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 ResolveMod-Severe TBI

• Sleep

• Epilepsy

Problems Which PersistMild

• Attitude to siblings

• Nightmares

• Lost hobbies

• Personality change

• Temper

Problems Which PersistModerate/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

Pragmaticlanguage

SocialProblemSolving

Social Outcome

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 1-800-544-5243

• Brain Injury Support Group of Portland 1-503-413-7707

• Brain Injury Assoc of the US www.biausa.org

• Teaching Research, Western Oregon University 1-541-346-0573