Traumatic Brain Injury

Teacher-Reported Behavioral Disturbances in Children With Traumatic Brain Injury: An Examination of the BASC-2

Authors: Thaler NS, Mayfield J, Reynolds CR, Hadland C, Allen DN.

Pediatric traumatic brain injury (TBI) is associated with behavioral disturbances that can interfere with adjustment in the classroom. As such, standardized assessments of behavioral disturbances following TBI are useful in treatment planning and rehabilitation, although few studies have examined the sensitivity of standardized behavior assessments to behavioral abnormalities in this population. The present study compared the Behavior Assessment System for Children-Second Edition Teacher Rating Scale (BASC-2 TRS) profiles of 25 children who sustained TBI to those of 25 matched controls and to the BASC-2 standardization sample. Results indicated that teachers endorsed externalizing and school-related problems more severely and frequently than internalizing problems, with the greatest elevations on the Hyperactivity, Attention Problems, and Learning Problems subscales. In addition, BASC-2 scores appeared unrelated to IQ but were influenced by achievement functioning. Findings are consistent with previous studies of behavioral abnormalities in children with TBI and provide support for the usefulness of the BASC-2 TRS in evaluating behavioral disturbances in children that result from TBI.

Delayed extradural haemorrhage: a case for intracranial pressure monitoring in sedated children with traumatic brain injury within tertiary centres

Authors: Hughes A, Lee C, Kirkham F, Durnford AJ.

A 15-year-old girl sustained a mild isolated traumatic brain injury  following a pedestrian road traffic accident. She was ventilated for head computed tomography (CT) scan which revealed no intracranial abnormalities. Ventilation was not withdrawn until 15 h later when poor neurological recovery prompted urgent repeat CT, which demonstrated a delayed extradural haemorrhage (EDH). She underwent surgical evacuation, and intracranial pressure (ICP) monitoring was initiated postoperatively. She developed persistently raised ICP resistant to medical therapy, prompting further CT. This showed a recurrence of the delayed EDH requiring further surgical drainage. She made a good neurological recovery. There should be a low threshold for repeat CT to exclude delayed EDH when neurological status is poor despite normal CT soon after initial primary injury. ICP monitoring should be undertaken in children and adolescents who have normal initial CT, but in whom serial neurological assessment is not possible owing to sedation.

High-Dose Barbiturates for Refractory Intracranial Hypertension in Children With Severe Traumatic Brain Injury

Authors: Mellion SA, Bennett KS, Ellsworth GL, Moore K, Riva-Cambrin J, Metzger RR, Bratton SL.

OBJECTIVES:: To evaluate high-dose barbiturates as a second-tier therapy for pediatric refractory intracranial hypertension complicating severe traumatic brain injury. DESIGN:: This is a retrospective cohort study of children with refractory intracranial hypertension treated with high-dose barbiturates. SETTING:: A single center level I pediatric trauma from 2001 to 2010. PATIENTS:: Thirty-six children with refractory intracranial hypertension defined as intracranial pressure greater than 20 mm Hg despite standard management treated with high-dose barbiturates after severe traumatic brain injury. INTERVENTIONS:: High-dose barbiturates were administered for refractory intracranial hypertension for a minimum duration of 6 hrs and monitored by continuous electroencephalography. MEASUREMENTS AND MAIN RESULTS:: Exposure was control of refractory intracranial hypertension defined as > 20 mm Hg within 6 hrs after starting barbiturates. Pediatric cerebral performance category scores at hospital discharge and at 3 months (or longer) follow-up were the primary outcomes. Ten (28%) of 36 patients had control of refractory intracranial hypertension. Neither demographic nor injury characteristics were associated with refractory intracranial hypertension control. Children who responded received barbiturates significantly later after injury (76 vs. 29 median hours). Overall, 14 children died, 13 without control of intracranial pressure. Survival was more common in those who responded compared with those who did not respond to high-dose barbiturates, although this did not reach statistical significance (relative risk of death 0.2; 95% confidence interval; ). Of the 22 survivors, 19 had an acceptable survival (pediatric cerebral performance category less than 3) at 3 months or longer after injury; however, only three returned to normal function. Among survivors, control of refractory intracranial hypertension was associated with significantly better pediatric cerebral performance category scores and over two-fold likelihood of acceptable long-term outcome (relative risk 2.3; 95% confidence interval ) compared with uncontrolled refractory intracranial hypertension despite high-dose barbiturates. CONCLUSIONS:: Addition of high-dose barbiturates achieved control of refractory intracranial hypertension in almost 30% of treated children. Control of refractory intracranial hypertension was associated with increased likelihood of an acceptable long-term outcome.

Expression of candidate plasticity-related gene 15 is increased following traumatic brain injury

Authors: He Y, Yang G, Wang Y, Ren Y, He X, Zhang X, Fei Z.

OBJECTIVES: Candidate plasticity-related gene 15 (cpg15) is an activity-regulated gene that mediates synaptic plasticity; this study assesses the potential link between cpg15 expression levels and repair and regeneration following traumatic brain injury (TBI).
METHODS: We investigated the expression of cpg15 in the frontal lobe of rats subjected to TBI and sham rats, using the following methods: immunohistochemical analysis, Western blotting, and reverse transcription-polymerase chain reaction.
RESULTS: CPG15(+) neurons were present in coronal sections of the frontal lobe at Day 1, reached the highest level around Day 14, and maintained elevated levels through Day 21. CPG15 protein and mRNA levels were noticed to increase in a similar temporal pattern. In contrast, rats in the sham group had undetectable levels of CPG15.
CONCLUSIONS: Elevated cpg15 expression in the frontal cortex suggests its possible involvement in regenerative and reparative processes that follow TBI.

Understanding and treating blast traumatic brain injury in the combat theater

Authors: Wang EW, Huang JH.

OBJECTIVES: Blast injury is a frequent cause of traumatic brain injury (TBI) in the modern combat theater. We sought to explain the research and treatment associated with this injury.
METHODS: We reviewed literature on the prevalence of blast TBI (bTBI), blast injury mechanisms, research, and perspectives on the neurosurgical experience treating bTBI.
RESULTS: A majority of combat-related casualties in recent wars are due to blast. A majority of survivors of blast injuries are diagnosed with TBI. Blast injury may induce changes in the brain not seen with non-blastrelated mechanisms. However, long-term symptoms are not significantly different from non-blast mechanisms. Aggressive decompressive craniectomies are commonly performed in the combat theater.
DISCUSSION: Due to the prevalence and debilitating nature of bTBI, understanding injury mechanisms is crucial in treating the injury before symptoms become permanent. Treatment is currently limited to decompressive craniectomies, which are the most effective treatment for a relatively young and fit military population.

Examination of outcome after mild traumatic brain injury: The contribution of injury beliefs and Leventhal's Common Sense Model

Authors: Snell DL, Hay-Smith EJ, Surgenor LJ, Siegert RJ.

Associations between components of Leventhal's common sense model of health behaviour (injury beliefs, coping, distress) and outcome after mild traumatic brain injury (MTBI) were examined. Participants (n = 147) were recruited within three months following MTBI and assessed six months later, completing study questionnaires at both visits (Illness Perceptions Questionnaire Revised, Brief COPE, Hospital Anxiety and Depression Scale). Outcome measures included the Rivermead Post-Concussion Symptoms Questionnaire and Rivermead Head Injury Follow-Up Questionnaire. Univariate and multivariate (logistic regression) analyses examined associations between injury beliefs, coping and distress at baseline, and later outcome. Participants endorsing stronger injury identity beliefs (p < .01), expectations of lasting severe consequences (p < .01), and distress (p < .01) at time one, had greater odds of poor outcome at time two. Coping styles were also associated with later outcome although variability in findings limited interpretability. Associations between psychological variables and outcome were examined and 76.5% of cases were correctly classified by the model. Consistent with Leventhal's model, participant beliefs about their injury and recovery had significant associations with outcome over time. Coping also appeared to have important associations with outcome but more research is required to examine these. Current reassurance-based interventions may be improved by targeting variables such as injury beliefs, coping and adjustment soon after injury.

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