Implications of DTI in mild traumatic brain injury for detecting neurological recovery and predicting long-term behavioural outcome in paediatric and young population-a systematic review

Factors Associated with Loss to Follow-Up in Pediatric Concussion Patients after Initial Visit: A Retrospective Study at a Concussion Clinic

Objective

The objective of this retrospective study is to identify factors associated with loss to follow-up for postconcussion clearance in pediatric patients by comparing loss to follow-up and full clearance patients.

Study design

This retrospective single-center cohort study analyzed 140 consecutive patients at a pediatric concussion clinic of a safety-net hospital for loss to follow-up, defined as not achieving clearance at last appointment. Univariate and multivariate regression models were fit on variables of interest, including demographic, mechanism and severity of concussion, and characteristics of the first evaluation postconcussion and follow-up management.

Results

Of the sample, 40% (n = 56) achieved clearance and 60% (n = 84) were lost to follow-up. Median age was 15 (IQR 11-17), with male predominance (60.7%). Living with a biological parent (OR = 0.145, 95% CI = 0.028-0.760) and sports involvement (OR = 0.256, 95% CI = 0.092-0.764) were protective factors, while being 10 years old or older (OR = 13.466, 95% CI = 2.792-64.958) and attending 2 or fewer follow-up appointments (OR = 19.027, 95% CI = 4.991-72.533) were risk factors for loss to follow-up. No significant differences were found between sex, race, driving distance, type of insurance, and mechanism of injury.

Conclusions

Living with a biological parent and involvement in sports showed to be protective factors for loss to follow-up. Age at time of concussion and number of appointments were risk factors. A "golden window" of 2 appointments was identified, highlighting the need of a strong rapport and engagement in shared decision-making. Future directions include prospective studies implementing strategies targeting adolescents and building a strong patient-provider relationship.

Brain Function and Structure Changes in the Prognosis Prediction of Prolonged Disorders of Consciousness

OBJECTIVES

To observe the functional differences in the key brain areas in patients with different levels of consciousness after severe brain injury, and provide reference for confirming the objective diagnosis indicators for prolonged disorders of consciousness (pDoCs).

METHODS

This prospective study enrolled patients with pDoCs hospitalized in the department of rehabilitation medicine of our Hospital. Levels of consciousness and clinical outcomes were assessed according to diagnostic criteria and behavioral scales. Resting-state functional magnetic resonance imaging (rs-fMRI) and diffusion tensor imaging (DTI) of 30 patients with different levels of consciousness was performed. The patients were grouped as conscious or unconscious according to whether they regained consciousness during the 12-month follow-up.

RESULTS

Thirty patients were enrolled, including eight with unresponsive wakefulness syndrome/vegetative state, eight with minimally conscious state, six with emergence from the minimally conscious state, and eight with a locked-in syndrome. There were 19 and 11 patients in the conscious and unconscious groups. Compared with the unconscious group, the left basal nucleus was activated in the conscious group, and there were significant differences in white matter fiber bundles. Correlations were observed between the regional homogeneity (ReHo) value of the cerebellum and the Glasgow coma scale score (r = 0.387, P = 0.038) and between the ReHo value of the left temporal and the coma recovery scale-revised score (r = 0.394, P = 0.035).

CONCLUSIONS

The left insula and cerebellum might be important for regaining consciousness. The brain function activity and structural remodeling of the key brain regions and the activation level of the cerebellum are correlated with clinical behaviors and have potential application value for the prognosis prediction of pDoCs patients.

Executive functioning, behavior, and white matter microstructure in the chronic phase after pediatric mild traumatic brain injury: results from the adolescent brain cognitive development study

BACKGROUND

Mild traumatic brain injury (mTBI) is common in children. Long-term cognitive and behavioral outcomes as well as underlying structural brain alterations following pediatric mTBI have yet to be determined. In addition, the effect of age-at-injury on long-term outcomes is largely unknown.

METHODS

Children with a history of mTBI (n = 406; Mage = 10 years, SDage = 0.63 years) who participated in the Adolescent Brain Cognitive Development (ABCD) study were matched (1:2 ratio) with typically developing children (TDC; n = 812) and orthopedic injury (OI) controls (n = 812). Task-based executive functioning, parent-rated executive functioning and emotion-regulation, and self-reported impulsivity were assessed cross-sectionally. Regression models were used to examine the effect of mTBI on these domains. The effect of age-at-injury was assessed by comparing children with their first mTBI at either 0-3, 4-7, or 8-10 years to the respective matched TDC controls. Fractional anisotropy (FA) and mean diffusivity (MD), both MRI-based measures of white matter microstructure, were compared between children with mTBI and controls.

RESULTS

Children with a history of mTBI displayed higher parent-rated executive dysfunction, higher impulsivity, and poorer self-regulation compared to both control groups. At closer investigation, these differences to TDC were only present in one respective age-at-injury group. No alterations were found in task-based executive functioning or white matter microstructure.

CONCLUSIONS

Findings suggest that everyday executive function, impulsivity, and emotion-regulation are affected years after pediatric mTBI. Outcomes were specific to the age at which the injury occurred, suggesting that functioning is differently affected by pediatric mTBI during vulnerable periods. Groups did not differ in white matter microstructure.

Clinical performance of a multiparametric MRI-based post concussive syndrome index

Introduction

Diffusion Tensor Imaging (DTI) has revealed measurable changes in the brains of patients with persistent post-concussive syndrome (PCS). Because of inconsistent results in univariate DTI metrics among patients with mild traumatic brain injury (mTBI), there is currently no single objective and reliable MRI index for clinical decision-making in patients with PCS.

Purpose

This study aimed to evaluate the performance of a newly developed PCS Index (PCSI) derived from machine learning of multiparametric magnetic resonance imaging (MRI) data to classify and differentiate subjects with mTBI and PCS history from those without a history of mTBI.

Materials and methods

Data were retrospectively extracted from 139 patients aged between 18 and 60 years with PCS who underwent MRI examinations at 2 weeks to 1-year post-mTBI, as well as from 336 subjects without a history of head trauma. The performance of the PCS Index was assessed by comparing 69 patients with a clinical diagnosis of PCS with 264 control subjects. The PCSI values for patients with PCS were compared based on the mechanism of injury, time interval from injury to MRI examination, sex, history of prior concussion, loss of consciousness, and reported symptoms.

Results

Injured patients had a mean PCSI value of 0.57, compared to the control group, which had a mean PCSI value of 0.12 (p = 8.42e-23) with accuracy of 88%, sensitivity of 64%, and specificity of 95%, respectively. No statistically significant differences were found in the PCSI values when comparing the mechanism of injury, sex, or loss of consciousness.

Conclusion

The PCSI for individuals aged between 18 and 60 years was able to accurately identify patients with post-concussive injuries from 2 weeks to 1-year post-mTBI and differentiate them from the controls. The results of this study suggest that multiparametric MRI-based PCSI has great potential as an objective clinical tool to support the diagnosis, treatment, and follow-up care of patients with post-concussive syndrome. Further research is required to investigate the replicability of this method using other types of clinical MRI scanners.

Prognostic Factors and Outcome of Surgically Treated Supratentorial versus Infratentorial Epidural Hematoma in Pediatrics: A Comparative Study of 350 Patients at a Tertiary Center of a Developing Country

PURPOSE

In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients.

METHODS

This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score.

RESULTS

Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups.

CONCLUSIONS

Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission.