Pediatric Traumatic Brain Injury
Janice L. Cockrell MD Medical Director, Pediatric Rehabilitation Legacy Emanuel Children’s Hospital
Incidence
• Annual incidence 180/100,000 in 1-15 year olds (Kraus, 1995) • Most common cause of mortality
Pediatric TBI
• • • • 81% mild 8% moderate 6% severe 5% fatal
Injury Severity
• Mild – unconscious <15 min; GCS 13-15 • Mod – unconscious >15 min; GCS 9-12 • Severe – unconscious >6hr; GCS 3-8
Etiology
• • • • Non-accidental trauma in infants Falls in toddlers Ped vs. MVA in school-age children MVA in >16 year olds
Types of Injuries
• Trauma
– Focal – Diffuse
• Stroke • Hypoxia
Trauma
• Focal injuries
– Prefrontal regions – Intracranial hematomas
Anatomy of the Skull
Trauma
• Focal injuries
– Prefrontal regions – Intracranial hematomas
• Diffuse injuries
– Diffuse axonal injury (DAI) – Hypoperfusion – Excitatory cascades of neurotransmitters producing free radicals
Risk Factors
• • • • Age Previous TBI Socioeconomic deprivation Premorbid behavior problems only a minor risk factor
(Demellweek et al, 2002)
•
Effect of AANS Trauma Protocols
• Implementation of the AANS protocols for TBI resulted in a 9.13 times higher odds ratio of a good outcome compared to prior outcomes in a community hospital. • Hospital charges increased by more than $97,000 per patient.
(Palmer, Bader, Qureshi et al, 2001)
Most Common Physical Problems (Hawley, 2003)
• • • • • • • • Headache Blurred vision Difficulty sleeping Fatigue Clumsiness Seizures Hearing problems Change in appetite
Sensory Problems
• • • • • Blurry vision Visual field cuts Cortical blindness Diplopia Hearing loss/central auditory processing problems • Loss of smell
Motor Problems
• • • • Spasticity Ataxia Clumsiness Tend to improve markedly over time
Outcomes measurement
• • • • • • • Glasgow Outcome Score IQ Academic achievement Motor skills Adaptive skills Problem solving Executive function
Glasgow Outcome Score
• • • • • 1 - Expired 2 - Vegetative 3 - Severe disability 4 - Moderate disability 5 - Good outcome
Most Common Sequelae
• Intellectual • Academic • Personality/behavioral
Cognitive Outcomes
• Declines in
– IQ – Attention and concentration – Memory – Language – Non-verbal skills – Executive functions
Behavioral Outcomes
• • • • • Impulsivity Irritability Agitation (overstimulation) Apathy Emotional lability
Academic Outcomes
• Declines in achievement • Declines in school performance • Decreased adaptability
Problems Which Resolve Mild TBI
• Clumsiness • Speech • Hearing
Problems Which Resolve Mod-Severe TBI
• Sleep • Epilepsy
Problems Which Persist Mild
• • • • • Attitude to siblings Nightmares Lost hobbies Personality change Temper
Problems Which Persist Moderate/Severe
• • • • • • Attitude toward siblings Clumsiness Concentration Hearing Mood fluctuations Temper
Adult Outcomes
• Difficulty maintaining employment • Marital problems • Social isolation (adults described as less likable, less interesting, less socially skilled) • Involvement with criminal justice system
Long-term Neuropsychological Outcomes
• Family factors influence behavior and academic outcomes • Family factors did not moderate neuropsychological outcomes
(Yeates, Taylor, Wade, et al 2002)
Intellectual & Emotional Functioning in College Students with Hx of Mild TBI
• Intellectually unimpaired • Significantly higher level of emotional distress (Marschark et al, 2000)
Executive Functions
• Modulated by frontal lobe and prefrontal circuits • Involve both monitoring and controlling behavior • Interact with declarative memory and processing speed but are distinct abilities
Anatomy of the Skull
Outcomes of Frontal Lesions
• Children with unilateral frontal lesions regardless of severity had a higher frequency of maladaptive behaviors than those without, even if there was no difference in cognition.
(Levin, Zhang, Dennis et al 2004)
Mediating Factors
• Age • Severity • SEC
– Family functioning – Education – Economic resources
• Premorbid personality
Predictors of Social Outcome
(Yeates, Swift, Taylor, et al, 2004)
Executive function
Social Problem Solving
Social Outcome
Pragmatic language
SADHD
• Omission vs commission errors • Omission errors immediately after TBI predicted SADHD • Children with ADHD have a high number of commission errors • SADHD is likely fundamentally different than ADHD. (Wassenberg, Max, Lindgren et al, 2004)
What can the treating physician do?
• Follow patient closely for the first few months • Evaluate hearing and vision • Monitor growth, nutrition • Monitor and treat sleep disorders • Educate patient and family regarding TBI • Refer family for counseling if needed
Resources
• Brain Injury Association of Oregon 1-800544-5243 • Brain Injury Support Group of Portland 1503-413-7707 • Brain Injury Assoc of the US www.biausa.org • Teaching Research, Western Oregon University 1-541-346-0573