Cerebral Blood Flow Velocities and Functional Outcomes in Pediatric Mild Traumatic Brain Injury

Abstract

Outcomes can be challenging to predict in children with mild traumatic brain injury (TBI). Transcranial Doppler (TCD) ultrasound has become an increasingly useful modality in adult and pediatric TBI by measuring blood flow velocities within the circle of Willis. In children with moderate-to-severe TBI, multiple studies have correlated abnormal TCD measurements and poor outcomes. Additionally, TCD has shown value in assessing adults with mild brain injury. To date, there are no studies that correlate TCD findings and outcomes in children with mild TBI. We hypothesize that altered cerebral blood flow after mild TBI is associated with poor functional outcome using the Glasgow Outcome Scale-Extended, Pediatrics (GOS-E Peds). TCD was performed within 24 h of admission on 60 patients at a tertiary Level 1 children's hospital. A secondary analysis was performed on the subgroup of 28 mild TBI patients. GOS-E Peds was measured at the time of hospital discharge and 4-6 weeks post-discharge. Cerebral blood flow velocities did not show correlation with outcome. At discharge, the right-sided Spearman's correlation coefficient was 0.19 (p value = 0.33) and the left-sided was 0.36 (p = 0.06). At follow up the right-sided coefficient was -0.04 (p = 0.84), the left-sided was -0.25 (p = 0.24). Pulsatility index likewise showed no correlation. Right and left-sided correlation at discharge were -0.25 (p = 0.19) and 0.01 (p = 0.96), respectively. At follow up the right side showed 0.004 (p = 0.99), and the left showed 0.18 (p = 0.41). Although our data did not show correlation, it showed that the investigation could feasibly be done in pediatric patients with mild TBI. The study was limited by small sample size and infrequent outcome of interest. Future studies may help define the role of TCD in the large population of mild pediatric TBI patients.

A Pilot Prospective Observational Study of Cerebral Autoregulation and 12-Month Outcomes in Children With Complex Mild Traumatic Brain Injury: The Argument for Sufficiency Conditions Affecting TBI Outcomes

“…In addition, published studies lack quality of life data and/or only examined short-term outcomes. 8,9 The largest study of complex mild TBI published in 2011 showed that patients with mild TBI and intracranial hemorrhage had a substantial reduction in quality of life, participation in activities with others, and communication and care for themselves at 3 months after injury. 7 Since recovery after mild TBI is variable, with many children having residual long-term needs, 10 and since children with complex mild TBI may have more significant TBI, there is an unmet need to understand outcomes of children specifically with complex mild TBI.…”

“…Prior work has shown that impaired autoregulation occurs commonly in adolescents admitted with a sports-related concussion, 17 and in children with complex mild TBI, 14 and that there is no relationship between cerebral blood flow velocities and outcomes 4 to 6 weeks after injury. 8 However, the association between autoregulation status and long-term functional outcomes has not been studied. The specific aim of this study was to examine the association between static cerebral autoregulation measured by the autoregulatory index (ARI) during the first week after TBI and long-term outcomes in children with complex mild TBI.…”

“…Although patients with complex mild TBI are a subset of those with mild TBI, data on postdischarge outcomes from patients with complex mild TBI have been combined with patients with mild TBI who may be evaluated and discharged without admission to hospital. In addition, published studies lack quality of life data and/or only examined short-term outcomes 8,9. The largest study of complex mild TBI published in 2011 showed that patients with mild TBI and intracranial hemorrhage had a substantial reduction in quality of life, participation in activities with others, and communication and care for themselves at 3 months after injury 7.…”

“…Although cerebral autoregulation is a protective homeostatic mechanism that typically maintains adequate and near-constant cerebral blood flow, systemic hypotension after TBI can result in cerebral hypoperfusion or ischemia if mechanisms that govern cerebral autoregulation are only minimally or moderately impaired. Prior work has shown that impaired autoregulation occurs commonly in adolescents admitted with a sports-related concussion,17 and in children with complex mild TBI,14 and that there is no relationship between cerebral blood flow velocities and outcomes 4 to 6 weeks after injury 8. However, the association between autoregulation status and long-term functional outcomes has not been studied.…”

Best Practices for Obtaining Genomic Consent in Pediatric Traumatic Brain Injury Research

“…The informed consent and assent documents were provided in English and Spanish, with translation services available as needed. Interested individuals were enrolled into the parent study, the results of which have been previously published (Dienes, Chang & Reuter-Rice, 2018;Reuter-Rice, Regier, Bennett & Laskowitz, 2018;Vaewpanich & Reuter-Rice, 2016). The consent form allowed for the use of the collected samples for the parent study, as well as potential use in future related TBI studies.…”