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Alarming Statistics
 TBI: leading cause of death and disability in
children
- in US:
US 79// 100000 admission for head injury,
j y,
chidren: 200000 head injury /year: 10%
severe TBI
National Centers for Injury Prevention and Control.

- in KSA:
KSA NGH: 1598 admissions :664MVA: 378: TBI:
24% severe TBI: 30 died
Crankson SJ; motor vehicle injuries in childhood: a hospital-based
study in Saudi Arabia, Pediatr Surg Int 2006

 Mortality : 22% severe TBI

Ducrocq. Epidemiology and predictive factors of mortality and outcome in children
with traumatic severe brain injury: experience of a French pediatric trauma center.
Pediatric Crit Care Med. 2006

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Result of the direct mechanical damage that occurs at

the time of trauma
→ focal lesions: skull fracture, epidural hematoma, sub
d
durall hematoma,
h t i t
intracerebral
b l hematoma
h t
→ Diffuse axonal injury

Occurs after the initial trauma: the damage to neurons

due to the systemic physiologic response to the initial injury
→ Release of cytokines, free radicals, glutamate:
→ deleterious cascade of continued cell membrane
break down that further harm the injured brain
→ Hypotension and hypoxia are majors causes of
secondary brain injury
Bishop. Curr Probl Pediatr Adolesc Health Care Oct 2006

Pediatric Crit Care Med 2003

Vol. 4, No. 3 (Suppl.)

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Objectives

Review the new developments and

advances in the field pediatric TBI since

the 2003 guidelines

Beyond the 2003 Pediatric TBI

Guidelines

 Pathoph siolog
Pathophysiology

 Neuromonitoring

 Therapy

 Biomarkers

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Beyond the 2003 Pediatric TBI

Guidelines

 Pathoph siolog
Pathophysiology

 Neuromonitoring

 Therapy

 Biomarkers

Optimal CPP

Guidelines.
Guidelines

CPP in children with TBI should be

maintained > 40mmHg

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9-year retrospective review of patients with STBI

who required ICP monitoring:156 child/ GOS 12M

Catala-Temprano. Intracranial pressure and cerebral perfusion pressure as risk

factors in children with traumatic brain injury. J Neurosurg. 2007

 CPP: age dependent

Prospective study 235 children with TBI:
CPP during first 6H / outcome at 12 weeks

- 2-6 years: 50mmHg

- 7-10 years: 60mmHg CPP targets

- 11-16 years: 65mmHg

Chambers IR et al. Age related differences in

intracranial pressures and cerebral perfusion pressure in the
first 6 hours of monitoring after children’s head injury:
association with outcome. Childs NervSyst 2005

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Beyond the 2003 Pediatric TBI

Guidelines

 Pathoph siolog
Pathophysiology

 Neuromonitoring

 Th
Therapy

 Biomarkers

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ICP monitoring

 Recommendation:

Options. ICP monitoring is appropriate in

Options
infants and children with severe
au a c b
traumatic a injury
brain ju y

 ICP monitoring :
WHY ?
- Strong evidence supports the association of Increased ICP
and poor neurological outcome
- ICP monitoring and aggressive treatment of increased ICP
are associated with the best reported clinical outcome
- guideline level in the adult literature

When ?
- GCS≤ 8 - with abnormal CT scan
- hemodynamic instability
- GCS 8 patient sedated or on neuromuscular blockade.

How ?
- intraventricular ICP
- intraparenchymal ICP….

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Aim:

 to monitor the effect of intervention

( hyperventilation to test for auto-regulatory
capabilities within the brain…)

 to detect significant cerebral hypoxia

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 PbO2 > 25mmHg +

( ICP< 20mmHg, CPP> 60mmHg): decreased
mortality
y (44%vs
( 25%,, p
p<0.O5))
Stiefel MF et al. Reduced mortality rate in patient with sever traumatic brain
injury treated with brain tissue oxygen monitoring. J Neurosurg 2005

- PbO2 < 20mmHg in 11/14 after standard

resuscitation to ICP and CPP goals
- PbO2 respond to O2
- PbO2 was increased in survivors (p=0.009)
Narotam PK et al cerebral oxygenation in major pediatric trauma and its
relevance to trauma severity and outcome . J ped Surg 2006

 assess adequacy of CBF

- mean (Vm> 30cm/s) diastolic (Vd>
20cm/s) blood flow velocity /MCA
- Pulsatility index( PI= (Vs-Vd/Vm<1.4)

 CPPni = MBP x Vd/Vm +14

 Reactivity to CO2 : cerebral autoregulation

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TCD « goal
goal-- directed therapy »

Assess Vm, Vd, PI at T0 and treat with mannitol and

norepinephrine:

 46% abnormal TCD value and 2 @ the time of

insertion of ICP monitoring
 ICP was greater in patients with abnormal TCD @
admission
 CPP and SjvO2 were normal: more adequate
cerebral
b l resuscitation
it ti

Ract C et al. Transcranial Doppler ultrasound goal-directed

therapy for the early management of severe traumatic brain injury.
Intensive Care Med. 2007

 The specificity of PI for detecting an ICP≥

20mmHg g is high,
g but the sensitivity is very
low.

 The relationship between PI and the CPP

appears to be stronger.

Figagi AA et al. Transcranial Doppler pulsatility index is not a

reliable indicator of intracranial pressure in children with severe TBI.
Surgical Neurology 2009

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 Detection of convulsion:
High incidence of post traumatic non non-
convulsive seizure in adult TBI/ increased
ICP and interstitial Lactate/pyruvate

Vespa PM. Et al. Nonconvulsive electrographic seizures after

traumatic brain injury result in a delayed, prolonged increase in
intracranial pressure and metabolic crisis. Crit Care Med. 2007

 Evaluation of brain function by analysis

of the synchronous nature of cEEG

EEG
 Prognostic value in patient with disorder of
consciousness post TBI.

Bagato S et al. Prognostic value of standard EEG in traumatic

and non traumatic disorders of consiousness following coma. Clin
Neurophysiol 2010

 EEG-SEP changes identify brain function

deterioration. changes can precede an ICP
increase and they can constitute a
complementary tool to interpret ICP trends.

Amantini A etal. Continuous EEG-SEP monitoring in severe brain

injury. Neurophysiol Clin. 2009

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Beyond the 2003 Pediatric TBI

Guidelines

 Pathoph siolog
Pathophysiology

 Neuromonitoring

 Therapy

 Biomarkers

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 Recommendations

Option.

CSF drainage can be considered as in

option in the management of elevated
ICP in children with severe closed head
injury

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continuous CSF drainage > intermittent

CSF drainage ?

Compared to cCSF drainage,

drainage iCSF drainage was
associated with :
- 2 fold greater CSF concentrations of CSF
mediator (p < 0.05)

- ≈1/2 the volume of CSF removal (p = 0.002).

)
- Higher mean ICPs (21.8 vs13.6 mm Hg, p < 0.0001).

Shore PM et al. Continuous versus intermittent

cerebrospinal fluid drainage after severe traumatic brain injury in
children: effect on biochemical markers. J Neurotrauma. 2004.

 Recommendations

Options.

Decompressive craniectomy should be

considered in pediatric patients with
severe TBI,
TBI diff
diffuse cerebral
b l swelling,
lli and
d
intracranial hypertension refractory to
intensive medical management

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Decompressive craniectomy

 Indications:
 Diffuse cerebral swelling on CT brain
 Within 48hrs of injury
 No episodes of sustained ICP>40mmHg
 GCS>3 at some point subsequent to
injury
 Secondary clinical deterioration
 Evolving cerebral herniation

Decompressive craniectomy
 As Rescue therapy:
therapy
Jagannathan J et al. Outcome following decompressive
craniectomy in children with severe TBI: a10-year single center experience with
long term follow up. J Neurosurg 2007

 As Early intervention:

- Survival rate : 100% craniectomy group vs 33% in

the non-operative group.

- 1 year GOS was better in the craniectomy group.

Josan VA Sgouros S. Early decompressive craniectomy may be effective

in the treatment of refractory intracranial hypertension after traumatic brain injury.
Childs Nerv Syst. 2006

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 Recommendations

Options.
- Extrapolated from the adult data, hyperthermia
should be avoided in children with severe TBI

- Despite the lack of clinical data in children,

hypothermia may be considered in the setting of
refractory intracranial hypertension

Mechanisms of action

 Antioxidant effect

 Decrease metabolism and O2

consumption
p

 Risk: coagulopathy , IC hemorrhage,

arrhythmia

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 Phase II clinical trial

- Moderate HYPO after severe TBI in children was found
to be safe
- early hypothermia : better mortality rate

Adelson PD Phase II clinical trial of moderate hypothermia after severe

traumatic brain injury in children. Neurosurgery 2005

 CANADIAN Phase III clinical trial:

- Hypothermia group had worse outcome
- Methodology?

Hutchison
H t hi J ett al.
l HyP-HIT
H P HIT Investigators
I ti t anad
d canadian
di critical
iti l care trial
ti l
group. Hypothermia therapy after TBI in children. N.Engl.j.Med.2008

 Ongoing US Phase III TRIAL: Cool Kids Trial

Adelson PD. Hypothermia following pediatric traumatic brain injury.
J Neurotrauma. 2009 .

Anti--seizure Prophylaxis
Anti
 Recommendations:
 Guidelines.
Prophylactic anti-seizure therapy may be
considered to prevent early PTS in pediatric patient
 Options.
Prophylactic use of anti-seizure therapy is not
recommended for children with severe TBI for
preventing late PTS
 Indications from adult guidelines
Use of phenytoin has been shown to decrease the
risk of early PTS. There is no evidence that outcome
is improved.

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New anti-epileptics drugs

LEV patients/ PHT patients:

- better long-term outcomes :

lower Disability Rating Scale score at 3 months
(P = 0.042) and higher GOS at 6 months (P = 0.039).

- No differences between groups in : seizure

occurrence during cEEG or at 6 months
and in mortality .
Szaflarski JP et al. Prospective, randomized, single-blinded
comparative trial of intravenous levetiracetam versus phenytoin for
seizure prophylaxis. Neurocrit Care 2010

Beyond the 2003 Pediatric TBI

Guidelines

 Pathoph siolog
Pathophysiology

 Neuromonitoring

 Therapy

 Biomarkers

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Assesses neuronal death

Early peak level after TBI(<12h)
Delayed in inflected neurotrauma

Marker of astrocyte death or injury

Maximal early peak after the insult

Biomarker of axonal injury

Increased only in TBI and inflected
neurotrauma and not HIE

 Serum biomarker:
- Adjunct to clinical examination in case of
inflicted trauma
- Prognostic
g factors
Bergers et al Serum biomarker concentrations and
outcome after pediatric traumatic brain injury. J Neurotrauma. 2007

 Multiplex methods: /CSF analysis

- Assessments of multiple
p markers
(cytokines)
- Assess the effect of therapy on the
biochemical response to TBI
 Urine: source for biomarkers

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Dash KP. Biomarkers for the Diagnosis, Prognosis, and Evaluation of Treatment
Efficacy for Traumatic Brain Injury. Neurotherapeutics 2010

Dash KP. Biomarkers for the Diagnosis, Prognosis, and Evaluation of Treatment
Efficacy for Traumatic Brain Injury. Neurotherapeutics 2010

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 Primary prophylaxis

 Secondary prophylaxis: secondary injury

 More study since 2003 guidelines

 Need more pediatric study

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