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Kouitcheu R, Diallo M, Mbende A, Pape A, Sugewe E, Varlet G. Traumatic brain injury in children: 18 years of management. Pan Afr Med J 2020; 37:235. [PMID: 33552353 PMCID: PMC7847206 DOI: 10.11604/pamj.2020.37.235.23400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/26/2020] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury in children is a common cause of emergency department admission to our institution. The aim was to summarize the management of all head injuries in children. This was a retrospective, descriptive single center study performed in the Neurosurgery Department, University Hospital Center, Yopougon-Abidjan, Ivory Coast from January 2000 to December 2017. We included all patients less than 16-years-old admitted to the emergency department and all admitted in neurosurgery department for a traumatic brain injury with a cerebral tomodensitometry and/or a magnetic resonance imaging. 292 patients were admitted in neurosurgery department during the study period. The average age of our patients was 7.8 ± 0.80 years with a male predominance (64%). Road accidents were the main causes (78.7%) followed by falls. Brain trauma was mild in 53.8% of cases, moderate in 36.8% and severe in 9.4% of cases. Initial loss of consciousness and headache were the main reasons for admission to the emergency room after the injury with a proportion of 87.6%. The oedemato-haemorrhagic contusion was the most frequent lesion found in our patients with a frequency of 33.9%. The surgery was performed in 36.9% of cases. The overall mortality of patients in the study remains high with a proportion of 13.18%. Traumatic brain injuries in children had a high mortality rate in our practice. Specialized centers should be developed to optimize their care.
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Affiliation(s)
- Romuald Kouitcheu
- Neurosurgery Department, University Hospital Center of Yopougon, Abidjan, Ivory Coast
| | - Moussa Diallo
- Neurosurgery Department, University Hospital Center of Yopougon, Abidjan, Ivory Coast.,Neurosurgery Department, University Hospital Center of Gabriel Touré, Bamako, Mali
| | - Alban Mbende
- Neurosurgery Department, University Hospital Center of Yopougon, Abidjan, Ivory Coast.,Neurosurgery Department, King´s College Hospital National Health Service Trust, London, United Kingdom
| | - Aïcha Pape
- Neurosurgery Department, University Hospital Center of Yopougon, Abidjan, Ivory Coast
| | - Ernest Sugewe
- Neurosurgery Department, University Hospital Center of Yopougon, Abidjan, Ivory Coast
| | - Guy Varlet
- Neurosurgery Department, University Hospital Center of Yopougon, Abidjan, Ivory Coast
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Pedersen SH, Lilja-Cyron A, Astrand R, Juhler M. Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma. Front Neurol 2020; 10:1376. [PMID: 32010042 PMCID: PMC6973131 DOI: 10.3389/fneur.2019.01376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/12/2019] [Indexed: 01/09/2023] Open
Abstract
Purpose of Review: Monitoring of intracranial pressure (ICP) is an important and integrated part of the treatment algorithm for children with severe traumatic brain injury (TBI). Guidelines often recommend ICP monitoring with a treatment threshold of 20 mmHg. This focused review discusses; (1) different ICP technologies and how ICP should be monitored in pediatric patients with severe TBI, (2) existing evidence behind guideline recommendations, and (3) how we could move forward to increase knowledge about normal ICP in children to support treatment decisions. Summary: Current reference values for normal ICP in adults lie between 7 and 15 mmHg. Recent studies conducted in “pseudonormal” adults, however, suggest a normal range below this level where ICP is highly dependent on body posture and decreases to negative values in sitting and standing position. Despite obvious physiological differences between children and adults, no age or body size related reference values exist for normal ICP in children. Recent guidelines for treatment of severe TBI in pediatric patients recommend ICP monitoring to guide treatment of intracranial hypertension. Decision on ICP monitoring modalities are based on local standards, the individual case, and the clinician's choice. The recommended treatment threshold is 20 mmHg for a duration of 5 min. Both prospective and retrospective observational studies applying different thresholds and treatment strategies for intracranial hypertension were included to support this recommendation. While some studies suggest improved outcome related to ICP monitoring (lower rate of mortality and severe disability), most studies identify high ICP as a marker of worse outcome. Only one study applied age-differentiated thresholds, but this study did not evaluate the effect of these different thresholds on outcome. The quality of evidence behind ICP monitoring and treatment thresholds in severe pediatric TBI is low and treatment can potentially be improved by knowledge about normal ICP from observational studies in healthy children and cohorts of pediatric “pseudonormal” patients expected to have normal ICP. Acceptable levels of ICP − and thus also treatment thresholds—probably vary with age, disease and whether the patient has intact cerebral autoregulation. Future treatment algorithms should reflect these differences and be more personalized and dynamic.
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Affiliation(s)
| | | | - Ramona Astrand
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol 2019; 10:1261. [PMID: 32038449 PMCID: PMC6988791 DOI: 10.3389/fneur.2019.01261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/13/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Improved methods of monitoring real-time cerebral physiology are needed to better understand when secondary brain injury develops and what treatment strategies may alleviate or prevent such injury. In this review, we discuss emerging technologies that exist to better understand intracranial pressure (ICP), cerebral blood flow, metabolism, oxygenation and electrical activity. We also discuss approaches to integrating these data as part of a multimodality monitoring strategy to improve patient care.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - Brian T Burrows
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Stephen Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
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Multimodality neuromonitoring in severe pediatric traumatic brain injury. Pediatr Res 2018; 83:41-49. [PMID: 29084196 DOI: 10.1038/pr.2017.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/31/2017] [Indexed: 12/18/2022]
Abstract
Each year, the annual hospitalization rates of traumatic brain injury (TBI) in children in the United States are 57.7 per 100K in the <5 years of age and 23.1 per 100K in the 5-14 years age group. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Historically, TBI management has been guided by clinical examination. This has been assisted progressively by clinical imaging, intracranial pressure (ICP) monitoring, and finally a software that can calculate optimal brain physiology. Multimodality monitoring affords clinicians an early indication of secondary insults to the recovering brain including raised ICP and decreased cerebral perfusion pressure. From variables such as ICP and arterial blood pressure, correlations can be drawn to determine parameters of cerebral autoregulation (pressure reactivity index) and "optimal cerebral perfusion pressure" at which the vasculature is most reactive. More recently, significant advances using both direct and near-infrared spectroscopy-derived brain oxygenation plus cerebral microdialysis to drive management have been described. Here in, we provide a perspective on the state-of-the-art techniques recently implemented in clinical practice for pediatric TBI.
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Shen L, Wang Z, Su Z, Qiu S, Xu J, Zhou Y, Yan A, Yin R, Lu B, Nie X, Zhao S, Yan R. Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis. PLoS One 2016; 11:e0168901. [PMID: 28030638 PMCID: PMC5193438 DOI: 10.1371/journal.pone.0168901] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 12/05/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The Brain Trauma Foundation (BTF) guidelines published in 2007 suggest some indications for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). However, some studies had not shown clinical benefit in patients with severe TBI; several studies had even reported that ICP monitoring was associated with an increased mortality rate. The effect of ICP monitoring has remained controversial, regardless of the ICP monitoring guidelines. Here we performed a meta-analysis of published studies to assess the effects of ICP monitoring in patients with severe TBI. METHODS We searched three comprehensive databases, the Cochrane Library, PUBMED, and EMBASE, for studies without limitations published up to September 2015. Mortality, ICU LOS, and hospital LOS were analyzed with Review Manager software according to data from the included studies. RESULTS Eighteen eligible studies involving 25229 patients with severe TBI were included in our meta-analysis. The results indicated no significant reduction in the ICP monitored group in mortality (hospitalized before 2007), hospital mortality (hospitalized before 2007), mortality in randomized controlled trials. However, overall mortality, mortality (hospitalized after 2007), hospital mortality (hospitalized after 2007), mortality in observational studies (hospitalized after 2007), 2-week mortality, 6-month mortality, were reduced in ICP monitored group. Patients with an increased ICP were more likely to require ICP monitoring. CONCLUSION Superior survival was observed in severe TBI patients with ICP monitoring since the third edition of "Guidelines for the Management of Severe Traumatic Brain Injury," which included "Indications for intracranial pressure monitoring," was published in 2007.
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Affiliation(s)
- Liang Shen
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Zhuo Wang
- Department of Medical College, Nursing College of Huzhou University, Huzhou, Zhejiang, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Sheng Qiu
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Jie Xu
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Yue Zhou
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Ai Yan
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Rui Yin
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Bin Lu
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Xiaohu Nie
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Shufa Zhao
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Renfu Yan
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, Zhejiang, China
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Abstract
OPINION STATEMENT Pediatric severe traumatic brain injury continues to be a major cause of disability and death. Rapid initial airway and hemodynamic stabilization is critical, followed by the need for immediate recognition of intracranial pathology that requires neurosurgical intervention. Intracranial hypertension and cerebral hypoperfusion have been recognized as major insults after trauma and management should be directed at preventing both. Sedation with opioids, moderate hyperventilation to arterial carbon dioxide level of 35-40 mmHg, hyperosmolar therapy with 3 % saline or mannitol, normothermia, and cerebrospinal fluid drainage continue to be the cornerstones of initial management of intracranial hypertension (intracranial pressure >20 mmHg). Refractory intracranial hypertension is treated with high-dose barbiturate therapy to achieve medical burst suppression on electroencephalography and decompressive craniectomy. In addition, those children require antiepileptic medications for seizure prophylaxis, adequate nutritional management, and early physical therapy and rehabilitation referrals. Most of the evidence for care of children with brain injury comes from center-specific practice and experience rather than objective data. This lack of evidence provides the ground for ongoing research; nevertheless, outcomes after traumatic brain injury continue to show improvement.
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Affiliation(s)
- Haifa Mtaweh
- Department of Critical Care Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada,
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Clevenger AC, Kilbaugh T, Margulies SS. Carotid artery blood flow decreases after rapid head rotation in piglets. J Neurotrauma 2014; 32:120-6. [PMID: 25133889 DOI: 10.1089/neu.2014.3570] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Modification of cerebral perfusion pressure and cerebral blood flow (CBF) are crucial components of the therapies designed to reduce secondary damage after traumatic brain injury (TBI). Previously we documented a robust decrease in CBF after rapid sagittal head rotation in our well-validated animal model of diffuse TBI. Mechanisms responsible for this immediate (<10 min) and sustained (∼24 h) reduction in CBF have not been explored. Because the carotid arteries are a major source of CBF, we hypothesized that blood flow through the carotid arteries (Q) and vessel diameter (D) would decrease after rapid nonimpact head rotation without cervical spine injury. Four-week-old (toddler) female piglets underwent rapid (<20 msec) sagittal head rotation without impact, previously shown to produce diffuse TBI with reductions in CBF. Ultrasonographic images of the bilateral carotid arteries were recorded at baseline (pre-injury), as well as immediately after head rotation and 15, 30, 45, and 60 min after injury. Diameter (D) and waveform velocity (V) were used to calculate blood flow (Q) through the carotid arteries using the equation Q=(0.25)πD(2)V. D, V, and Q were normalized to the pre-injury baseline values to obtain a relative change after injury in right and left carotid arteries. Three-way analysis of variance and post-hoc Tukey-Kramer analyses were used to assess statistical significance of injury, time, and side. The relative change in carotid artery diameter and flow was significantly decreased in injured animals in comparison with uninjured sham controls (p<0.0001 and p=0.0093, respectively) and did not vary with side (p>0.39). The average carotid blood velocity did not differ between sham and injured animals (p=0.91). These data suggest that a reduction in global CBF after rapid sagittal head rotation may be partially mediated by a reduction in carotid artery flow, via vasoconstriction.
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Affiliation(s)
- Amy C Clevenger
- 1 Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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Badri S, Chen J, Barber J, Temkin NR, Dikmen SS, Chesnut RM, Deem S, Yanez ND, Treggiari MM. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med 2012; 38:1800-9. [PMID: 23011528 DOI: 10.1007/s00134-012-2655-4] [Citation(s) in RCA: 162] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 07/09/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE Elevated intracranial pressure (ICP) has been associated with increased mortality in patients with severe traumatic brain injury (TBI). We have examined whether raised ICP is independently associated with mortality, functional status and neuropsychological functioning in adult TBI patients. METHODS Data from a randomized trial of 499 participants were secondarily analyzed. The primary endpoints were mortality and a composite measure of functional status and neuropsychological function (memory, speed of information processing, executive function) over a 6-month period. The area under the curve of the ICP profile (average ICP) during the first 48 h of monitoring was the main predictor of interest. Multivariable regression was used to adjust for a priori defined confounders: age, Glasgow Coma Score, Abbreviated Injury Scale-head and hypoxia. RESULTS Of the participants, 365 patients had complete 48-h ICP data. The overall 6-month mortality was 18 %. The adjusted odds ratio of mortality comparing 10-mmHg increases in average ICP was 3.12 (95 % confidence interval 1.79, 5.44; p < 0.01). Overall, higher average ICP was associated with decreased functional status and neuropsychological functioning (p < 0.01). Importantly, among survivors, increasing average ICP was not independently associated with worse performance on neuropsychological testing (p = 0.46). CONCLUSIONS Average ICP in the first 48 h of monitoring was an independent predictor of mortality and of a composite endpoint of functional and neuropsychological outcome at the 6-month follow-up in moderate or severe TBI patients. However, there was no association between average ICP and neuropsychological functioning among survivors.
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Affiliation(s)
- Shide Badri
- Department of Anesthesiology and Pain Medicine, Harborview Anesthesiology Research Center, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104, USA
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Chambers IR, Stobbart L, Jones PA, Kirkham FJ, Marsh M, Mendelow AD, Minns RA, Struthers S, Tasker RC. Age-related differences in intracranial pressure and cerebral perfusion pressure in the first 6 hours of monitoring after children's head injury: association with outcome. Childs Nerv Syst 2005; 21:195-9. [PMID: 15580513 DOI: 10.1007/s00381-004-1060-x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Severe head injury in childhood is associated with considerable mortality and morbidity. In this study we determined age-related differences in the relationship between outcome and intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in the first 6 h of monitoring in a large cohort of head-injured children. METHODS Two hundred and thirty-five head-injured children (admitted to five UK hospitals over a 15-year period) in whom intracranial pressure monitoring was clinically indicated were studied. RESULTS Patients were divided into three age groups (2-6, 7-10 and 11-16 years). The sensitivity of ICP and CPP were similar. Differences were found in the specificity of ICP and CPP for each group and these were more marked for CPP. For a specificity of 50% the pressures were 53, 63 and 66 mmHg for the three age groups. CONCLUSIONS There are age-related differences in the specificity of intracranial pressure and cerebral perfusion pressure in relation to outcome. These differences may be important in the clinical management of head-injured children. Thus cerebral perfusion pressures of 53, 63 and 66 mmHg should be the minimum to strive for in these three age groups respectively.
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Affiliation(s)
- I R Chambers
- Regional Medical Physics Department, Newcastle General Hospital, Newcastle upon Tyne, NE4 6BE, UK.
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