Induction of the stress response after inflicted and non-inflicted traumatic brain injury in infants and children

Rapid induction of 72-kD heat shock protein (Hsp70) is a key component of the stress response and is seen after a variety of insults to the brain including experimental hyperthermia, ischemia, seizures, and traumatic brain injury (TBI). Little is known about the endogenous stress response in pediatric patients after brain injury. Accordingly, the concentration of Hsp70 was determined in 61 cerebrospinal fluid (CSF) samples from 20 infants and children after TBI. Peak Hsp70 level were increased in TBI patients vs. controls (4.60 [1.49-78.99] vs. 2.18 [1.38-4.25] ng/mL, respectively, median (range), p = 0.01) and occurred most often on day 1 after injury. Strikingly, CSF levels of Hsp70 were positively and independently associated with inflicted vs. non-inflicted TBI (7.03 [2.30-27.22] vs. 2.06 [1.06-78.99] ng/mL, respectively, p = 0.05). Endogenous Hsp70 expression was confirmed by Western blot and immunocytochemistry using brain tissue samples removed from patients who underwent decompressive craniotomy for refractory intracranial hypertension or at autopsy. These data suggest that the endogenous stress response, as measured and quantified by the Hsp70 concentration in CSF, occurs in infants and children after TBI. The endogenous stress response is more robust in victims of child abuse, compared with patients with accidental TBI, supporting age-dependence or a difference in either injury frequency, duration, severity, or mechanism in this subgroup of TBI patients. Further studies are needed to determine the role of Hsp70 in both non-inflicted and inflicted TBI in infants and children.     

Neurointensive care; impaired cerebral autoregulation in infants and young children early after inflicted traumatic brain injury: a preliminary report

The objective of this report is to describe cerebral autoregulation after severe inflicted pediatric traumatic brain injury (iTBI). We examined cerebral autoregulation of both cerebral hemispheres (mean autoregulatory index; ARI) in children <5 years with Glasgow Coma Scale (GCS) score of <9 and no evidence of brain death within the first 48 h of pediatric intensive care unit (PICU) admission. Discharge and 6-month Glasgow Outcome Scale (GOS) scores were collected. GOS of <4 reflected poor outcome. All three iTBI and all seven noninflicted TBI (nTBI) patients had admission GCS score of <9. Eight of 10 patients had Autoregulatory Index (ARI) of <0.4 (impaired cerebral autoregulation) of at least one hemisphere. All children with iTBI had poor outcome, and none had intact cerebral autoregulation in both hemispheres. Children with nTBI had better overall outcome than those with iTBI. Two of the children with nTBI had intact autoregulation in both hemispheres and good outcome. Two of the three children with iTBI had differential effects on autoregulation between hemispheres despite bilateral injury. These are, to our knowledge, the first data on cerebral blood flow autoregulation in the unique setting of iTBI and provide a rationale for further study of their relationship to outcome and effects of therapy.     

Pediatric spine and spinal cord injury after inflicted trauma

Pediatric spine and spinal cord injury are rare sequelae of intentional trauma. They may easily be overlooked, however, and probably represent an underreported phenomenon. Recent autopsy data analyzed in conjunction with prior case series indicate that injury to the upper cervical spine and brainstem may significantly contribute to the major morbidity, mortality, and neuropathology in shaken infants. The findings in the previous case report illustrate several important points regarding spine and spinal cord injury after intentional trauma. First, the very young are susceptible to severe, higher cervical injury of both spine and spinal cord. Second, spine and spinal cord injury were initially overlooked because of masked neurologic findings with the concomitant head injury and multiple other systemic injuries. Finally, the child's outcome with significant cognitive delay because of global brain injury in conjunction with the focal high cervical cord injury may support the hypothesis that hypoxic damage could have occurred secondary to brainstem and high cervical cord injury. At the authors' institution, a detailed history and vigilant physical examination are stressed. When the mechanism of injury reported in the history is incongruous with the physical or initial radiographic findings and intentional trauma is suspected, a full skeletal survey, ophthalmologic evaluation, and social evaluation is undertaken. MRI and CT scanning are individualized according to the clinical assessment.     

Blunt traumatic vertebral artery injury: a clinical review

Blunt traumatic vertebral injury (TVAI) is frequently associated with head and neck injury and is being detected with increasing frequency due to improved imaging of the trauma patient. In a few cases, it can lead to potentially fatal posterior circulation ischaemia There is debate in the literature regarding whether TVAI should be actively screened for and, if so, how. Management of TVAI may be conservative, medical (antiplatelet agents or anticoagulation), endovascular or open surgery. We review the literature concerning the mechanisms and presentation of TVAI following blunt injury and the current screening recommendations. Management strategies proposed are based on the radiological grade and clinical severity of TVAI, where high-grade symptomatic injuries and high-grade injuries in patients where anticoagulation is contraindicated are treated endovascularly and asymptomatic or low-grade injuries are managed with anticoagulation where it is not contraindicated. Follow-up is via CT angiography to assess for resolution of the injury.     

Carotid artery injury caused by blunt cervical trauma. Case report

Three cases of carotid artery injury following blunt cervical trauma are reported and the literature is reviewed. The condition carries high morbidity and mortality rates, due to occlusion of the internal carotid artery. The diagnosis is often delayed, as the symptoms of carotid injury frequently are mistakenly attributed to head injury. The insidious course, with neurologic deficit developing in an alert patient prior to lowering of consciousness, distinguishes blunt carotid artery injury from head injury. Aortic arch angiography is crucial for the diagnosis, and should be frequently performed in patients who have sustained blunt cervical trauma. Normal computed tomography of the brain does not exclude ischaemic cerebral infarction, visualization of which requires several days. Tomography of the neck following intravenous injection of contrast medium may be useful for demonstrating occlusion of the carotid artery. Heightened awareness of this injury is important for early diagnosis. Immediate revascularization may improve the poor prognosis.     

Carotid artery pseudoaneurysm in Behcet''s disease

We report a case of carotid artery pseudoaneurysm occurring in a patient with Behcet's disease for the purpose of discussing approach to this unusual complication of Behcet's disease.     

Carotid artery disease in young adults

The angiographic and clinical findings in 17 young adults (14-39 years) with stenosis and/or occlusion of at least one of the common or internal carotid arteries were reviewed to determine the spectrum of carotid artery disease in this age group. Five aetiological groups were identified: atherosclerosis (3 patients), arteritis (4), non-inflammatory arteriopathies (6), compression by neoplasm (1), and occlusions of undetermined cause (3). Over a mean follow-up time of 19.7 months, 2 patients died (12.5%) and further cerebrovascular events occurred in 4 others (25%). We conclude that carotid angiography plays a meaningful role in providing a definitive diagnosis in young adults with carotid artery disease and thus may assist with therapy and prognosis.     

Carotid artery stenting after carotid endarterectomy

Atherosclerotic carotid artery disease remains an important cause of cerebrovascular ischemic disease. We present a patient with residual stenosis of the distal internal carotid artery following carotid endarterectomy that was treated with stenting. The case highlights the potential complimentary benefits of carotid endarterectomy and carotid stenting.     

Neurocognitive outcome and serum biomarkers in inflicted versus non-inflicted traumatic brain injury in young children

Traumatic brain injury (TBI) in infants and toddlers is frequently explained by child abuse. This study compared 6-month outcome in children with inflicted TBI (iTBI) or non-inflicted TBI (nTBI) who were injured before 3 years of age, and assessed the relationship between outcome and serum concentrations of neuron-specific enolase (NSE), S100B, and myelin-basic protein (MBP). Children with iTBI (n = 15) or nTBI (n = 15) of varying severity were assessed 6 months after injury using the Glasgow Outcome Scale (GOS), Vinel and Adaptive Behavior Scale (VABS), and an intelligence quotient (IQ) measure. Serum concentrations of NSE, S100B, and MBP were measured soon after injury and every 12 h, for up to 5 days. Groups were matched by ethnicity, gender, socioeconomic status, and injury severity. Student's t-tests, analysis of covariance, or nonparametric tests assessed between-group differences for GOS, IQ, and biomarkers; correlation coefficients assessed relationships between outcome and biochemical markers. Functional and cognitive tests showed significant between-group differences (p < or = 0.05); the iTBI group performed more poorly (GOS, 2.00 +/- 1.00 vs.1.23 +/- 0.60; VABS, 95.92 +/- 14.05 vs. 115.80 +/- 20.02; IQ, 69.00 +/- 20.85 vs. 97.33 +/- 23.66). Significant between-group differences (iTBI vs. nTBI) were found for time to peak NSE (66.48 +/- 53.56 vs.8.11 +/- 11.58), S100B (43.30 +/- 51.41 vs. 8.21 +/- 8.29), and MBP (77.66 +/- 56.77 vs. 21.63 +/- 28.39). Time to peak concentrations were significantly correlated with outcome measures. Children with iTBI are at risk for poorer outcome. Acute measurement of NSE, S100B, and MBP serum concentrations may provide a quantitative predictor of outcome after TBI in young children. Outcome may be due to the mechanism of iTBI, cumulative effects of unreported TBI, and/or other unidentified risk factors.     

Carotid cavernous fistula in a patient with coronary artery disease

Carotid cavernous fistulas are abnormal communications between the carotid and cavernous vasculature, with potential for serious neurological and ocular sequelae. There is considerable literature on the neuro-radiological management of carotico-cavernous fistula depending upon their flow status. The coronary artery bypass grafting (CABG) for coronary artery disease (CAD) is a well established method of revascularization. However, the association of carotid cavernous fistula in presence of CAD is an infrequent occurrence. We present a case of coronary artery disease scheduled for bypass surgery, developed spontaneous bilateral carotid cavernous fistulas, highlighting a unique aspect of association between coronary and carotid disease.