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Janas AM, Miller KR, Stence NV, Wyrwa JM, Ruzas CM, Messer R, Mourani PM, Fink EL, Maddux AB. Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury. Neurocrit Care 2023:10.1007/s12028-023-01898-9. [PMID: 38148435 DOI: 10.1007/s12028-023-01898-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 11/16/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes. METHODS Children (3-17 years) admitted in 2010-2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site's trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h. RESULTS Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2-4). Patients with early MRI were a median age of 11 years (IQR 7-14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1-4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53-0.89) and worse WeeFIM scores (estimate β - 4.67, 95% confidence interval - 8.33 to - 1.01). CONCLUSIONS Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.
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Affiliation(s)
- Anna M Janas
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA.
| | - Kristen R Miller
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicholas V Stence
- Section of Neuroradiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jordan M Wyrwa
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine and Children's Hospital of Colorado, Aurora, CO, USA
| | - Christopher M Ruzas
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA
| | - Ricka Messer
- Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
| | - Aline B Maddux
- Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA
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Hong SJ, Wainwright MS, Abend NS, Appavu BL, Francoeur C, Erklauer JC, Guerguerian AM, Guerriero RM, Guilliams KP, Lee-Eng J, Loeb J, Lovett ME, Murphy SA, Pardo AC, Pineda JA, Ruzas CM, Topjian AA. A Survey of Pediatric Neurocritical Care Fellowship Training in North America. Pediatr Neurol 2023; 146:1-7. [PMID: 37356227 DOI: 10.1016/j.pediatrneurol.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/22/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Pediatric neurocritical care (PNCC) has emerged as a field to care for children at the intersection of critical illness and neurological dysfunction. PNCC fellowship programs evolved over the past decade to train physicians to fill this clinical need. We aimed to characterize PNCC fellowship training infrastructure and curriculum in the United States and Canada. METHODS Web-based survey of PNCC fellowship program leaders during November 2019 to January 2020. RESULTS There were 14 self-identified PNCC fellowship programs. The programs were supported by Child Neurology and/or Pediatric Critical Care Medicine divisions at tertiary/quaternary care institutions. Most programs accepted trainees who were board-eligible or board-certified in child neurology or pediatric critical care medicine. Clinical training consisted mostly of rotations providing PNCC consultation (n = 13) or as a provider on the pediatric intensive care unit-based neurointensive care team (n = 2). PNCC-specific didactics were delivered at most institutions (n = 13). All institutions provided training in electroencephalography use in the intensive care unit and declaration of death by neurological criteria (n = 14). Scholarly activity was supported by most programs, including protected time for research (n = 10). CONCLUSIONS We characterized PNCC fellowship training in the United States and Canada, which in this continuously evolving field, lays the foundation for exploring standardization of training going forward.
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Affiliation(s)
- Sue J Hong
- Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Mark S Wainwright
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Nicholas S Abend
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Brian L Appavu
- University of Arizona College of Medicine - Phoenix, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Conall Francoeur
- CHU de Québec - Université Laval Research Center, Quebec, Canada
| | | | | | - Réjean M Guerriero
- Washington University School of Medicine in St. Louis, St. Louis Children's Hospital, St. Louis, Missouri
| | - Kristin P Guilliams
- Washington University School of Medicine in St. Louis, St. Louis Children's Hospital, St. Louis, Missouri
| | | | - Joshua Loeb
- Loma Linda University Children's Hospital, Loma Linda, California
| | - Marlina E Lovett
- Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Sarah A Murphy
- Harvard Medical School, Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Andrea C Pardo
- Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jose A Pineda
- USC Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Christopher M Ruzas
- University of Colorado School of Medicine, Children's Hospital of Colorado, Aurora, Colorado
| | - Alexis A Topjian
- University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Piantino JA, Ruzas CM, Press CA, Subramanian S, Balakrishnan B, Panigrahy A, Pettersson D, Maloney JA, Vossough A, Topjian A, Kirschen MP, Doughty L, Chung MG, Maloney D, Haller T, Fabio A, Fink EL. Use of Magnetic Resonance Imaging in Neuroprognostication After Pediatric Cardiac Arrest: Survey of Current Practices. Pediatr Neurol 2022; 134:45-51. [PMID: 35835025 PMCID: PMC9883065 DOI: 10.1016/j.pediatrneurol.2022.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/11/2022] [Accepted: 06/13/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Use of magnetic resonance imaging (MRI) as a tool to aid in neuroprognostication after cardiac arrest (CA) has been described, yet details of specific indications, timing, and sequences are unknown. We aim to define the current practices in use of brain MRI in prognostication after pediatric CA. METHODS A survey was distributed to pediatric institutions participating in three international studies. Survey questions related to center demographics, clinical practice patterns of MRI after CA, neuroimaging resources, and details regarding MRI decision support. RESULTS Response rate was 31% (44 of 143). Thirty-four percent (15 of 44) of centers have a clinical pathway informing the use of MRI after CA. Fifty percent (22 of 44) of respondents reported that an MRI is obtained in nearly all patients with CA, and 32% (14 of 44) obtain an MRI in those who do not return to baseline neurological status. Poor neurological examination was reported as the most common factor (91% [40 of 44]) determining the timing of the MRI. Conventional sequences (T1, T2, fluid-attenuated inversion recovery, and diffusion-weighted imaging/apparent diffusion coefficient) are routinely used at greater than 97% of centers. Use of advanced imaging techniques (magnetic resonance spectroscopy, diffusion tensor imaging, and functional MRI) were reported by less than half of centers. CONCLUSIONS Conventional brain MRI is a common practice for prognostication after CA. Advanced imaging techniques are used infrequently. The lack of standardized clinical pathways and variability in reported practices support a need for higher-quality evidence regarding the indications, timing, and acquisition protocols of clinical MRI studies.
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Affiliation(s)
- Juan A Piantino
- Division of Child Neurology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon
| | - Christopher M Ruzas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Craig A Press
- Division of Neurology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Binod Balakrishnan
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - David Pettersson
- Division of Neuroradiology, Department of Diagnostic Radiology, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - John A Maloney
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Arastoo Vossough
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexis Topjian
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lesley Doughty
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Melissa G Chung
- Divisions of Critical Care Medicine and Pediatric Neurology, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - David Maloney
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tamara Haller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania.
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Abstract
BACKGROUND Traumatic brain injury (TBI) causes substantial morbidity and mortality in US children. Post-traumatic seizures (PTS) occur in 11-42% of children with severe TBI and are associated with unfavorable outcome. Electroencephalographic (EEG) monitoring may be used to detect PTS and antiepileptic drugs (AEDs) may be used to treat PTS, but national rates of EEG and AED use are not known. The purpose of this study was to describe the frequency and timing of EEG and AED use in children hospitalized after severe TBI. METHODS Retrospective cohort study of 2165 children at 30 hospitals in a probabilistically linked dataset from the National Trauma Data Bank (NTDB) and the Pediatric Health Information Systems (PHIS) database, 2007-2010. We included children (age <18 years old at admission) with linked NTDB and PHIS records, severe (Emergency Department [ED] Glasgow Coma Scale [GCS] <8) TBI, hospital length of stay >24 h, and non-missing disposition. The primary outcomes were EEG and AED use. RESULTS Overall, 31.8% of the cohort had EEG monitoring. Of those, 21.8% were monitored on the first hospital day. The median duration of EEG monitoring was 2.0 (IQR 1.0, 4.0) days. AEDs were prescribed to 52.0% of the cohort, of whom 61.8% received an AED on the first hospital day. The median duration of AED use was 8.0 (IQR 4.0, 17.0) days. EEG monitoring and AED use were more frequent in children with known risk factors for PTS. EEG monitoring and AED use were not related to hospital TBI volume. CONCLUSION EEG use is relatively uncommon in children with severe TBI, but AEDs are frequently prescribed. EEG monitoring and AED use are more common in children with known risk factors for PTS.
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Affiliation(s)
- Christopher M Ruzas
- Pediatric Critical Care, Children's Hospital Colorado, University of Colorado School of Medicine, 13199 E. Montview Blvd, Suite 300, Campus Mail F443, Aurora, CO, 80045, USA
| | - Peter E DeWitt
- Bioinformatics and Biostatistics, Colorado School of Public Health, Aurora, CO, USA
| | - Kimberly S Bennett
- Pediatric Critical Care, Children's Hospital Colorado, University of Colorado School of Medicine, 13199 E. Montview Blvd, Suite 300, Campus Mail F443, Aurora, CO, 80045, USA
| | - Kevin E Chapman
- Pediatric Neurology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Harlaar
- Department of Pediatrics, Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tellen D Bennett
- Pediatric Critical Care, Children's Hospital Colorado, University of Colorado School of Medicine, 13199 E. Montview Blvd, Suite 300, Campus Mail F443, Aurora, CO, 80045, USA.
- Adult and Child Consortium for Health Outcomes Research and Delivery Science (ACCORDS), Children's Hospital Colorado, University of Colorado, Aurora, CO, USA.
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Capitena CE, Wagoner HJ, Ruzas CM, Bennett TD, Baker PR, Jung JL, Weisfeld-Adams JD. Rapid resolution of infantile lipemia retinalis following exchange transfusion. J Inherit Metab Dis 2016; 39:889-890. [PMID: 27518769 DOI: 10.1007/s10545-016-9968-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/09/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Cara E Capitena
- Department of Pediatrics, Divisions of Pediatric Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Holly J Wagoner
- Department of Pediatrics, Divisions of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher M Ruzas
- Department of Pediatrics, Divisions of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Tellen D Bennett
- Department of Pediatrics, Divisions of Pediatric Critical Care, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter R Baker
- Department of Pediatrics, Divisions of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer L Jung
- Department of Pediatrics, Divisions of Pediatric Ophthalmology, University of Colorado School of Medicine, Aurora, CO, USA
| | - James D Weisfeld-Adams
- Department of Pediatrics, Divisions of Clinical Genetics and Metabolism, University of Colorado School of Medicine, Aurora, CO, USA
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