of prophylaxis on early seizures, four on late seizures and one on any seizure. The mean incidence of posttraumatic seizures with AED prophylaxis was 8% for early seizures and 7.1% for late seizures. Moreover, one study revealed no benefit of AED prophylaxis for early posttraumatic seizures. Meta-analysis revealed a significant difference in the incidence of early posttraumatic seizures with antiepileptic prophylaxis. However, no significant difference for late posttraumatic seizures has been shown. In conclusion, AED prophylaxis seems to be effective against early posttraumatic seizures for the pediatric population, with levetiracetam possibly being more effective. Also, there is no observed benefit for late posttraumatic seizures.
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Affiliation(s)
- Qais A Samara
- Department of Neurosurgery, Faculty of Medicine, Al-Balqa Applied University, PO Box 206, Al Salt, 19117, Jordan.
| | - Ali S Ifraitekh
- Faculty of Medicine, Hashemite University, PO Box 330127, Zarqa, Jordan
| | - Obada Al Jayyousi
- Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Siya Sawan
- Faculty of Medicine, University of Jordan, PO Box 11942, Amman, Jordan
| | - Ethar Hazaimeh
- Neurology Department, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
| | - Omar F Jbarah
- Neurosurgery Department, Faculty of Medicine, Jordan University of Science & Technology, PO Box 3030, 22110, Irbid, Jordan
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Cuenca CM, Borgman MA, Dengler BA, Schauer SG. Incidence of post-traumatic seizures in children during combat operations in Afghanistan and Iraq. Injury 2022; 53:3297-3300. [PMID: 35831207 DOI: 10.1016/j.injury.2022.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 06/15/2022] [Accepted: 07/03/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Children represent a significant portion of the patient population treated at combat support hospitals. There is significant data regarding post injury seizures in adults but with children it is lacking. We seek to describe the incidence of post-traumatic seizures within this population. METHODS This is a secondary analysis of previously described data from the Department of Defense Trauma Registry (DODTR). Within our dataset, we searched for documentation of seizures after admission. RESULTS Of the 3439 encounters in our dataset, we identified 37 casualties that had a documented seizure after admission. Most were in the 1-4 year age group (37.8%), male (59.4%), injured by explosive (40.5%), with serious injuries to the head/neck (75.6%). The median ISS was higher in the seizure group (22 versus 10, p<0.001). Most survived to hospital discharge with no statistically significant increased mortality noted in the seizure group (seizure 90.2% versus 91.8%, p = 1.000). In the prehospital setting, the seizure group was more frequently intubated (16.2% versus 6.0%, p = 0.023), received ketamine (20.0% versus 3.2%, p<0.001), and administered an anti-seizure medication (5.4% versus 0.1%, p = 0.001). In the hospital setting, the seizure group was more frequently intubated (56.7% versus 17.7%, p<0.001), had intracranial pressure monitoring (24.3% versus 2.6%, p<0.001), craniectomy (10.8% versus 2.5%, p = 0.014), and craniotomy (21.6% versus 4.7%, p<0.001). CONCLUSIONS Within our dataset, we found an incidence of 1% of pediatric casualties experiencing a post-traumatic seizure. While this number appears infrequent, there is likely significant under detection of subclinical seizures.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA
| | | | - Bradley A Dengler
- Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda Maryland, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, Texas, USA; Brooke Army Medical Center, JBSA Fort Sam Houston, Texas, USA; Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
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Abstract
BACKGROUND: Post-traumatic headache is the most common sequela of brain injury and can last months or years after the damaging event. Many headache types are associated with visual concerns also known to stem from concussion. OBJECTIVES: To describe the various headache types seen after head injury and demonstrate how they impact or are impacted by the visual system. METHODS: We will mirror the International Classification of Headache Disorders (ICHD) format to demonstrate the variety of headaches following brain injury and relate correlates to the visual pathways. The PubMed database was searched using terms such as headache, head pain, vision, concussion, traumatic brain injury, glare, visuomotor pathways. RESULTS: Every type of headache described in the International Classification of Headache Disorders Edition III can be initiated or worsened after head trauma. Furthermore, there is very often a direct or indirect impact upon the visual system for each of these headaches. CONCLUSION: Headaches of every described type in the ICHD can be caused by brain injury and all are related in some way to the afferent, efferent or association areas of the visual system.
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Affiliation(s)
- Patrick T. Quaid
- Head of Optometry, VUE Cubed Vision Therapy Clinics, ON, Canada
- College of Optometrists of Ontario (Regulatory Body), ON, Canada
| | - Eric L. Singman
- Ophthalmology & Visual Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
- Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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Nickerson TE, Villo L, Eisner M, Lovett ME, Chung MG, O'Brien NF, Sribnick EA, Ostendorf AP. Associations between Electroencephalographic Variables, Early Post-Traumatic Seizure Risk, and Outcomes following Pediatric Severe Traumatic Brain Injury. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1743500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractEarly post-traumatic seizures (PTS) are associated with worse outcomes in children with traumatic brain injury (TBI). Our aim was to identify the association between continuous electroencephalogram (cEEG) characteristics and early PTS risk following pediatric severe TBI. We also evaluated the relationship between cEEG background features and outcomes. A single-center retrospective cohort study was performed on children between 0 and 18 years of age admitted to the pediatric intensive care unit from 2016 to 2019 with severe TBI and cEEG monitoring within 7 days of injury. Raw cEEG tracings were reviewed by an epileptologist in accordance with American Clinical Neurophysiology Society (ACNS) Critical Care EEG terminology. Univariate comparisons were made between children with and without early PTS, as well as between those with and without varying cEEG background features. Eighteen children (31%) of the 59 included had early PTS. Interictal abnormalities, inclusive of sporadic spikes and sharp waves, rhythmic delta activity, or lateralized periodic discharges (LPDs) were more common among children with seizures (100 vs. 22%; p < 0.01). LPDs were also more common in the seizure group (44 vs. 2%; p < 0.01). Background discontinuity was associated with worse Glasgow Outcome Scale—Extended Pediatric Version (GOS-E Peds) scores at discharge and 3-, 6-, and 12-month post-discharge (p < 0.01). Lack of reactivity was also associated with worse GOS-E Peds scores at 3-, 6-, and 12-month post-discharge (p < 0.01). Interictal abnormalities and LPDs were each associated with early PTS following pediatric severe TBI. Larger studies should evaluate if high-risk patients would benefit from prolonged cEEG monitoring and/or more aggressive anti-seizure prophylaxis. Discontinuity and lack of variability were associated with worse outcomes. Future studies should attempt to clarify their role as potential early markers of prognosis.
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Affiliation(s)
- Taylor E. Nickerson
- Division of Critical Care Medicine, Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, United States
| | - Lauren Villo
- Division of Critical Care Medicine, Department of Pediatrics, Atrium Health Navicent, Mercer University, Macon, Georgia, United States
| | - Mariah Eisner
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, United States
| | - Marlina E. Lovett
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Melissa G. Chung
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
- Division of Neurology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Nicole F. O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Eric A. Sribnick
- Division of Neurological Surgery, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
| | - Adam P. Ostendorf
- Division of Neurology, Department of Pediatrics, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio, United States
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Chong SL, Qian S, Yao SHW, Allen JC, Dang H, Chan LCN, Ming M, Gan CS, Ong JSM, Kurosawa H, Lee JH. Early posttraumatic seizures in pediatric traumatic brain injury: a multicenter analysis. J Neurosurg Pediatr 2022; 29:225-231. [PMID: 34715667 DOI: 10.3171/2021.8.peds21281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early posttraumatic seizures (EPTSs) in children after traumatic brain injury (TBI) increase metabolic stress on the injured brain. The authors sought to study the demographic and radiographic predictors for EPTS, and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes among children with moderate to severe TBI in Asia. METHODS A secondary analysis of a retrospective TBI cohort among participating centers of the Pediatric Acute & Critical Care Medicine Asian Network was performed. Children < 16 years of age with a Glasgow Coma Scale (GCS) score ≤ 13 who were admitted to pediatric intensive care units between January 2014 and October 2017 were included. Logistic regression analysis was performed to study risk factors for EPTS and to investigate the association between EPTS and death, and between EPTS and poor functional outcomes. Poor functional outcomes were defined as moderate disability, severe disability, and coma as defined by the Pediatric Cerebral Performance Category scale. RESULTS Overall, 313 children were analyzed, with a median age of 4.3 years (IQR 1.8-8.9 years); 162 children (51.8%) had severe TBI (GCS score < 8), and 76 children (24.3%) had EPTS. After adjusting for age, sex, and the presence of nonaccidental trauma (NAT), only younger age was significantly associated with EPTS (adjusted odds ratio [aOR] 0.85, 95% CI 0.78-0.92; p < 0.001). Forty-nine children (15.6%) in the cohort died, and 87 (32.9%) of the 264 surviving patients had poor functional outcomes. EPTS did not increase the risk of death. After adjusting for age, sex, TBI due to NAT, multiple traumas, and a GCS score < 8, the presence of EPTS was associated with poor functional outcomes (aOR 2.08, 95% CI 1.05-4.10; p = 0.036). CONCLUSIONS EPTSs were common among children with moderate to severe TBI in Asia and were associated with poor functional outcomes among children who survived TBI.
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Affiliation(s)
- Shu-Ling Chong
- 1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
- 2SingHealth Duke-NUS Global Health Institute, Duke-NUS Medical School, Singapore
| | - Suyun Qian
- 3Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Sarah Hui Wen Yao
- 1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | | | - Hongxing Dang
- 5Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Lawrence C N Chan
- 6Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Meixiu Ming
- 7Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, Shanghai, China
| | - Chin Seng Gan
- 8Department of Paediatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Jacqueline S M Ong
- 9Khoo Teck Puat National University Children's Medical Institute, National University Hospital, Singapore
- 10Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hiroshi Kurosawa
- 11Department of Pediatric Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan; and
| | - Jan Hau Lee
- 2SingHealth Duke-NUS Global Health Institute, Duke-NUS Medical School, Singapore
- 12Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
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11
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Prophylactic Activation of Shh Signaling Attenuates TBI-Induced Seizures in Zebrafish by Modulating Glutamate Excitotoxicity through Eaat2a. Biomedicines 2021; 10:biomedicines10010032. [PMID: 35052712 PMCID: PMC8773121 DOI: 10.3390/biomedicines10010032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 12/21/2022] Open
Abstract
Approximately 2 million individuals experience a traumatic brain injury (TBI) every year in the United States. Secondary injury begins within minutes after TBI, with alterations in cellular function and chemical signaling that contribute to excitotoxicity. Post-traumatic seizures (PTS) are experienced in an increasing number of TBI individuals that also display resistance to traditional anti-seizure medications (ASMs). Sonic hedgehog (Shh) is a signaling pathway that is upregulated following central nervous system damage in zebrafish and aids injury-induced regeneration. Using a modified Marmarou weight drop on adult zebrafish, we examined PTS following TBI and Shh modulation. We found that inhibiting Shh signaling by cyclopamine significantly increased PTS in TBI fish, prolonged the timeframe PTS was observed, and decreased survival across all TBI severities. Shh-inhibited TBI fish failed to respond to traditional ASMs, but were attenuated when treated with CNQX, which blocks ionotropic glutamate receptors. We found that the Smoothened agonist, purmorphamine, increased Eaat2a expression in undamaged brains compared to untreated controls, and purmorphamine treatment reduced glutamate excitotoxicity following TBI. Similarly, purmorphamine reduced PTS, edema, and cognitive deficits in TBI fish, while these pathologies were increased and/or prolonged in cyclopamine-treated TBI fish. However, the increased severity of TBI phenotypes with cyclopamine was reduced by cotreating fish with ceftriaxone, which induces Eaat2a expression. Collectively, these data suggest that Shh signaling induces Eaat2a expression and plays a role in regulating TBI-induced glutamate excitotoxicity and TBI sequelae.
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Snooks KC, Yan K, Farias-Moeller R, Fink EL, Hanson SJ. Continuous Electroencephalogram and Antiseizure Medication Use in an International Pediatric Traumatic Brain Injury Population. Neurocrit Care 2021; 36:573-583. [PMID: 34553297 DOI: 10.1007/s12028-021-01337-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/17/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Electrographic seizures are frequent and associated with worse outcomes following traumatic brain injury (TBI). Despite this, the use of continuous electroencephalogram (cEEG) remains low. Our study describes cEEG usage and treatment dosing antiseizure medications (ASMs) in an international pediatric TBI population, hypothesizing that children monitored with cEEG have an increased rate of treatment ASMs because of electrographic seizure detection, compared with children who are not monitored with cEEG. METHODS This subanalysis of the TBI cohort of the international PANGEA study included children, 7 days to 17 years of age, with acute neurological insults admitted to pediatric intensive care units. We analyzed demographics, injury severity, and therapies including prophylactic or treatment ASMs. We evaluated the relationships between cEEG use, seizure frequency, and receipt of treatment ASMs. [Formula: see text] or Fisher's exact test was used to analyze categorical variables, and the Kruskal-Wallis or Mann-Whitney U-test was used for continuous variables. Multivariable analysis for treatment ASM use was performed using logistic regression. RESULTS One hundred-twenty-three of 174 patients with TBI were included. Twenty-seven patients (21.9%) underwent cEEG at any point during pediatric intensive care unit admission. Preexisting seizure disorder (18.2% vs. 2.3%, p = 0.014) and neuromuscular blockade use (52.4% vs. 24.1%, p = 0.011) were more frequently observed in the group monitored on cEEG when compared with those that were not. Presenting median Glasgow Coma Scale score was worse in the cEEG group (7 vs. 9, p = 0.044). There was no significant difference in age, use of intracranial pressure monitoring, or hyperosmolar therapy between the cEEG monitored and nonmonitored groups. Patients who were monitored on cEEG were more likely to receive a treatment dose ASM than those without cEEG monitoring (66.7% vs. 28.1%, p = 0.0002). When compared with those without treatment ASM, the treatment ASM group had more electrographic seizures on their first electroencephalogram following injury (51.6% vs. 4%, p = 0.0001) and more clinical seizures (55.8% vs. 0%, p < 0.0001). CONCLUSIONS Children monitored with cEEG after TBI have an increased prescription of treatment ASMs and clinical and electrographic seizures. The increased rate of treatment ASMs in the cEEG group may indicate increased recognition of electrographic seizures.
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Affiliation(s)
- Kellie C Snooks
- Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI, 53226, USA.
| | - Ke Yan
- Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | | | - Ericka L Fink
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sheila J Hanson
- Medical College of Wisconsin, 9000 W. Wisconsin Ave, Milwaukee, WI, 53226, USA
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National Trends in Total Hip Arthroplasty Bearing Surface Usage in Extremely Young Patients Between 2006 and 2016. Arthroplast Today 2021; 10:51-56. [PMID: 34307811 PMCID: PMC8283017 DOI: 10.1016/j.artd.2021.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/22/2021] [Accepted: 05/16/2021] [Indexed: 11/20/2022] Open
Abstract
Background Long-term implant durability is a key concern when considering total hip arthroplasty (THA) in young patients. The ideal bearing surface used in these patients remains unknown. The purpose of this study was to analyze trends in THA bearing surface use from 2006 to 2016 using a large, pediatric national database. Methods This was a retrospective review from January 1, 2006, to December 31, 2016, using the Kids’ Inpatient Database. International Classification of Diseases, 9th revision and 10th revision codes were used to identify patients who underwent THA and create cohorts based on bearing surfaces: metal-on-metal, metal-on-polyethylene, ceramic-on-polyethylene (CoP), and ceramic-on-ceramic (CoC). Annual utilization of each bearing surface and associated patient and hospital demographics were analyzed. Results A total of 1004 THAs were identified during the 11-year study period. The annual number of THAs performed increased by 169% from 2006 to 2016. The mean patient age was 17.1 years. The most prevalent bearing surface used in 2006 was CoC (37.3%), metal-on-metal (31.8%) in 2009, and CoP in 2012 and 2016 (50.6% and 64.8%, respectively). From 2006 to 2016, utilization of CoP increased from 5.0% to 64.8%, representing a 1196% increase over the study period. Conclusions The number of THAs performed in pediatric patients is increasing significantly. Although CoC was previously the most commonly used bearing surface in this patient population, CoP is currently the most common. Further investigation is needed to determine whether bearing longevity and clinical outcomes with CoP are superior to other bearing surfaces.
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Elsamadicy AA, Koo AB, David WB, Lee V, Zogg CK, Kundishora AJ, Hong C, Reeves BC, Sarkozy M, Kahle KT, DiLuna M. Post-traumatic seizures following pediatric traumatic brain injury. Clin Neurol Neurosurg 2021; 203:106556. [PMID: 33636505 DOI: 10.1016/j.clineuro.2021.106556] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 01/26/2021] [Accepted: 02/06/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the national impact of demographic, hospital, and inpatient risk factors on post-traumatic seizure (PTS) development in pediatric patients who presented to the ED following a traumatic brain injury (TBI). PATIENTS AND METHODS The Nationwide Emergency Department Sample database years 2010-2014 was queried. Patients (<21 years old) with a primary diagnosis of TBI and subsequent secondary diagnosis of PTS were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. We identified demographic variables, hospital characteristics, pre-existing medical comorbidities, etiology of injuries, and type of injury. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with post-traumatic seizures. RESULTS We identified 1,244,087 patients who sustained TBI, of which 10,340 (0.83%) developed PTS. Of the patients who had seizures, the youngest cohort aged 0-5 years had the greatest proportion of seizure development (p < 0.001). Compared to those TBI patients with loss of consciousness (LOC), patients encountering no LOC after TBI had the smallest proportion of seizures while Prolonged LOC with baseline return had the greatest proportion. On univariate analysis of the effect of in-hospital complication on rate of seizures, respiratory, renal and urinary, hematoma, septicemia, and other neurological complications were all significantly associated with seizure development. On multivariate regression, age 6-10 years (OR: 0.48, p < 0.001) 11-15 years (OR: 0.41, p < 0.001), and 16-20 years (OR: 0.51, p < 0.001) were independently associated with decreased risk of developing seizures. Extended LOC with baseline return (OR: 6.33, p < 0.001), extended LOC without baseline return (OR: 1.95, p = 0.009), and Other LOC (OR: 3.02, p < 0.001) were independently associated with increased risk of developing seizures. Subarachnoid hemorrhage (OR: 4.14, p < 0.001), subdural hemorrhage [OR: 7.72, p < 0.001), and extradural hemorrhage (OR: 3.13, p < 0.001) were all independently associated with increased risk of developing seizures. CONCLUSION Out study demonstrates that various demographic, hospital, and clinical risk factors are associated with the development of seizures following traumatic brain injury. Enhancing awareness of these drivers may help provide greater awareness of patients likely to develop post-traumatic seizures such that this complication can be decreased in incidence so as to improve quality of care and decrease healthcare costs.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Victor Lee
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Cheryl K Zogg
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Christopher Hong
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Kristopher T Kahle
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, 06520, CT, United States.
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Mikkonen ED, Skrifvars MB, Reinikainen M, Bendel S, Laitio R, Hoppu S, Ala-Kokko T, Karppinen A, Raj R. Posttraumatic epilepsy in intensive care unit-treated pediatric traumatic brain injury patients. Epilepsia 2020; 61:693-701. [PMID: 32221978 DOI: 10.1111/epi.16483] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/02/2020] [Accepted: 03/02/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Posttraumatic epilepsy (PTE) is a well-described complication of traumatic brain injury (TBI). The majority of the available data regarding PTE stem from the adult population. Our aim was to identify the clinical and radiological risk factors associated with PTE in a pediatric TBI population treated in an intensive care unit (ICU). METHODS We used the Finnish Intensive Care Consortium database to identify pediatric (<18 years) TBI patients treated in four academic university hospital ICUs in Finland between 2003 and 2013. Our primary outcome was the development of PTE, defined as the need for oral antiepileptic medication in patients alive at 6 months. We assessed the risk factors associated with PTE using multivariable logistic regression modeling. RESULTS Of the 290 patients included in the study, 59 (20%) developed PTE. Median age was 15 years (interquartile range [IQR] 13-17), and 80% had an admission Glasgow Coma Scale (GCS) score ≤12. Major risk factors for developing PTE were age (adjusted odds ratio [OR] 1.08, 95% confidence interval [CI] 1.00-1.16), obliterated suprasellar cisterns (OR 6.53, 95% CI 1.95-21.81), and an admission GCS score of 9-12 in comparison to a GCS score of 13-15 (OR 2.88, 95% CI 1.24-6.69). SIGNIFICANCE We showed that PTE is a common long-term complication after ICU-treated pediatric TBI. Higher age, moderate injury severity, obliterated suprasellar cisterns, seizures during ICU stay, and surgical treatment are associated with an increased risk of PTE. Further studies are needed to identify strategies to decrease the risk of PTE.
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Affiliation(s)
- Era D Mikkonen
- Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital & University of Helsinki, Helsinki, Finland.,Department of Emergency Care and Services, Helsinki University Hospital & University of Helsinki, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital & University of Helsinki, Helsinki, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Stepani Bendel
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Ruut Laitio
- Department of Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Department of Intensive Care, Tampere University Hospital & Tampere University, Tampere, Finland
| | - Tero Ala-Kokko
- Division of Intensive Care, Medical Research Center Oulu MRC, Oulu University Hospital, Research Group of Anesthesiology, Surgery and Intensive Care Medicine, University of Oulu, Oulu, Finland
| | - Atte Karppinen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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16
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Hersh DS, Smith LGF, Jones TL, Fraser BD, Kumar R, Vaughn B, Klimo P. Predictors of an Extended Length of Stay following an Elective Craniotomy in Children and Young Adults. Pediatr Neurosurg 2020; 55:259-267. [PMID: 33099552 DOI: 10.1159/000511090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Length of stay (LOS) is now a generally accepted clinical metric within the USA. An extended LOS following an elective craniotomy can significantly impact overall costs. Few studies have evaluated predictors of an extended LOS in pediatric neurosurgical patients. OBJECTIVE The aim of the study was to determine predictors of an extended hospital LOS following an elective craniotomy in children and young adults. METHODS All pediatric patients and young adults undergoing an elective craniotomy between January 1, 2010, and April 1, 2019, were retrospectively identified using a prospectively maintained database. Demographic, clinical, radiological, and surgical data were collected. The primary outcome was extended LOS, defined as a postsurgical stay greater than 7 days. Bivariate and multivariable analyses were performed. RESULTS A total of 1,498 patients underwent 1,720 elective craniotomies during the study period over the course of 1,698 hospitalizations with a median LOS of 4 days (interquartile range 3-6 days). Of these encounters, 218 (12.8%) had a prolonged LOS. Multivariable analysis demonstrated that non-Caucasian race (OR = 1.9 [African American]; OR = 1.6 [other]), the presence of an existing shunt (OR = 1.8), the type of craniotomy (OR = 0.3 [vascular relative to Chiari]), and the presence of a postoperative complication (OR = 14.7) were associated with an extended LOS. CONCLUSIONS Inherent and modifiable factors predict a hospital stay of more than a week in children and young adults undergoing an elective craniotomy.
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Affiliation(s)
- David S Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut, USA, .,Department of Surgery, UConn School of Medicine, Farmington, Connecticut, USA,
| | - Luke G F Smith
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio, USA
| | - Tamekia L Jones
- Departments of Pediatrics and Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Brittany D Fraser
- Department of Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Rahul Kumar
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Brandy Vaughn
- Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA
| | - Paul Klimo
- Neuroscience Institute, Le Bonheur Children's Hospital, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Semmes Murphey, Memphis, Tennessee, USA
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17
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Nasr IW, Chun Y, Kannan S. Neuroimmune responses in the developing brain following traumatic brain injury. Exp Neurol 2019; 320:112957. [PMID: 31108085 DOI: 10.1016/j.expneurol.2019.112957] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 12/26/2022]
Abstract
Traumatic brain injury (TBI) is one of the leading causes of both acute and long-term morbidity in the pediatric population, leading to a substantial, long-term socioeconomic burden. Despite the increase in the amount of pre-clinical and clinical research, treatment options for TBI rely heavily on supportive care with very limited targeted interventions that improve the acute and chronic sequelae of TBI. Other than injury prevention, not much can be done to limit the primary injury, which consists of tissue damage and cellular destruction. Secondary injury is the result of the ongoing complex inflammatory pathways that further exacerbate tissue damage, resulting in the devastating chronic outcomes of TBI. On the other hand, some level of inflammation is essential for neuronal regeneration and tissue repair. In this review article we discuss the various stages of the neuroimmune response in the immature, pediatric brain in the context of normal maturation and development of the immune system. The developing brain has unique features that distinguish it from the adult brain, and the immune system plays an integral role in CNS development. Those features could potentially make the developing brain more susceptible to worse outcomes, both acutely and in the long-term. The neuroinflammatory reaction which is triggered by TBI can be described as a highly intricate interaction between the cells of the innate and the adaptive immune systems. The innate immune system is triggered by non-specific danger signals that are released from damaged cells and tissues, which in turn leads to neutrophil infiltration, activation of microglia and astrocytes, complement release, as well as histamine release by mast cells. The adaptive immune response is subsequently activated leading to the more chronic effects of neuroinflammation. We will also discuss current attempts at modulating the TBI-induced neuroinflammatory response. A better understanding of the role of the immune system in normal brain development and how immune function changes with age is crucial for designing therapies to appropriately target the immune responses following TBI in order to enhance repair and plasticity.
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Affiliation(s)
- Isam W Nasr
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States of America
| | - Young Chun
- Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States of America
| | - Sujatha Kannan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States of America.
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