Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury

Approaches to Minimise the Neurodevelopmental Impact of Choroid Plexus Carcinoma and Its Treatment

Choroid plexus carcinomas (CPC) are rare aggressive tumours that primarily affect very young children. Treatment for CPC typically involves a combination of surgery, chemotherapy, and radiation therapy. Whilst considered necessary for a cure, these therapies have significant neurocognitive consequences for patients, negatively impacting cognitive function including memory, attention, executive functioning, and full-scale intelligence quotients (FSIQ). These challenges significantly impact the quality of life and ultimately socioeconomic parameters such as the level of educational attainment, marital status, and socioeconomic status. This review looks at the tumour- and treatment-related causes of neurocognitive damage in CPC patients and the progress made in finding strategies to reduce these. Opportunities to mitigate the neurodevelopmental consequences of surgery, chemotherapy, and radiation therapy are explored in the context of CPC treatment. Evaluation of the pathological and biological mechanisms of injury has identified innovative approaches to neurocognitive protection and neurorehabilitation, which aim to limit the neurocognitive damage. This review aims to highlight multiple approaches physicians can use when treating young children with CPC, to focus on neurocognitive outcomes as a measure of success.

A phase II dose evaluation pilot feasibility randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study)

BACKGROUND

Vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (ICU) and associated with worse clinical course. Trials in adult ICU demonstrate rapid restoration of vitamin D status using an enteral loading dose is safe and may improve outcomes. There have been no published trials of rapid normalization of VDD in the pediatric ICU.

METHODS

We conducted a multicenter placebo-controlled phase II pilot feasibility randomized clinical trial from 2016 to 2017. We randomized 67 critically ill children with VDD from ICUs in Canada, Chile and Austria using a 2:1 randomization ratio to receive a loading dose of enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or placebo. Participants, care givers, and outcomes assessors were blinded. The primary objective was to determine whether the loading dose normalized vitamin D status (25(OH)D > 75 nmol/L). Secondary objectives were to evaluate for adverse events and assess the feasibility of a phase III trial.

RESULTS

Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary analyses (40 treatment, 19 placebo). Thirty-one/38 (81.6%) participants in the treatment arm achieved a plasma 25(OH)D concentration > 75 nmol/L versus 1/18 (5.6%) the placebo arm. The mean 25(OH)D concentration in the treatment arm was 125.9 nmol/L (SD 63.4). There was no evidence of vitamin D toxicity and no major drug or safety protocol violations. The accrual rate was 3.4 patients/month, supporting feasibility of a larger trial. A day 7 blood sample was collected for 84% of patients. A survey administered to 40 participating families showed that health-related quality of life (HRQL) was the most important outcome for families for the main trial (30, 75%).

CONCLUSIONS

A single 10,000 IU/kg dose can rapidly and safely normalize plasma 25(OH)D concentrations in critically ill children with VDD, but with significant variability in 25(OH)D concentrations. We established that a phase III multicentre trial is feasible. Using an outcome collected after hospital discharge (HRQL) will require strategies to minimize loss-to-follow-up.

TRIAL REGISTRATION

CLINICALTRIALS

gov NCT02452762 Registered 25/05/2015.

Physiological status and anatomical severity factors associated with child versus adult bicyclist fatalities based on a national trauma dataset

Bicyclists still account for the majority of child deaths in traffic accidents, despite a gradual decrease in incidence. Therefore, we investigated factors associated with child and adult bicyclist fatalities. In this retrospective study, we used data from a national hospital-based database, the Japan Trauma Data Bank. Data from 2004 to 2019 were obtained for child cyclists (5-18 years; n = 4832) and adult cyclists (26-45 years; n = 3449). In each age group, physiological variables, outcomes, and injury severity were compared between fatal and non-fatal cases. Multivariate logistic regression was performed to determine factors associated with fatality. In adults, fatality was associated with lower values for body temperature, Glasgow Coma Scale score, and Abbreviated Injury Scale (AIS) score for the neck and upper extremities, and with higher values for respiratory rate, heart rate, focused assessment with sonography for trauma positivity rate, and AIS scores for the head, chest, and abdomen. In children, fatality was associated with lower values for body temperature and the Glasgow Coma Scale score, and with higher values for the AIS chest score. These findings point to factors associated with bicyclist fatalities and may help in the development of effective strategies to reduce these fatalities.

Factors Affecting Death and Severe Injury in Child Motor Vehicle Passengers

Saving children from motor vehicle collisions is a high priority because the injury rate among motor vehicle passengers has been increasing in Japan. This study aimed to examine the factors that influence death and serious injury in child motor vehicle passengers to establish effective preventive measures. To identify these factors, we performed a retrospective study using a nationwide medical database. The data of child motor vehicle passengers younger than 15 years (n = 1084) were obtained from the Japanese Trauma Data Bank, registered from 2004 to 2019. Physiological variables, outcomes, and injury severity were compared between fatal and non-fatal patients and between those with and without severe injuries. Multivariate logistic regression analysis was performed to determine factors affecting fatality and severe injury. The Glasgow Coma Scale score (odds ratio (OR): 1.964), body temperature (OR: 2.578), and the Abbreviated Injury Scale score of the head (OR: 0.287) were identified as independent predictors of a non-fatal outcome. Systolic blood pressure (OR: 1.012), the Glasgow Coma Scale score (OR: 0.705), and Focused Assessment with Sonography for Trauma positivity (OR: 3.236) were identified as independent predictors of having severe injury. Decreasing the severity of head injury is the highest priority for child motor vehicle passengers to prevent fatality and severe injury.

Injury Severity, Arrival Physiology, Coagulopathy, and Outcomes Among the Youngest Trauma Patients

BACKGROUND

Although physiologic differences exist between younger and older children, pediatric trauma analyses are weighted toward older patients. Trauma-induced coagulopathy, determined by rapid thrombelastography (rTEG), is a predictor of outcome in trauma patients, but the significance of rTEG values among very young trauma patients remains unknown. Our objective was to identify the prehospital or physiologic factors, including rTEG values, that were associated with mortality in trauma patients younger than 5 y old.

MATERIALS AND METHODS

Patients younger than 5 y old that met the highest-level trauma activation criteria at an academic children's hospital from 2010-2016 were included. Data regarding demographics, pre-hospital management, laboratory values, injury severity, and outcome were queried. Univariate and multivariate analyses were performed comparing survivors and non-survivors.

RESULTS

A total of 356 patients were included. 60% were male, and the median age was 3 y (IQR 1-4). Overall mortality was 13% (n = 45); brain injury (91%) and hemorrhage (9%) were the causes of death. Compared to survivors, rTEG values in nonsurvivors showed longer activated clotting time and slower speed of clot formation. Clot strength was also decreased in nonsurvivors. On stepwise regression modeling, rTEG values were not significant predictors of mortality. Admission base deficit, arrival temperature, and head injury severity were identified as independent predictors of mortality.

CONCLUSIONS

While rTEG identified coagulopathy in trauma patients < 5 y old, it was not an independent predictor of mortality. Our findings suggest that trauma providers should pay close attention to admission base deficit, arrival temperature, and head injury severity when managing the youngest trauma patients.

Pulmonary Hygiene Protocol Reduces Incidence of Lobar Collapse in Severe Traumatic Brain Injury

Background

Traumatic brain injury (TBI) is a common cause of death among injured patients. In addition to neurologic sequelae which may increase mortality risk, trauma patients suffering severe TBI (Glasgow Coma Score≤8) have a predilection for pulmonary complications. We have previously demonstrated that patients with severe TBI who were intubated and mechanically ventilated are at greater risk of radiographic pulmonary lobar collapse that necessitates advanced directional suctioning and/or bronchoscopy. We sought to minimize the potentially deleterious effects of such lobar collapse by using a standardized pulmonary hygiene protocol.

Methods

We performed a retrospective comparison of lobar collapse incidence among three groups over 21 months: patients without severe TBI who were intubated and mechanically ventilated for greater than 24 hours (i.e. “NO TBI”); patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours who were not treated with a standardized pulmonary hygiene protocol (i.e. historical “CONTROL”); and patients with severe TBI who were intubated and mechanically ventilated for greater than 24 hours and who were treated with a standardized pulmonary hygiene protocol (i.e. “HYGIENE”). Our analysis excluded patients who had any significant neck injury as we had previously found that pulmonary complications are increased in this subpopulation.

Results

We reviewed the charts of 310 trauma patients (NO TBI = 104, CONTROL = 101, HYGIENE = 105) and analyzed demographics, injury severity and outcomes, including the incidence of pulmonary lobar collapse. Pulmonary hygiene protocol demonstrated a significant reduction in the incidence of lobar collapse among the HYGIENE group compared to CONTROL, approximating the incidence among patients with no TBI (11% vs 27% vs 10%, respectively, p = 0.0009). No significant difference was noted in ventilator days, intensive care unit length of stay, hospital length of stay, mortality, nor incidence of pneumonia. 

Conclusion

High-risk TBI patients have a predilection towards the development of pulmonary lobar collapse, which can be significantly reduced by the use of a standardized pulmonary hygiene protocol.

Epidemiological and Clinico-radiological Evaluation of Head Injury in Pediatric Population

BACKGROUND

Head injury in infancy and childhood has been documented as the single most common cause of death. In India, children aged <15 years constitute 35% of the total population and contribute to 20-30% of all head injuries. In this study, we attempted to analyze the epidemiological factors, management, and outcome of traumatic brain injury (TBI). The objective of this study were to find the causes of head injury in children and its pattern of distribution in this population and to analyze the efforts required to prevent the injury and management focusing on limiting the progression of primary brain injury and minimizing secondary brain insult.

RESULTS

A total of 2714 patients with head injury were admitted at our hospital during the study period and, out of them, 508 (18.17%) were pediatric patients with age less than 18 years. Of the 508 patients, only 497 patients were included in this study. In the present study, 357 (71.83%) were males and 140 (28.16%) were females. In total, 351 cases were managed conservatively whereas surgical intervention was conducted in 146 cases (P < 0.001). In this study, the most common mode of injury was a road traffic accident (RTA) (46.88%; n=233), followed by fall from height (34.8%; n=173) (P < 0.001). It was also seen that epidural hematoma and fracture hematoma were the most common computed tomography findings in pediatric patients with head injury followed by parenchymal contusion or contusion with or without fracture followed by diffuse axonal injury. A total of 344 cases out of 497 cases were discharged with Glasgow outcome score (GOS)-5 whereas nine cases remained in a persistent vegetative state (GOS-2).

CONCLUSION

Early intervention aimed at the primary lesion in TBI in children generally carries a good outcome, and limits as much as possible the ongoing biomechanical, physiological, and pathological sequelae post-TBI. In teenagers, the importance of proper self-care along with adequate safety gears while doing any TBI-prone activity should be emphasized.

Delayed Sequelae Related to Mild Traumatic Brain Injury in Children

Delayed sequelae from mild traumatic brain injury (Glasgow Coma Score at admission >13, TBI) has been documented in case reports however larger studies of these effects are sparse. We undertook a telephone based survey to assess the long term sequelae of TBI. We tracked 100 pediatric TBI patients via our trauma registry for demographic data including age, injury severity, and mechanism of injury. Then we proceeded to contact these patient’s parents via telephone. We asked regarding residual symptoms and signs of concussive injury.

Duration out from initial concussive injury ranged from 4 to 68 months. The parents of 66 boys and 34 girls were surveyed. The age of the patients at the time of mild TBI ranged from 1 to 14 years. The injury severity score ranged from 1 to 21. One being the most common Injury severity score. Thirty-three percent of patients had residual effects of concussion at the time of telephone survey. Fourteen percent had memory loss issues, 21% had anxiety/depression issues, 20% had learning disability issues, and 15% had sleep disturbance issues. Duration of time post concussive injury, mechanism, and age did not influence incidence of sequelae. Mild traumatic brain injury has significant long term sequelae. Better identifying characteristics are needed to characterize patients susceptible to long term residual effects of concussion.

Hypotension on admission in patients with isolated traumatic brain injury: contemporary examination of the incidence and outcomes using a national registry

PURPOSE

This study was primarily aimed at establishing the incidence and impact of hypotension in patients with blunt traumatic brain injury based on National Trauma Registry Database.

METHODS

A retrospective cohort study using the National Trauma Registry was conducted. Patients with TBI following blunt mechanisms of injury were examined, comparing those with and without hypotension (SBP < 90 mm Hg) on arrival.

RESULTS

During the period from 1998 to 2017, the registry included 437.354 blunt trauma patients. Of them, 7818 patients were hemodynamically unstable (SBP < 90 mm Hg) on admission. 513 met the inclusion criteria. Significant percentages of patients with high grade injures (ISS≥16) and low admission's GCS 3-12 (46% vs 16.4%), were found in the group of hypotensive TBI patients (p<0.0001). 323 (62.9%) patients had head AIS score 3-4 and only 190 (37.1%) patients AIS 5-6 (p<0.0001). Mortality in the hypotensive TBI group was 32.3%, whereas 6.1% patients died in the TBI hemodynamically stable group (p<0.0001).

CONCLUSION

TBI patients presenting with hypotension represent an appreciable portion blunt trauma patients. Prompt brain CT, expedient efforts at optimal resuscitation and possibly early inotropic and vasopressors agents use may have an impact on final outcome in these patients.

Injury Biomechanics of a Child’s Head: Problems, Challenges and Possibilities with a New aHEAD Finite Element Model

Traumatic brain injury (TBI) is a major public health problem among children. The predominant causes of TBI in young children are motor vehicle accidents, firearm incidents, falls, and child abuse. The limitation of in vivo studies on the human brain has made the finite element modelling an important tool to study brain injury. Numerical models based on the finite element approach can provide valuable data on biomechanics of brain tissues and help explain many pathological conditions. This work reviews the existing numerical models of a child’s head. However, the existing literature is very limited in reporting proper geometric representation of a small child’s head. Therefore, an advanced 2-year-old child’s head model, named aHEAD 2yo (aHEAD: advanced Head models for safety Enhancement And medical Development), has been developed, which advances the state-of-the-art. The model is one of the first published in the literature, which entirely consists of hexahedral elements for three-dimensional (3D) structures of the head, such as the cerebellum, skull, and cerebrum with detailed geometry of gyri and sulci. It includes cerebrospinal fluid as Smoothed Particle Hydrodynamics (SPH) and a detailed model of pressurized bringing veins. Moreover, the presented review of the literature showed that material models for children are now one of the major limitations. There is also no unambiguous opinion as to the use of separate materials for gray and white matter. Thus, this work examines the impact of various material models for the brain on the biomechanical response of the brain tissues during the mechanical loading described by Hardy et al. The study compares the inhomogeneous models with the separation of gray and white matter against the homogeneous models, i.e., without the gray/white matter separation. The developed model along with its verification aims to establish a further benchmark in finite element head modelling for children and can potentially provide new insights into injury mechanisms.

Survival and Functional Outcomes at Discharge After Traumatic Brain Injury in Children versus Adults in Resource-Poor Setting

BACKGROUND

More than 90% of trauma mortality occurs in low- and middle-income countries, especially in sub-Saharan Africa. Head injury is the primary driver of trauma mortality in the prehospital and in-hospital setting.

METHODS

An observational study was performed on patients presenting with traumatic brain injury (TBI) from October 2016 through May 2017 at Kamuzu Central Hospital, Malawi. Bivariate analysis and logistic regression were performed to determine the odds of favorable functional outcomes and mortality after controlling for significant covariates.

RESULTS

Of the 356 patients with TBI, 72 (20.2%) were children <18 years of age. Males comprised 202 (87.1%) and 46 (63.9%) of the adult and pediatric cohorts, respectively. Motor vehicle crash was the leading etiology in adults and children. There was no significant difference between adult and pediatric Glasgow Coma Scale score on admission, 10.8 ± 3.9 versus 10.9 ± 3.5, respectively (P = 0.8). More adult (n = 76, 32.3%) than pediatric (n = 13, 18.1%) patients died. On multivariable analysis, pediatric patients were more likely to have a favorable outcome defined by a Glasgow Outcome Scale of good recovery or moderate disability (odds ratio 3.70, 95% confidence interval 1.22-11.17, P = 0.02) and were less likely to die after TBI (odds ratio 0.29, 95% confidence interval 0.09-0.93, P = 0.04).

CONCLUSIONS

We show a survival advantage and better functional outcomes in children following TBI. This may be attributable to increased resiliency to TBI in children or the prioritization of children in a resource-poor environment. Investments in neurosurgical care following TBI are needed to improve outcomes.

Injury Causes and Severity in Pediatric Traumatic Brain Injury Patients Admitted to the Ward or Intensive Care Unit: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

Background: Traumatic brain injury (TBI) is the leading cause of death and disability in children. It includes a range of different pathologies that differ considerably from adult TBI. Analyzing and understanding injury patterns of pediatric TBI is essential to establishing new preventive efforts as well as to improve clinical management.

Methods: The multi-center, prospectively collected CENTER-TBI core and registry databases were screened and patients were included when younger than 18 years at enrollment and admitted to the regular ward (admission stratum) or intensive care unit (ICU stratum) following TBI. Patient demographics, injury causes, clinical findings, brain CT imaging details, and outcome (GOSE at 6 months follow-up) were retrieved and analyzed. Injury characteristics were compared between patients admitted to the regular ward and ICU and multivariate analysis of factors predicting an unfavorable outcome (GOSE 1-4) was performed. Results from the core study were compared to the registry dataset which includes larger patient numbers but no follow-up data.

Results: Two hundred and twenty seven patients in the core dataset and 687 patients in the registry dataset were included in this study. In the core dataset, road-traffic incidents were the most common cause of injury overall and in the ICU stratum, while incidental falls were most common in the admission stratum. Brain injury was considered serious to severe in the majority of patients and concurrent injuries in other body parts were very common. Intracranial abnormalities were detected in 60% of initial brain CTs. Intra- and extracranial surgical interventions were performed in one-fifth of patients. The overall mortality rate was 3% and the rate of unfavorable outcome 10%, with those numbers being considerably higher among ICU patients. GCS and the occurrence of secondary insults could be identified as independent predictors for an unfavorable outcome. Injury characteristics from the core study could be confirmed in the registry dataset.

Conclusion: Our study displays the most common injury causes and characteristics of pediatric TBI patients that are treated in the regular ward or ICU in Europe. Road-traffic incidents were especially common in ICU patients, indicating that preventive efforts could be effective in decreasing the incidence of severe TBI in children.

Operative versus non-operative treatment of traumatic brain injuries in patients 80 years of age or older

Traumatic brain injury (TBI) in older adults is an increasing issue in modern medicine. Nevertheless, it remains unclear which patients presenting with TBI and 80 years of age or older benefit from an operative treatment. The aim of this study was to explore the effect of an operative treatment in isolated TBI patients ≥ 80 years of age. Data were derived from the TraumaRegister DGU^® from 2002 to 2016. Inclusion criteria were ≥ 80 years of age, an Abbreviated Injury Scale_Head (AIS) ≥ 3, and an AIS_Non-Head ≤ 1. The cohort was split in operatively and non-operatively treated patients, and outcome was assessed at discharge using the Glasgow Outcome Scale (GOS). A favorable outcome was defined as a GOS of 4 or 5. A total of 1.693 patients (431 operatively and 1.262 non-operatively treated patients) were analyzed. Mortality rate was 54.4% (687 patients) in the non-operative group and 49.4% in the operative group. Simultaneously, there were more patients discharged with a GOS 2 (persistent vegetative state) in the operative group (7.9%, 34 patients) than in the non-operative group (1.0%, 13 patients). An analysis of the operatively treated patients showed an association between a higher mortality risk and brainstem hemorrhage (p = 0.04), fixed pupils (p = 0.001), initial intubation (p = 0.03), and an AIS_Head of 5/6 (p = 0.03). Patients 80 years of age or older seem to benefit from an operative treatment regarding mortality rate. However, there has been a higher rate of a poor neurological outcome particularly with regard to persistent vegetative state in the operative treatment group at discharge.

Divergent age-dependent peripheral immune transcriptomic profile following traumatic brain injury

The peripheral immune system is a major regulator of the pathophysiology associated with traumatic brain injury (TBI). While age-at-injury influences recovery from TBI, the differential effects on the peripheral immune response remain unknown. Here, we investigated the effects of TBI on gene expression changes in murine whole blood using RNAseq analysis, gene ontology and network topology-based key driver analysis. Genome-wide comparison of CCI-injured peripheral whole blood showed a significant increase in genes involved in proteolysis and oxidative-reduction processes in juvenile compared to adult. Conversely, a greater number of genes, involved in migration, cytokine-mediated signaling and adhesion, were found reduced in CCI-injured juvenile compared to CCI-injured adult immune cells. Key driver analysis also identified G-protein coupled and novel pattern recognition receptor (PRR), P2RY10, as a central regulator of these genes. Lastly, we found Dectin-1, a c-type lectin PRR to be reduced at the protein level in both naïve neutrophils and on infiltrating immune cells in the CCI-injured juvenile cortex. These findings demonstrate a distinct peripheral inflammatory profile in juvenile mice, which may impact the injury and repair response to brain trauma.

Persistent symptoms in mild pediatric traumatic brain injury

Background: Traumatic brain injury (TBI) is the leading cause of morbidity and mortality for children in the US. The objective was to examine the epidemiology of self-reported neurologic and neuro-psychiatric symptoms in pediatric patients with mild TBI within 14 months post-injury.

Methods: A telephone based survey was conducted on all pediatric patients (aged<15 years) with a mild traumatic brain injury diagnosed at our urban level 1 adult/level 2 pediatric trauma center within 1 year. Subjects were identified by our trauma registry, and medical records were reviewed for demographic data and mechanism of injury. Parents or guardians were interviewed using a standardized questionnaire to collect data regarding the presence or absence of headaches, weakness, numbness, coordination impairment, speech impairment, nausea, vomiting, confusion, short-term memory impairment, sleep disturbances, anhedonia, depression, anxiety, fear, and agitation.

Results: Thirty-three parents of patients responded. The average age of the patients at time of TBI was 9.3±1.7 years. The age range was 3–14 years. The mechanisms of injury included pedestrian struck (54.5%), fall (39.4%), motor vehicle collision (3%), and assault (3%). The time from injury was stratified into 1–3 months (n=9), 4–6 months (n=9), 7–9 months (n=6), and 10–12 months (n=8), one patient surveyed was 14 months post-injury. Headaches (39.4%), anxiety (30.3%), fear (18.2%), and anhedonia (18.2%) were the most frequently reported symptoms. Less common were sleep disturbances (12.1%), depression (9.1%), nausea (6.1%), coordination impairment (6.1%), short-term memory impairment (6.1%), weakness (3%), numbness (3%), vomiting (3%), and agitation (3%). There were no instances of speech impairment.

Conclusions: Approximately 1/3 of patients complained of anxiety post-injury, and 1/5 reportedly experienced anhedonia and fear. Considering the ongoing neurologic and psychosocial development of the pediatric population, long-term follow-up and periodic screening examinations should be considered in patients diagnosed with TBI.

The Pediatric Cell Atlas: Defining the Growth Phase of Human Development at Single-Cell Resolution

Single-cell gene expression analyses of mammalian tissues have uncovered profound stage-specific molecular regulatory phenomena that have changed the understanding of unique cell types and signaling pathways critical for lineage determination, morphogenesis, and growth. We discuss here the case for a Pediatric Cell Atlas as part of the Human Cell Atlas consortium to provide single-cell profiles and spatial characterization of gene expression across human tissues and organs. Such data will complement adult and developmentally focused HCA projects to provide a rich cytogenomic framework for understanding not only pediatric health and disease but also environmental and genetic impacts across the human lifespan.

Scandinavian Multicenter Acute Subdural Hematoma (SMASH) Study: Study Protocol for a Multinational Population-Based Consecutive Cohort

BACKGROUND

Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved.

OBJECTIVE

To evaluate postoperative (30-d) mortality in younger vs elderly (≥70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables.

METHODS

This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (≥18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190.

EXPECTED OUTCOMES

We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified.

DISCUSSION

An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.

Prediction of Poor Prognosis After Severe Head Injury in Children Using Logistic Regression

OBJECTIVES

Head trauma is one of the main causes of death in childhood and often leaves severe disability with serious neurological damage. Appropriate treatment must be provided immediately to improve outcomes. This study was performed to identify factors associated with a poor prognosis at an early stage of severe head injury in children.

METHODS

The subjects were registered in the Japan Neurotrauma Data Bank. They were 119 children (mean age, 8 years; male, 67.2%) with severe head injury registered during a period of 4 years (from July 1, 2004 to June 30, 2006 and from July 1, 2009 to June 30, 2011). Univariate and multivariate analyses were performed to examine relationships among factors and outcome 6 months after discharge. Logistic regression analysis was performed to develop models for poor prognosis and death.

RESULTS

Outcome was evaluated based on the Glasgow Outcome Scale: 73 children (61.3%) had good recovery, 11 (9.2%) had moderate disability, 8 (6.7%) had severe disability, 4 (3.3%) were in a vegetative state, and 23 (19.3%) had died. Four factors were identified as predictors of a poor prognosis: serum glucose level greater than or equal to 200 mg/dL, Glasgow Coma Scale score on admission less than or equal to 5, presence of mydriasis, and presence of traumatic subarachnoid hemorrhage. Three factors were identified as predictors of death: serum glucose level greater than or equal to 200 mg/dL, Glasgow Coma Scale score on admission less than or equal to 5, and presence of mydriasis.

CONCLUSIONS

Using these predictors, subsequent exacerbation may be predicted just after arrival at the hospital and appropriate treatment can be provided immediately.

An International Interprofessional Study of Mental Models and Factors Delaying Neuroimaging of Critically Head-Injured Children Presenting to Emergency Departments

OBJECTIVES

Thousands of head-injured children are cared for by interprofessional teams in emergency departments every day. Teams must balance performing time-consuming interventions with safe transport for neuroimaging. This study aims to describe and compare providers' perspectives on the transfer of head-injured children to neuroimaging and factors contributing to delays.

METHODS

Participants were interprofessional health care providers involved in the care of head-injured children at sites in the United Kingdom, the United States, and New Zealand. They first viewed a 3-minute video of a child with a severe head injury presenting to their resuscitation bay. Next, they were presented with 5 physiologically different simulated scenarios and asked to report whether interventions were required before transporting each patient to neuroimaging. Then, they reported team and system factors contributing to delays in neuroimaging.

RESULTS

Two hundred forty of 296 providers completed the intervention. The percentage of providers reporting that they would directly transport to neuroimaging without intervention was 89% for "stable," 49% for "Cushing's triad," 26% for "hypoxic," 25% for "tachycardic," and 5% for "extremis." There were differences noted in responses by profession for the hypoxia and tachycardia cases. No differences were noted between trainees and attending physicians for any cases. The most frequent factors reported as delaying neuroimaging were team decision making and waiting for equipment, medications, and scanner availability.

CONCLUSIONS

There is variability in providers' perspectives on the interventions required before transporting severely head-injured patients for imaging. Diverse team and system factors contribute to delays in imaging.

Epidemiology of Pediatric Traumatic Brain Injury in a Dense Urban Area Served by a Helicopter Trauma Service

OBJECTIVE

Pediatric traumatic brain injury is the most common cause of death and a major cause of morbidity in children and young adults worldwide. Despite this, our understanding of epidemiological factors relating to this type of injury is incomplete. The objective of this study was to explore a variety of factors relating to these injuries including mechanism, timing of emergency response, prehospital management, radiological diagnosis, neurosurgical care, and final outcomes.

METHODS

A retrospective review of all pediatric traumas attending a single large, densely populated urban area within a 2-year period was undertaken, and all cases with significant pediatric traumatic brain injury, as defined by a computed tomography scan showing an intracranial injury, were included for further analysis. Various epidemiological and treatment factors were explored.

RESULTS

One hundred sixteen patients fulfilled the inclusion criteria, and their injuries and management were explored further. A variety of key trends were identified. The most common mechanism of injury was pedestrian struck by car followed by falls from height. Males were injured 5 times more frequently than girls. A helicopter emergency trauma team attended 22% of the patients and intubated 11 in total. The most common intracranial injuries were skull fractures followed by contusions. Nineteen neurosurgical interventions were undertaken. Overall mortality in all patients was 8%.

CONCLUSIONS

An improved understanding of the epidemiology of pediatric brain injury will provide baselines for future outcome measurement and comparative analysis. This may improve service organization and delivery.

Traumatic brain injury in Indian children

INTRODUCTION

Traumatic brain injury (TBI) in children and adolescents is a community-based medical and educational challenge world-over due to increasing urbanization and motorization. In India, children between 1 to 15 years constitute significant proportion of the total population, who are vulnerable for TBI. In developed countries, pediatric trauma mortality still represents more than half of all childhood fatalities, which is 18 times more common than brain tumors. In this study, we attempted to analyze epidemiological factors, management, and outcome of TBI in children at a tertiary care center in Pune, Maharashtra.

AIM AND OBJECTIVES

To study the clinical spectrum of pediatric traumatic brain injury cases received at a Tertiary Care Hospital.

MATERIALS AND METHODS

This prospective study (August 2015-July 2017), conducted at our institution, includes all children < 16 years with TBI reporting to the neurosurgical emergency department. All the case records were reviewed and the pertinent data (clinical history, age, sex, mode of injury, computed tomography (CT) scan findings, interventions, morbidity, and mortality) analyzed. Any residual neurological deficits at the time discharge were assessed as the outcome of TBI.

RESULTS

A total 76 pediatric cases of TBI were admitted during the period of August 2015-July 2017, with 51 males (67%) and 25 females (33%) with male to female ratio 2:1. Mean age of incidence in our study is 5.5 years. Out of 76 children with TBI, 60.5% were of mild, 14.5% moderate, and 25% severe TBI. Overall, RTA (40.8%) is the most common mode of injury followed by fall from height (30.2%) and slippage in and around home (26.4%). Clinical evaluation revealed, loss of consciousness(LOC) in 36 (47.3%) patients, vomiting in 42 (55%) patients, headache in 10 (13%) patients, ENT bleeding in 18 (23.6%), and seizure in 16 (21%) patients, no external injuries in 25 (33%) patients, normal sensorium was found in 41 (54%) patients, 18 (23.6%) children were drowsy at presentation, and 17 (22.3%) children were unconscious. CT scan findings revealed no gross abnormality in (26%), extradural heamorrhage (EDH) (18.4%), subdural hemorrhage (SDH) (14.4%), subarachnoid hemorrhage (21%), fracture skull (55.26%), cerebral oedema, and contusion (48.68%) as the radiological injury patterns. Out of 76 children, 42 (55%) children are managed with only observation, 26 (34%) children required only medical pharmacological treatment, and 8 (10.5%) children required surgical intervention, 24, (31.6%) children required mechanical ventilation. Overall mortality is 5.26%. Thus among the survivors (n = 72), 57 (79%) went home with no residual deficit, 3 (4%) had headache, 4 (5.5%) had hemiparesis, 2 (2.7%) had monoparesis, 1 (1.4%) had hypertonia, 3 (4%) had seizures, 2 (2.7%) had hydrocephalus, 2 (2.7%) had facial palsy, 2 (2.7%) had vision impairment, and 2 (2.7%) had speech impairment. In our study, we found that there is a significant association between residual deficits and severity of injury (p = 0.3), there is no significant association between mode of injury and outcome (p = 0.7). Mean duration of stay in hospital was 6.9 days but 60% of patients had stay of less than 5 days.

CONCLUSION

Most of these injuries are preventable in infancy and childhood by ensuring proper vigilance, tender care by the parents and the caretakers. Safe driving techniques have to be followed by parents while traveling with children in their motor vehicles. Need to focus on grading the severity of TBI rather than on factors like age, mode of injury, and presence or absence of external injuries.

Cerebrospinal Fluid NLRP3 is Increased After Severe Traumatic Brain Injury in Infants and Children

BACKGROUND

Inflammasome-mediated neuroinflammation may cause secondary injury following traumatic brain injury (TBI) in children. The pattern recognition receptors NACHT domain-, Leucine-rich repeat-, and PYD-containing Protein 1 (NLRP1) and NLRP3 are essential components of their respective inflammasome complexes. We sought to investigate whether NLRP1 and/or NLRP3 abundance is altered in children with severe TBI.

METHODS

Cerebrospinal fluid (CSF) from children (n = 34) with severe TBI (Glasgow coma scale score [GCS] ≤8) who had externalized ventricular drains (EVD) placed for routine care was evaluated for NLRP1 and NLRP3 at 0-24, 25-48, 49-72, and >72 h post-TBI and was compared to infection-free controls that underwent lumbar puncture to rule out CNS infection (n = 8). Patient age, sex, initial GCS, mechanism of injury, treatment with therapeutic hypothermia, and 6-month Glasgow outcome score were collected.

RESULTS

CSF NLRP1 was undetectable in controls and detected in 2 TBI patients at only <24 h post-TBI. CSF NLRP3 levels were increased in TBI patients compared with controls at all time points, p < 0.001. TBI patients ≤4 years of age had higher peak NLRP3 levels versus patients >4 (15.50 [3.65-25.71] vs. 3.04 [1.52-8.87] ng/mL, respectively; p = 0.048). Controlling for initial GCS in multivariate analysis, peak NLRP3 >6.63 ng/mL was independently associated with poor outcome at 6 months.

CONCLUSIONS

In the first report of NLRP1 and NLRP3 in childhood neurotrauma, we found that CSF NLRP3 is elevated in children with severe TBI and independently associated with younger age and poor outcome. Future studies correlating NLRP3 with other markers of inflammation and response to therapy are warranted.

Effects of Mild Blast Traumatic Brain Injury on Cerebral Vascular, Histopathological, and Behavioral Outcomes in Rats

To determine the effects of mild blast-induced traumatic brain injury (bTBI), several groups of rats were subjected to blast injury or sham injury in a compressed air-driven shock tube. The effects of bTBI on relative cerebral perfusion (laser Doppler flowmetry [LDF]), and mean arterial blood pressure (MAP) cerebral vascular resistance were measured for 2 h post-bTBI. Dilator responses to reduced intravascular pressure were measured in isolated middle cerebral arterial (MCA) segments, ex vivo, 30 and 60 min post-bTBI. Neuronal injury was assessed (Fluoro-Jade C [FJC]) 24 and 48 h post-bTBI. Neurological outcomes (beam balance and walking tests) and working memory (Morris water maze [MWM]) were assessed 2 weeks post-bTBI. Because impact TBI (i.e., non-blast TBI) is often associated with reduced cerebral perfusion and impaired cerebrovascular function in part because of the generation of reactive oxygen and nitrogen species such as peroxynitrite (ONOO-), the effects of the administration of the ONOO- scavenger, penicillamine methyl ester (PenME), on cerebral perfusion and cerebral vascular resistance were measured for 2 h post-bTBI. Mild bTBI resulted in reduced relative cerebral perfusion and MCA dilator responses to reduced intravascular pressure, increases in cerebral vascular resistance and in the numbers of FJC-positive cells in the brain, and significantly impaired working memory. PenME administration resulted in significant reductions in cerebral vascular resistance and a trend toward increased cerebral perfusion, suggesting that ONOO- may contribute to blast-induced cerebral vascular dysfunction.

Significant increase in acute subdural hematoma in octo- and nonagenarians: surgical treatment, functional outcome, and predictors in this patient cohort

OBJECTIVE

Acute subdural hematoma (aSDH) is a common disease increasing in prevalence given the demographic growth of the aging population. Yet, the benefit of surgical treatment for aSDH and the subsequent functional outcome in elderly patients (age ≥ 80 years) remain unclear. Therefore, the aims of this study were to evaluate the incidence of aSDH in patients 80 years or older, determine overall functional outcome, identify predictors of an unfavorable or favorable outcome, and establish specific risk factors for seizures.

METHODS

The authors retrospectively analyzed patients 80 years and older who presented with isolated aSDH in the past 10 years at their institution. The following parameters were assessed: baseline characteristics, clinical status on admission and 24 hours after surgery, and clinical course. Functional outcome was assessed at discharge and the 3-month follow-up (FU).

RESULTS

In the period from January 2007 to December 2016, 165 patients with aSDH were admitted to the authors’ institution. Sixty-eight patients (41.2%) were 80 years old or older, and the mean age overall was 85 years (range 80–96 years). The incidence of aSDH in the elderly had significantly increased over past decade, with more than 50% of patients admitted to our institution for aSDH now being 80 years or older. The overall mortality rate was 28% at discharge and 48% at the FU. Independent predictors of an unfavorable outcome at discharge were a GCS score ≤ 8 at 24 hours after operation (p < 0.001) and pneumonia (p < 0.02). At the FU, a GCS score ≤ 8 at 24 hours after operation (p < 0.001) and cumulative comorbidities (≥ 5; p < 0.05) were significant independent predictors. All patients with more than 6 comorbidities had died by the FU. Surgical treatment in comatose compared to noncomatose patients had statistically significant, higher mortality rates at discharge and the FU. Still, 23% of the comatose patients and more than 50% of the noncomatose patients had a favorable outcome at the FU (p = 0.06).

CONCLUSIONS

The number of octo- and nonagenarians with aSDH significantly increased over the last decade. These patients can achieve a favorable outcome, especially those with a noncomatose status and fewer than 5 comorbidities. Surgical and nonsurgical treatment of octo- and nonagenarians during and after discharge should be optimized to increase clinical improvement.

Influence of guidelines on management of paediatric mild traumatic brain injury: CT-assessment and admission policy

BACKGROUND

The annual number of paediatric injury-related emergency visits and application of computed tomography (CT) has substantially increased, with associated higher risk of malignancies. In 2010, a guideline for CT-assessment based on risk factors for patients with mild traumatic brain injury (mTBI) became effective in all Emergency Departments (ED) in the Netherlands. This study evaluated the influence of this guideline on the frequency of CT-assessments, hospital admissions and factors that are related to guideline adherence.

METHODS

Retrospective cohort study of paediatric mTBI (<18 years), defined by Glasgow Coma Scale score of 13-15 admitted to the ED of the University Medical Center Groningen from 2008 to 2014. Data before (pre-GL) and after (post-GL) introduction of the guideline were evaluated. Primary outcome parameters were frequency of CT-assessments and hospital admissions after ED.

RESULTS

In total 633 patients were enrolled and data from pre-GL (n = 216) and post-GL (n = 315) were compared. Mean age was 7.9 years (SD 5.9), 59% were male. CT-assessments increased from 32% to 46% (p = .001), mostly in children aged 6-18 years. Hospital admissions increased from 38% to 54% (p < .001), mostly in children <6 years. No significant increase in CT-abnormalities is seen. Guideline adherence was 57%, although CT-assessments varied from 44 to 100% depending on presence of specific major risk factors.

CONCLUSIONS

Introduction of a new guideline on management of paediatric mTBI showed significant increase in CT-assessments and more hospital admissions. In clinical practice, despite increase of guideline adherence the applications of cranial CT-scan varies within age groups and depends on the weighing of risk factors.

Mortality and Epidemiology in 256 Cases of Pediatric Traumatic Brain Injury: Korean Neuro-Trauma Data Bank System (KNTDBS) 2010-2014

Objective

Among pediatric injury, brain injury is a leading cause of death and disability. To improve outcomes, many developed countries built neurotrauma databank (NTDB) system but there was not established nationwide coverage NTDB until 2009 and there have been few studies on pediatric traumatic head injury (THI) patients in Korea. Therefore, we analyzed epidemiology and outcome from the big data of pediatric THI.

Methods

We collected data on pediatric patients from 23 university hospitals including 9 regional trauma centers from 2010 to 2014 and analyzed their clinical factors (sex, age, initial Glasgow coma scale, cause and mechanism of head injury, presence of surgery).

Results

Among all the 2617 THI patients, total number of pediatric patients was 256. The average age of the subjects was 9.07 (standard deviation±6.3) years old. The male-to female ratio was 1.87 to 1 and male dominance increases with age. The most common cause for trauma were falls and traffic accidents. Age (p=0.007), surgery (p<0.001), mechanism of trauma (p=0.016), subdural hemorrhage (SDH) (p<0.001), diffuse axonal injury (DAI) (p<0.001) were statistically significant associated with severe brain injury.

Conclusion

Falls were the most common cause of trauma, and age, surgery, mechanism of trauma, SDH, DAI increased with injury severity. There is a critical need for effective fall and traffic accidents prevention strategies for children, and we should give attention to these predicting factors for more effective care.

Association of Out-of-Hospital Hypotension Depth and Duration With Traumatic Brain Injury Mortality

STUDY OBJECTIVE

Out-of-hospital hypotension has been associated with increased mortality in traumatic brain injury. The association of traumatic brain injury mortality with the depth or duration of out-of-hospital hypotension is unknown. We evaluated the relationship between the depth and duration of out-of-hospital hypotension and mortality in major traumatic brain injury.

METHODS

We evaluated adults and older children with moderate or severe traumatic brain injury in the preimplementation cohort of Arizona's statewide Excellence in Prehospital Injury Care study. We used logistic regression to determine the association between the depth-duration dose of hypotension (depth of systolic blood pressure <90 mm Hg integrated over duration [minutes] of hypotension) and odds of inhospital death, controlling for significant confounders.

RESULTS

There were 7,521 traumatic brain injury cases included (70.6% male patients; median age 40 years [interquartile range 24 to 58]). Mortality was 7.8% (95% confidence interval [CI] 7.2% to 8.5%) among the 6,982 patients without hypotension (systolic blood pressure ≥90 mm Hg) and 33.4% (95% CI 29.4% to 37.6%) among the 539 hypotensive patients (systolic blood pressure <90 mm Hg). Mortality was higher with increased hypotension dose: 0.01 to 14.99 mm Hg-minutes 16.3%; 15 to 49.99 mm Hg-minutes 28.1%; 50 to 141.99 mm Hg-minutes 38.8%; and greater than or equal to 142 mm Hg-minutes 50.4%. Log2 (the logarithm in base 2) of hypotension dose was associated with traumatic brain injury mortality (adjusted odds ratio 1.19 [95% CI 1.14 to 1.25] per 2-fold increase of dose).

CONCLUSION

In this study, the depth and duration of out-of-hospital hypotension were associated with increased traumatic brain injury mortality. Assessments linking out-of-hospital blood pressure with traumatic brain injury outcomes should consider both depth and duration of hypotension.

Pediatric Head Injury: A Study of 403 Cases in a Tertiary Care Hospital in a Developing Country

INTRODUCTION

Traumatic brain injury (TBI) in children is a significant cause of morbidity and mortality worldwide. Falls are the most common type of injury, followed by motor vehicle-related accidents and child abuse.

AIMS AND OBJECTIVES

The aim and objective of this study was to elucidate the various modes of injury, prognostic factors, complications, incidence of various modes of injury, and outcome in TBI in pediatric population.

MATERIALS AND METHODS

Patients with TBI, 18 years or less in age, managed in our Department of Neurosurgery, over a period of 2 years, were studied prospectively. Detailed history, general physical examination, systemic examination, and central nervous system examination including assessment of Glasgow Coma Scale score (GCS) and pupillary size and reaction were noted in every patient. Based on GCS, patients were divided into mild head injury (GCS 13-15), moderate head injury (GCS 9-12), and severe head injury (GCS ≤8) categories. All the patients were subjected to plain computed tomography (CT) scan head, and CT findings were noted. Patients were managed conservatively or surgically as per the standard indications. The outcome of all these patients was assessed by Glasgow outcome scale and divided into good (normal, moderate disability) and poor (severe, vegetative, dead) outcome. Outcome was assessed in relation to age, sex, GCS, pupil size and reaction, CT scan features, intervention, and associated injuries.

RESULTS

A total of 403 patients aged between 1 day and 18 years were included in the study comprising 252 males (63%) and 151 females (37.75%). The common modes of injury were fall 228 (56.6%) followed by road traffic accidents 138 (34.2%), assault 10 (2.5%), and others 27 (6.7%) which include sports injury, hit by some object on head, and firearm injury. Majority of our patients had a GCS of 13-15 (mild head injury), 229 (57.3%), followed by 9-12 (moderate head injury) 119 (29.8%), followed by 8 or less (severe head injury) 52 (13%). In group of patients in the category of GCS ≤ 8, poor outcome was seen in 65.3%, followed by patients in group GCS 9-12 at 2.45% succeeded by group of patients with GCS 13-15 at 2.6%, which was statistically significant (P < 0.0001). A total of 354 (87.8%) patients had normal pupils, 37 (9.2%) had anisocoria, and 12 (3%) patients had fixed dilated pupils. Fixed dilated pupil had poor outcome (100%) followed by anisocoria (40.5%) and normal pupils (16%), which was statistically significant (P < 0.0001).

CONCLUSION

Majority of children who suffer from TBI do well although it still continues to be a significant cause of morbidity and mortality in them. The outcome is directly related to the neurological status in which they present to the hospital.

Pediatric tracheotomy: A comparison of outcomes and lengths of hospitalization between different indications

OBJECTIVES

To assess outcomes of pediatric tracheotomy and duration of associated hospital stay according to indications.

SUBJECTS AND METHODS

In this retrospective study, subjects were 142 consecutive pediatric patients (<18 years old) who underwent tracheotomy at a tertiary referral medical center, National Taiwan University Hospital, in 1997-2012. Age, sex, indications, pre-operative status (oxygen demand, number of repeated intubations), and post-operative status (duration of weaning, length of hospital stay, mortality) were analyzed.

RESULTS

The indications included craniofacial anomalies (n = 19, 13.4%), upper airway obstruction (n = 41, 28.9%), neurological deficit (n = 58, 40.8%), prolonged ventilation (n = 15, 10.6%), and trauma (n = 9, 6.3%). Ninety-one patients (64.1%) were successfully weaned off ventilation after tracheotomy (40% in the prolonged ventilation group). Total hospital stay and duration of ventilation before tracheotomy were longest in patients with craniofacial anomalies (150.9 ± 98.8 days, p = 0.004; 108.8 ± 88.2, p < 0.001). The early tracheotomy group had a shorter duration of post-tracheotomy mechanical ventilation support than the late tracheotomy group (14.4 ± 19.0, n = 49 vs. 34.9 ± 58.6, n = 80, p = 0.004). Decannulation was successful in 20 patients (14.1%), with the highest rate in the upper airway obstruction group (n = 14, 34.1%) and lowest in the prolonged ventilation group (none). Thirteen patients (9.2%) died during admission from causes unrelated to tracheotomy.

CONCLUSION

Outcomes of pediatric tracheotomy and duration of hospitalization depend on indications. Children with craniofacial anomalies had earlier tracheotomy age and longer mechanical ventilation before tracheotomy resulted in longer hospitalization. Earlier tracheotomy can shorten the duration of post-tracheotomy mechanical ventilation in several conditions.

Impact of First Aid on Treatment Outcomes for Non-Fatal Injuries in Rural Bangladesh: Findings from an Injury and Demographic Census

Non-fatal injuries have a significant impact on disability, productivity, and economic cost, and first-aid can play an important role in improving non-fatal injury outcomes. Data collected from a census conducted as part of a drowning prevention project in Bangladesh was used to quantify the impact of first-aid provided by trained and untrained providers on non-fatal injuries. The census covered approximately 1.2 million people from 7 sub-districts of Bangladesh. Around 10% individuals reported an injury event in the six-month recall period. The most common injuries were falls (39%) and cuts injuries (23.4%). Overall, 81.7% of those with non-fatal injuries received first aid from a provider of whom 79.9% were non-medically trained. Individuals who received first-aid from a medically trained provider had more severe injuries and were 1.28 times more likely to show improvement or recover compared to those who received first-aid from an untrained provider. In Bangladesh, first-aid for non-fatal injuries are primarily provided by untrained providers. Given the large number of untrained providers and the known benefits of first aid to overcome morbidities associated with non-fatal injuries, public health interventions should be designed and implemented to train and improve skills of untrained providers.

Loss of PAFR prevents neuroinflammation and brain dysfunction after traumatic brain injury

Traumatic brain injury (TBI) is a principal cause of death and disability worldwide, which is a major public health problem. Death caused by TBI accounts for a third of all damage related illnesses, which 75% TBI occurred in low and middle income countries. With the increasing use of motor vehicles, the incidence of TBI has been at a high level. The abnormal brain functions of TBI patients often show the acute and long-term neurological dysfunction, which mainly associated with the pathological process of malignant brain edema and neuroinflammation in the brain. Owing to the neuroinflammation lasts for months or even years after TBI, which is a pivotal causative factor that give rise to neurodegenerative disease at late stage of TBI. Studies have shown that platelet activating factor (PAF) inducing inflammatory reaction after TBI could not be ignored. The morphological and behavioral abnormalities after TBI in wild type mice are rescued by general knockout of PAFR gene that neuroinflammation responses and cognitive ability are improved. Our results thus define a key inflammatory molecule PAF that participates in the neuroinflammation and helps bring about cerebral dysfunction during the TBI acute phase.

[Formula: see text]Associations among parent-child relationships and cognitive and language outcomes in a clinical sample of preschool children

OBJECTIVE

To examine associations among parent-child relationship characteristics and child cognitive and language outcomes.

METHODS

Preschool children (n = 72) with early neurological insult completed assessments of cognitive and language functioning and participated in a parent-child semi-structured interaction.

RESULTS

Quality of the parent-child relationship accounted for a significant amount of unique variance (12%) in predicting children's overall cognitive and language functioning. Impact of neurological insult was a significant predictor.

CONCLUSIONS

Caregiver-child interactions that are harmonious and reciprocal as evidenced by affective and/or verbal exchanges support children's cognitive and language development. Observations of interactions can guide providers in facilitating child- and family-centered interventions.

The Effect of Combined Out-of-Hospital Hypotension and Hypoxia on Mortality in Major Traumatic Brain Injury

STUDY OBJECTIVE

Survival is significantly reduced by either hypotension or hypoxia during the out-of-hospital management of major traumatic brain injury. However, only a handful of small studies have investigated the influence of the combination of both hypotension and hypoxia occurring together. In patients with major traumatic brain injury, we evaluate the associations between mortality and out-of-hospital hypotension and hypoxia separately and in combination.

METHODS

All moderate or severe traumatic brain injury cases in the preimplementation cohort of the Excellence in Prehospital Injury Care study (a statewide, before/after, controlled study of the effect of implementing the out-of-hospital traumatic brain injury treatment guidelines) from January 1, 2007, to March 31, 2014, were evaluated (exclusions: <10 years, out-of-hospital oxygen saturation ≤10%, and out-of-hospital systolic blood pressure <40 or >200 mm Hg). The relationship between mortality and hypotension (systolic blood pressure <90 mm Hg) or hypoxia (saturation <90%) was assessed with multivariable logistic regression, controlling for Injury Severity Score, head region severity, injury type (blunt versus penetrating), age, sex, race, ethnicity, payer, interhospital transfer, and trauma center.

RESULTS

Among the 13,151 patients who met inclusion criteria (median age 45 years; 68.6% men), 11,545 (87.8%) had neither hypotension nor hypoxia, 604 (4.6%) had hypotension only, 790 (6.0%) had hypoxia only, and 212 (1.6%) had both hypotension and hypoxia. Mortality for the 4 study cohorts was 5.6%, 20.7%, 28.1%, and 43.9%, respectively. The crude and adjusted odds ratios for death within the cohorts, using the patients with neither hypotension nor hypoxia as the reference, were 4.4 and 2.5, 6.6 and 3.0, and 13.2 and 6.1, respectively. Evaluation for an interaction between hypotension and hypoxia revealed that the effects were additive on the log odds of death.

CONCLUSION

In this statewide analysis of major traumatic brain injury, combined out-of-hospital hypotension and hypoxia were associated with significantly increased mortality. This effect on survival persisted even after controlling for multiple potential confounders. In fact, the adjusted odds of death for patients with both hypotension and hypoxia were more than 2 times greater than for those with either hypotension or hypoxia alone. These findings seem supportive of the emphasis on aggressive prevention and treatment of hypotension and hypoxia reflected in the current emergency medical services traumatic brain injury treatment guidelines but clearly reveal the need for further study to determine their influence on outcome.

Ruolo della tomografia computerizzata cerebrale nel trauma lieve

Sulla base della revisione delle richieste di Tomografia Computerizzata Cerebrale (TC) inoltrate dal Pronto Soccorso al Servizio di Neuroradiologia dell'Ospedale Maggiore Policlinico di Milano, si è osservata una percentuale di casi di trauma cranico pari al 41% degli esami richiesti.

È stato quindi effettuato lo studio retrospettivo di 300 casi di trauma cranico indagati con esame TC nel corso di un trimestre, il 92% dei quali è risultato negativo per complicanze intracraniche post-traumatiche. Tenuto conto di un'obiettività neurologica negativa al momento dell'ammissione in Pronto Soccorso, il 79% dei casi è stato ascritto alla categoria di trauma cranico lieve. Per essi si è rivelata una positività per lesioni intracraniche post-traumatiche del 2%, mentre si è osservato che un'obiettività neurologica positiva è associata alla presenza di lesioni intracraniche con una frequenza del 17%.

Si è osservata una maggiore positività per complicanze intracraniche nei pazienti di età superiore ai 50 anni, nei casi di incidente stradale, nei casi di trauma in sede parietale e nei casi di amnesia e episodi di vomito successivi all'evento traumatico. Non si è invece riscontrata una maggiore associazione con lesioni intracraniche nei casi di trauma commotivo rispetto ai casi di trauma non commotivo.

Gli autori, sulla base della esperienza presentata in questa sede e della revisione della letteratura in merito, propongono alcune linee guida per la gestione dei pazienti affetti da trauma cranico lieve.

Reduced power spectra of heart rate variability are correlated with anxiety in patients with mild traumatic brain injury

Anxiety is one of the most frequently diagnosed emotional disorders after a mild traumatic brain injury (mTBI); however, predictors of anxiety after an mTBI remain uncertain. Recent research indicated that anxiety is associated with abnormalities in the autonomic nervous system (ANS) which can be evaluated by a power spectral analysis of heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV could correlate with the occurrence of anxiety in mTBI patients. We recruited 165 Taiwanese patients diagnosed with an mTBI and 82 volunteer healthy controls from three affiliated hospitals of Taipei Medical University during 2010-2014. The Beck Anxiety Inventory (BAI) was assessed at the 1st, 6th, and 12th weeks. We found that mTBI patients were more vulnerable to anxiety compared to healthy controls. The power spectral density of HRV was significantly lower in mTBI patients than in healthy controls. A correlation analysis indicated that anxiety was negatively significantly correlated with low- and high-frequency power at the 6th week. Our study suggests the clinical usefulness of HRV as a potential noninvasive tool for evaluating later anxiety in mTBI patients.

Age-related carbon dioxide reactivity in children after moderate and severe traumatic brain injury

OBJECTIVE The objective of this study is to assess carbon dioxide reactivity (CO2R) in children following traumatic brain injury (TBI). METHODS This prospective observational study enrolled children younger than 18 years old following moderate and severe TBI. Thirty-eight mechanically ventilated children had daily CO2R testing performed by measuring changes in their bilateral middle cerebral artery flow velocities using transcranial Doppler ultrasonography (TCD) after a transient increase in minute ventilation. The cohort was divided into 3 age groups: younger than 2 years (n = 12); 2 to 5 years old (n = 9); and older than 5 years (n = 17). RESULTS Children younger than 2 years old had a lower mean CO2R over time. The 2-5-year-old age group had higher mean CO2R than younger patients (p = 0.01), and the highest CO2R values compared with either of the other age groups (vs > 5 years old, p = 0.046; vs < 2 years old, p = 0.002). Having a lower minimum CO2R had a statistically significant negative effect on outcome at discharge (p = 0.0413). Impaired CO2R beyond Postinjury Day 4 trended toward having an effect on outcome at discharge (p = 0.0855). CONCLUSIONS Abnormal CO2R is prevalent in children following TBI, and the degree of impairment varies by age. No clinical or laboratory parameters were identified as risk factors for impaired CO2R. Lower minimum CO2R values are associated with worse outcome at discharge.

Epidemiologic study in hospitalized patients with head injuries

PURPOSE

The aim of this study was to analyze epidemiologic data of patients with head injuries (HI) who were admitted to the Trauma and Emergency Surgery Department.

METHODS

The hospital records of 497 patients with HI who were admitted to the Trauma and Emergency Surgery Department from January 1, 2014, through 31 December, 2014, were analyzed retrospectively.

RESULTS

The male-to-female ratio was 2:1, and the mean age was 16.3 years. The rates of patients with mild, moderate, and severe HI were 93, 3, and 4 %, respectively. The most common cause of trauma was falls. Linear fractures were the most common radiologic diagnoses with 242 cases (49 %). Of the patients admitted to hospital, 22 % presented 4 h after the trauma had occurred. Mortality rate due to HI was 3 % (15 patients). Outcome was associated with admission Glasgow Coma Scale and presence of additional trauma.

CONCLUSIONS

The number of traffic accidents and assaults were considerably higher in the young adult population compared with the other age groups. Traffic accidents accounted for 46.6 % of the mortality rate. Mortality in HI patients mostly arises from preventable conditions, and the young adult population seems to be the most affected group. HI should be considered as a public health issue, and prevention of HI should be the primary goal.

Spectrum and outcome of traumatic brain injury in children <15 years: A tertiary level experience in India

BACKGROUND

Though, traumatic brain injury (TBI) has been documented as the single most common cause of morbidity and mortality in infancy and childhood, the exact incidence is unavailable in India. Moreover, modes of injury, mechanisms of damage, and management differ significantly from that of an adult.

AIMS AND OBJECTIVES

To analyze the epidemiological factors, the spectrum of TBI, modes of injury, types of injury, and the outcome in the children <15 years with TBI.

MATERIALS AND METHODS

This is a retrospective study from August 2012 to May 2013 at Department of Neurosurgery, S.C.B. Medical College, Cuttack, Odisha, India. All the pertinent details from case records of hundred and forty-seven children <15 years with TBI were analyzed. Follow-up was done for 6 months at outpatients department.

RESULTS

Age wise, incidence and severity of TBI is more common in 10-15 years. Males outnumber females with a male: female ratio 2.19:1. Overall, road traffic accident (RTA) is the commonest mode of injury. Assault is not uncommon (7.48% cases). Falls is common in <5 years while RTA is common in 5-15 years. The extradural hematoma was the most common injury pattern; however, surgical consideration was maximal for fracture skull. Overall mortality was 7.48%. Diffuse axonal injury has the maximum individual potential for mortality. We noticed excellent recovery in 68.7%, disabilities in 17.68%, and persistent vegetative state in 5.45% cases.

CONCLUSION

TBI in children carries good outcome, if resuscitated and referred early to a neurotrauma center, and managed subsequently on an individualized basis with a well-organized team approach. Severe TBI in children has a poor outcome.

Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study

OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIS_head) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIS_head score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.

Angioarchitectural Risk Factors for Hemorrhage and Clinical Long-Term Outcome in Pediatric Patients with Cerebral Arteriovenous Malformations

BACKGROUND

Intracranial arteriovenous malformation (AVM) in children is a rare diagnosis. Little is known about factors determining AVM rupture and appropriate treatment strategies to prevent hemorrhage and associated disability. Available data suggest that children are subject to an increased risk for AVM rupture compared with adults.

METHODS

In 46 pediatric patients with AVM, demographic factors, clinical presentation, angioarchitectural features, and treatment regimens as well as clinical and radiologic outcomes were retrospectively analyzed. First-line treatment option was microsurgical resection of the disease, with or without preoperative embolization.

RESULTS

Twenty-four boys (52.2%) and 22 girls (47.8%) with a mean age on admission of 12.4 years (4-18 years) were included. Mean follow-up was 4 years (median, 1.5; range, 0.1-16.4). Thirty-one children presented with intracerebral hemorrhage (67.4%). Small AVMs (<3 cm) ruptured in 83.3% (n = 25) and were shown to be more prone to hemorrhage than larger ones (P < 0.01). Small AVM size (P < 0.01; odds ratio [OR], 0.12; 95% confidence interval [CI] 0.02-0.59) and exclusive deep venous drainage (P < 0.01; OR, 29.74; 95% CI, 2.45-4445.34) were independent risk factors for hemorrhage in the presented cohort. Good long-term outcome was associated with a high score on the Glasgow Coma Scale on admittance (P < 0.05; OR, 0.148; 95% CI, 0.03-0.73).

CONCLUSIONS

Two-thirds of children with AVM are admitted with intracerebral hemorrhage. Microsurgical resection was successful as confirmed by radiologic studies in 95%, and 79.5% of patients presented in a good clinical condition on follow-up (modified Rankin Scale 0 or 1). Microsurgical treatment is recommended if the lesion is accessible and angioarchitectural risk factors favor definitive treatment.

Scandinavian guidelines for initial management of minor and moderate head trauma in children

BACKGROUND

The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.

RESULTS

The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.

CONCLUSIONS

We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.

Pediatric Rodent Models of Traumatic Brain Injury

Due to a high incidence of traumatic brain injury (TBI) in children and adolescents, age-specific studies are necessary to fully understand the long-term consequences of injuries to the immature brain. Preclinical and translational research can help elucidate the vulnerabilities of the developing brain to insult, and provide model systems to formulate and evaluate potential treatments aimed at minimizing the adverse effects of TBI. Several experimental TBI models have therefore been scaled down from adult rodents for use in juvenile animals. The following chapter discusses these adapted models for pediatric TBI, and the importance of age equivalence across species during model development and interpretation. Many neurodevelopmental processes are ongoing throughout childhood and adolescence, such that neuropathological mechanisms secondary to a brain insult, including oxidative stress, metabolic dysfunction and inflammation, may be influenced by the age at the time of insult. The long-term evaluation of clinically relevant functional outcomes is imperative to better understand the persistence and evolution of behavioral deficits over time after injury to the developing brain. Strategies to modify or protect against the chronic consequences of pediatric TBI, by supporting the trajectory of normal brain development, have the potential to improve quality of life for brain-injured children.

Magnetic Resonance Imaging of Pediatric Neurologic Emergencies

Although computed tomography is often the first line of imaging in the emergency setting, magnetic resonance imaging (MRI) is of increasing importance in the evaluation of central nervous system emergencies in the pediatric population. As such, it is necessary to understand the indications for which MRI may be necessary. This article reviews the unique pathophysiologic entities affecting the pediatric population and the associated MRI findings. Specifically, utility of emergent MRI and characteristic appearances of traumatic brain injury, traumatic spinal injury, nonaccidental trauma, arterial ischemic stroke, cerebral sinovenous thrombosis, stroke mimics, and central nervous system infections are described.

Early dysautonomia detected by heart rate variability predicts late depression in female patients following mild traumatic brain injury

Depression is one of the frequent complications following a mild traumatic brain injury (mTBI). Recent research indicated that abnormalities in the autonomic nervous system (ANS) can be evaluated by a noninvasive power spectral analysis of the heart rate variability (HRV). In this study, we investigated whether a frequency-domain analysis of HRV was correlated with late depression in mTBI patients. In total, 181 patients diagnosed with mTBI and 83 volunteers as healthy controls were recruited in 2010-2014. Beck Depression Inventory (BDI) scores were used to evaluate depression in the 1st week of assessment and at 1.5-, 3-, 6-, 12-, and 18-month follow-ups. Correlation and logistic regression analyses of the 1st week HRV parameters with BDI scores at 18 months were performed in individual female mTBI patients. Female mTBI patients were more vulnerable to depression accompanied by reduced HRV compared to healthy controls. Over time, depression was aggravated in female mTBI patients but was alleviated in male mTBI patients. A significantly lower parasympathetic proportion of the ANS was noted at 18 months with respect to the 1st week in female mTBI patients. In addition, depression in female mTBI patients at 18 months after injury was significantly correlated with a decrease in the parasympathetic proportion of the ANS in the 1st week (ρ = -0.411; p < .05). Dysautonomia resulted in higher risks of depression in female mTBI patients. We concluded that early dysautonomia following an mTBI contributes to late depression in female mTBI patients.