Low brain oxygenation and differences in neuropsychological outcomes following severe pediatric TBI

Schrieff-Elson, Leigh E.; Thomas, Kevin G. F.; Rohlwink, Ursula K.; Figaji, Anthony

doi:10.1007/s00381-015-2892-2

Cited by 21 publications

(16 citation statements)

References 63 publications

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“…Data from the largest series ( 126 ) is consistent with the adult experience in terms of thresholds related to outcome, although one report suggested a higher threshold may be more predictive for a favorable outcome ( 128 ). Published data and clinical experience also confirm its value as an ancillary test in patients diagnosed with brain death and as predictors of mortality and functional outcome ( 123 , 126 , 129 ). Whether treatment directed at maintaining PbtO2 improves outcomes is yet to be determined in adults and children.…”

Section: Brain Physiology and Monitoringmentioning

confidence: 68%

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

Figaji

2017

Front. Neurol.

128

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General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

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Section: Brain Physiology and Monitoringmentioning

confidence: 68%

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

Figaji

2017

Front. Neurol.

128

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“…The CBCL has both reported validity and reliability (Achenbach and Rescorla, 2001 ). There are some published research studies using the CBCL with South African samples (e.g., Shields et al, 2008 ; Palin et al, 2009 ; Schrieff-Elson et al, 2015 ).…”

Section: Methodsmentioning

confidence: 99%

“…The BRIEF shows high levels of internal consistency and stability, as well as test-retest reliability (Malloy and Grace, 2005 ; Chapman et al, 2010 ). It has been used cross-culturally in published studies, for example, in the Han Chinese and Dutch populations (Qian et al, 2010 ; Huizinga and Smidts, 2011 ) and in a published SA study (Schrieff-Elson et al, 2015 ).…”

Section: Methodsmentioning

confidence: 99%

Academic and Behavioral Outcomes in School-Age South African Children Following Severe Traumatic Brain Injury

2017

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Background: Children who have sustained severe traumatic brain injuries (TBIs) demonstrate a range of post-injury neurocognitive and behavioral sequelae, which may have adverse effects on their academic and behavioral outcomes and interfere with school re-entry, educational progress, and quality of life. These post-TBI sequelae are exacerbated within the context of a resource-poor country like South Africa (SA) where the education system is in a somewhat precarious state especially for those from disadvantaged backgrounds.Objectives: To describe behavioral and academic outcomes of a group of school-aged SA children following severe TBI.Methods: The sample included 27 school-age children who were admitted to the Red Cross War Memorial Children's Hospital (RXH), SA, between 2006 and 2011 for closed severe TBI and who received intracranial monitoring. We collected behavioral data using the Child Behavior Checklist (CBCL) and the Behavior Rating Inventory of Executive Function (BRIEF) and academic information sourced from the BRIEF, CBCL, medical folders, and caregivers. Analyses include descriptive statistics and bivariate correlation matrices.Results: The descriptive results show that (1) more than half of the participants experienced clinically-significant behavioral problems across the CBCL scales, (2) the working memory BRIEF subscale appeared to be the most problematic subdomain, (3) two thirds of the sample were receiving some form of, or were in the process of being placed in, special needs education, (4) there was a three-fold increase in the use of special education services from pre- to post-injury, and (5) more than half (n = 16) of the sample repeated at least one grade after returning to school post-injury. Correlation analyses results suggest that children with increased externalizing behavioral problems and executive dysfunction are more likely to repeat a grade post-injury; and that children with executive dysfunction post-TBI are more likely to require some form of special educational services.Conclusion: While there is a vast amount of literature on pediatric TBI (pTBI) academic and behavioral outcomes, little literature exists on the pTBI population from the developing world and SA specifically. This is important to address given unique challenges that face the country and its educational system, and its implications for the management and care of children post-TBI.

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“…In a prospective study of 53 patients with severe TBI, the authors found that the use of both ICP and brain tissue PbtO 2 monitors and therapy directed at brain tissue PO 2 was associated with reduced patient death following severe TBI (115). Furthermore, in a recently published study, the authors found that reaching a critical PbtO 2 threshold of ≤10 mmHg might be detrimental to cognitive outcomes following TBI (116). …”

Section: Cerebral Oxygenationmentioning

confidence: 99%

Aspects on the Physiological and Biochemical Foundations of Neurocritical Care

2017

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Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood–brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.

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Low brain oxygenation and differences in neuropsychological outcomes following severe pediatric TBI

Abstract: Results demonstrate that low PbtO2 may be prognostic of not only mortality but also neuropsychological outcomes.

Cited by 21 publications

References 63 publications

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

Academic and Behavioral Outcomes in School-Age South African Children Following Severe Traumatic Brain Injury

Aspects on the Physiological and Biochemical Foundations of Neurocritical Care

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