Outcome of infants with inflicted traumatic brain injury (shaken baby syndrome) in Estonia

This is a population-based prospective study to identify the long-term outcome of children with inflicted traumatic brain injury (ITBI). Twenty-two survivors were identified and followed up. Only 2 of 22 had no developmental problems at follow-up, 20 of 22 children were having different developmental problems, among them 3 of 22 were severely handicapped. Psychological tests passed 17 of 22, 5 did not pass due to severe handicap (3 children) or were too young (2 patients). Epilepsy was found in 7 of 22, being intractable in 3 cases. Serious motor problems were identified in 5 of 22. Ophthalmologic problems were found in 4 of 22. The most important predictor of adverse outcome was young age at the time of the insult. Conclusion: the outcome of these potentially healthy children is poor. The key question is prevention. Health care professionals should be more concerned about these problems.     

Sports related mild traumatic brain injury in adolescents

While head injuries are not common in youth sports, they may have catastrophic results. Concussion is also referred to as mild traumatic brain injury (MTBI). Although the occurrence of head injuries has been studied more extensively in American football, the findings have wider application for any MTBI. Recently, more attention has been directed at other sports in which both boys and girls participate. The diagnosis of MTBI is based on subjective findings and subtle changes in mental status. Other cerebral injuries requiring emergent or urgent neurosurgical attention should be ruled out. Objective tests such as CT scans and Magnetic Resonsance Imaging (MRI) are usually without significant findings in MTBI. Neuropsychological testing may demonstrate areas of deficiencies, however, results may be difficult to interpret because of confounding factors. Complications following MTBI have been known to occur. The most catastrophic of these is second impact syndrome. There are a variety of guidelines for return to play following a concussion, which have been designed in an effort to avoid problems such as second impact syndrome. These guidelines are based more on clinical experience than on scientific evidence. Education, good training and coaching techniques, improved equipment, and rule changes and enforcement, can all help in curbing the sports related head injuries in adolescents.     

小儿外伤性脑梗塞57例临床分析

目的 探讨并总结小儿外伤性脑梗塞的临床特点及治疗.方法 回顾性总结我院2000年至2006年收治的57例小儿外伤性脑梗塞临床及影像学特点及治疗方法.本组患儿均经CT扫描发现梗死灶,行适量脱水、Ca2+拮抗剂、扩血管、营养神经以及高压氧、针灸按摩等综合治疗措施保守治疗.结果 49例患儿于5～30 d内逐渐恢复良好,5例患儿出院时仍有肢体轻瘫,肌力4～5级,2例轻度面瘫,出院后均在半年内恢复,死亡1例,为大面积脑梗塞.结论 小儿外伤性脑梗塞,由于原发性脑损伤较轻,往往容易误诊及漏诊,临床治疗后症状加重尤其出现偏瘫者需及时复查CT或MRI,早期诊断,及时治疗,预后多较好.     

Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury

This case report describes a child with severe traumatic brain injury with clinical features of autonomic dysfunction in the immediate post-traumatic period. A history of severe asthma in this child contraindicated the use of beta-blockers, the first line approach, and she was managed with bromocriptine (0.05 mg/kg t.d.s) with good effect.     

The acute management of children's brain injuries

Traumatic brain injury is the leading cause of death in children in the UK. The pathway of care for severely brain injured children involves ambulance services, local and regional hospitals and regional trauma, critical care and rehabilitation networks. With so many stakeholders, effective advocacy for these children requires an understanding of their whole journey. Indeed, review of the pathway provides an opportunity to reflect on how improvements may be achieved.     

Incidence and mortality of moderate and severe traumatic brain injury in children: A ten year population-based cohort study in Norway

ObjectiveIn this study we wanted to estimate population-based rates of incidence and mortality of moderate and severe traumatic brain injury (TBI) in children in one specific region in Norway.MethodsIn the region there are seven acute care hospitals (ACHs) in addition to a Level 1 trauma centre. Of 702 869 inhabitants (2014), 145 395 were children aged 0–16 years. Data were collected during ten years (2004–2014). All children aged 0–16 years with moderate (Glasgow Coma Scale [GCS] score 9–13) or severe (GCS score ≤ 8) TBI admitted to the Level 1 trauma centre were prospectively included. Children treated outside the Level 1 trauma centre were retrospectively included from the ACHs. Children who died from TBI prehospitally were included from the National Cause of Death Registry. Poisson regression was used to estimate incidence rate ratios (with a 95% confidence interval) comparing age, sex, and time periods.ResultsA total of 71 children with moderate or severe TBI were identified. Crude incidence rates were 2·4 (95% CI 1·7–3·3) for moderate and 2·5 (95% CI 1·8–3·4) for severe TBI per 100 000 person-years (py). Mortality rate from TBI was 1·2 (95% CI 0·7–1·9) per 100 000 py, and 88% were prehospital deaths.ConclusionThe incidence rates and mortality of moderate and severe TBI were low compared to international reports. Most likely explained by successful national prevention of TBI.     

Performance monitoring in children following traumatic brain injury

Background:  Executive control deficits are common sequelae of childhood traumatic brain injury (TBI). The goal of the current study was to assess a specific executive control function, performance monitoring, in children following TBI.
Methods:  Thirty-one children with mild–moderate TBI, 18 with severe TBI, and 37 control children without TBI, of comparable age and sex, performed the stop signal task, a speeded choice reaction time task. On occasion, they were presented with a signal to stop their responses. Performance monitoring was defined as the extent of slowing in go-task reaction time following failure to stop responses.
Results:  The TBI group as a whole demonstrated less post-error slowing than did controls. This finding suggested impaired error monitoring performance. In addition, time since injury and socioeconomic status predicted less slowing after stopped responses.
Conclusions:  We suggest that alterations in performance monitoring expressed as the inability to notice, regulate and adjust behavior to changing situations are an effect of TBI in children.     

Neuroprotection in paediatric traumatic brain injury

Traumatic brain injury (TBI) is the leading cause of trauma-related death and disability in children worldwide. The outcome from TBI can be improved by early aggressive management of oxygenation and blood pressure. There is evidence to suggest that adhering to guidelines when managing these patients can have a positive effect on the outcomes. In this article we review the general supportive and targeted neuroprotective measures that are outlined in international paediatric guidelines and are most widely used in the critical care management of patients with TBI; we further review how these measures can influence the underlying evolving pathophysiology in these patients. The aim of critical care management of patients with TBI is to prevent or limit secondary brain injury by optimizing cerebral perfusion and oxygenation to improve survival and clinical outcomes. We also discuss how to monitor patients with traumatic brain injury on the paediatric intensive care unit and we give a practical approach on how to respond to deteriorating patients and to the complications arising during the course of their management.     

Mild traumatic brain injury: improving quality of care in the paediatric emergency department setting

Aim: Traumatic brain injury (TBI) in childhood can impose a significant threat to life and longer‐term disability. This study investigated the extent to which the documentation of key indicators of healthcare quality in the emergency department (ED) setting was consistent with clinical guidelines for the management of children with mild TBI (MTBI). Methods: The clinical records of a random sample of 60 children (stratified by ethnicity and age group), who were seen and discharged from a large metropolitan paediatric hospital ED following a head injury, were systematically reviewed to examine the processes of care and follow‐up. Results: Based on the documentation in clinical records, processes designed to identify and manage potentially life‐threatening acute complications (e.g. computed tomography scanning to identify intracranial haemorrhage) were consistent with best practice standards. However gaps existed between current and best practice for some aspects of care that could minimise risks of longer‐term disability from MTBI. For example, relevant clinical criteria were well documented, but this information did not appear to be applied systematically to identify and to follow up children with definite or possible MTBI. Conclusion: The apparent absence of a systematic approach to the diagnosis and follow‐up of MTBI in children presenting to ED suggests a missed opportunity to minimise the risk of disability following these injuries. Greater attention to an integrated care pathway that improves the identification, documentation, and follow‐up of children with MTBI presenting to ED is required.     

Elevated lactate as an early marker of brain injury in inflicted traumatic brain injury

Background: Traumatic brain injury is a major cause of disability and death in the pediatric population. The metabolic and neurochemical abnormalities that underlie traumatic brain injury remain poorly understood, but hypoxia-ischemic injury might play an important role. Objective: This study evaluated children with inflicted traumatic brain injury using magnetic resonance spectroscopy (MRS). We postulated that children with hypoxic-ischemic injury indicated by elevated lactate in the acute phase of injury will have worse early neurological status and short-term clinical outcomes than those without lactate upon MRS. Materials and methods: This prospective study employed proton MRS to sample bilaterally the frontal lobes and the parasagittal cortex within the parietal and occipital lobes of 11 patients with inflicted traumatic brain injury who were undergoing a clinical MRI examination. Patients measured clinical course while hospitalized included initial neurological evaluation, presence of seizure activity, need for admission to the pediatric intensive care unit (PICU), number of days hospitalized, presence of retinal hemorrhages and presence of bone fractures. Measurement of outcome was determined using the Pediatric Overall Performance Category Scale (POPCS; 1 = good performance; 6 = death). Results: Four children demonstrated elevated lactate and diminished N-acetyl aspartate (a neuronal marker) within several regions, indicating global ischemic injury (lactate-positive global group). These four children all had seizure activity and abnormal initial neurological examinations and required admission to the PICU. The mean POPCS for this group was 3.25. In four other children, lactate was detected within at least one region, indicating a focal ischemic injury (lactate-positive focal group); two of these children had seizure activity, and two had an abnormal initial neurological examination. The mean POPCS score was 1.5 for this group. The remaining three children had no evidence of lactate upon MRS (lactate-negative group). These children did not have seizure activity, did not require admission to the PICU, nor did they have initial abnormal neurological examinations. The mean POPCS score was 1.3 for this group. Summary: Patients with inflicted traumatic brain injury and evidence of hypoxic-ischemic injury as indicated by elevated lactate on MRS tend to have worse early neurological status and early outcome scores. Lactate levels as sampled by MRS might predict early clinical outcome in inflicted traumatic brain injury.     

Vitamin D deficiency rickets and allegations of non-accidental injury

Vitamin D deficiency rickets has long been recognized as a cause of fractures and fracture-like appearances in young children. Often seen in the early 20th century, rickets has recently been regarded as uncommon; the radiological appearances, familiar to previous generations, may not be recognized for what they are.
This article reports four children with unexplained fractures initially attributed confidently to non-accidental injury. In each case, the later evidence of vitamin D deficiency led to a reconsideration of that diagnosis.
Conclusion:  It is important to be aware of this bone disorder in the differential diagnosis of fractures, to investigate appropriately and to recognize that the radiological appearances may be misleading. A mistaken diagnosis of abuse does real harm, not least to the child itself.     

A pilot study on the effects of early use of valproate sodium on neuroinflammation after traumatic brain injury北大核心CSCD

Objective To study the effect of early use of sodium valproate on neuroinflammation after traumatic brain injury (TBI). Methods A total of 45 children who visited in Xuzhou Children's Hospital Affiliated to Xuzhou Medical University from August 2021 to August 2022 were enrolled in this prospective study, among whom 15 healthy children served as the healthy control group, and 30 children with TBI were divided into a sodium valproate treatment group and a conventional treatment group using a random number table (n=15 each). The children in the sodium valproate treatment group were given sodium valproate in addition to conventional treatment, and those in the conventional group were given an equal volume of 5% glucose solution in addition to conventional treatment. The serum concentrations of nucleotide-binding oligomerization domain-like receptor protein 3(NLRP3), high-mobility group box 1 (HMGB1), tumor necrosis factor-α (TNF-α), and interleukin-1β (IL-1β) were measured in the healthy control group on the day of physical examination and in the children with TBI on days 1, 3, and 5 after admission. Glasgow Outcome Scale-Extended (GOS-E) score was evaluated for the children with TBI 2 months after discharge. Results Compared with the healthy control group, the children with TBI had significantly higher serum concentrations of NLRP3, HMGB1, TNF- α, and IL-1β on day 1 after admission (P<0.017). The concentration of NLRP3 on day 5 after admission was significantly higher than that on days 1 and 3 after admission in the children with TBI (P<0.017). On days 3 and 5 after admission, the sodium valproate treatment group had a significantly lower concentration of NLRP3 than the conventional treatment group (P<0.05). For the conventional treatment group, there was no significant difference in the concentration of HMGB1 on days 1, 3, and 5 after admission (P>0.017), while for the sodium valproate treatment group, the concentration of HMGB1 on day 5 after admission was significantly lower than that on days 1 and 3 after admission (P<0.017). On day 5 after admission, the sodium valproate treatment group had a significantly lower concentration of HMGB1 than the conventional treatment group (P<0.05). For the children with TBI, the concentration of TNF-α on day 1 after admission was significantly lower than that on days 3 and 5 after admission (P<0.017). On days 3 and 5 after admission, the sodium valproate treatment group had a significantly lower concentration of TNF-α than the conventional treatment group (P<0.05). The concentration of IL-1β on day 3 after admission was significantly lower than that on days 1 and 5 after admission (P<0.017) in the children with TBI. On days 3 and 5 after admission, the sodium valproate treatment group had a significantly lower concentration of IL-1β than the conventional treatment group (P<0.05). The GOS-E score was significantly higher in the sodium valproate treatment group than that in the conventional treatment group 2 months after discharge (P<0.05). Conclusions Early use of sodium valproate can reduce the release of neuroinflammatory factors and improve the prognosis of children with TBI. © 2023 Xiangya Hospital of CSU. All rights reserved.     

Predictive value of clinical and radiological findings in inflicted traumatic brain injury

Aims: The aim of this study is to evaluate the value of early radiological investigations in predicting the long‐term neurodevelopmental outcome of infants with inflicted traumatic brain injury (ITBI). Methods: Clinical and radiological investigations of 24 infants with ITBI were performed during the acute phase of injury (1–3 days), and during the early (4 days up to 3 months) and late (>9 months) postinjury phases. The clinical outcome in survivors (n = 22) was based on the Rankin Disability Scale and the Glasgow Outcome Score. Results: Five out of 24 infants (21%) had a poor neurodevelopmental outcome (death and severe disability), 17 infants (71%) had different developmental problems and 2 infants were normal at the mean age of 62 (54–70) (95% CI) months. A low initial Glasgow Coma Scale score of 8 or below [p < 0.05, OR 13.0 (1.3–133.3)], the development of brain oedema [p < 0.005, OR 13.0 (1.6–773)], focal changes in the basal ganglia during the acute phase [p < 0.01, OR 45 (2.1–937.3)], the development of new intracerebral focal changes early postinjury [p < 0.05, OR 24.1(1.0–559.1)], a decrease in white matter [p < 0.01, OR 33 (1.37–793.4)] and the development of severe atrophy before 3 months postinjury [p < 0.05, OR 24 (11.0–559.1)] were significantly correlated with a poor neurodevelopmental outcome. Conclusions: Early clinical and radiological findings in ITBI are of prognostic value for neurodevelopmental outcome.     

Non-accidental fractures in infants: risk of further abuse

OBJECTIVES: To look for features of non-accidental fractures in infants aged under I year and assess the risk of subsequent morbidity and mortality. METHODOLOGY: A retrospective analysis of 99 children aged under 1 year who presented to the Mater Children's Hospital, Brisbane, between January 1990 and December 1993, and were found to have a fracture. The 99 infants were divided into non-accidental and accidental groups. Comparison was made between the two groups for age, sex and type of fracture. Deaths, subsequent injuries and child protection notifications until March 1997 were compared between groups. RESULTS: Of the 99 infants with fracture (64 males, 35 female), the skull and femur were the most prevalent sites of fracture. Twenty-six infants had fractures assessed as non-accidental. This group was younger but did not differ significantly in gender or site of fracture. Infants aged under 4 months had a significantly greater risk of their fracture being non-accidental (P = 0.0007). Subsequent substantiated child protection notifications occurred in nine of the non-accidental group and in one of the accidental group (P = 0.000001). There was no significant difference in the rate of subsequent notifications between those infants with abuse who were removed from their carers and those not removed. Subsequent injuries presenting to hospital occurred in 17 of the accidental group and three of the non-accidental group (P = 0.20). There were no deaths. CONCLUSION: Infants aged under 1 year with fractures have a high prevalence of abuse. The risk of abuse as cause for the fracture is greater in those aged under 4 months. Infants with non-accidental fractures have a high risk of further abuse even with intervention.     

Skeletal imaging of child abuse (non-accidental injury)

In recent years there has been a worldwide increased awareness that children are physically abused by their carers. Radiologists play a vital role in the detection of inflicted injuries. This article reviews the skeletal imaging findings seen in child abuse.     

Neurocritical care and traumatic brain injury

The majority of severely head injured children will not require neurosurgery. For the pediatrician, the central question must be whether medical interventions are effective in limiting morbidity and treating the problem of cerebral oedema. However, in order to address this issue we need to give some thought to the system of care in which we practice, how we assess the severity of brain injury and whether, in regard to pathophysiology, responses in children are significantly different from those seen in adults. In this regard, this review highlights some of the recent pediatric neurocritical care literature and provides, for the clinician, a framework on which to base ones medical management of severe traumatic brain injury occurring in childhood.