Developmental neuroscience
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Inflicted traumatic brain injury (iTBI) involves a combination of mechanical trauma and hypoxemia. Serum biomarker concentrations may provide objective information about their relative importance to the pathophysiology of iTBI. We compared the time course of neuron-specific enolase (NSE), S100B and myelin basic protein after pediatric hypoxic-ischemic brain injury, iTBI and noninflicted TBI (nTBI). ⋯ Initial NSE concentration was highest after nTBI. These results suggest that the biochemical response of the brain to iTBI is distinct from the response to nTBI and shares temporal similarities with hypoxic-ischemic brain injury. This may have important implications for the treatment and prognosis of children with iTBI.
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Randomized Controlled Trial Multicenter Study
Hypothermia pediatric head injury trial: the value of a pretrial clinical evaluation phase.
The utility of a pretrial clinical evaluation or run-in phase prior to conducting trials of complex interventions such as hypothermia therapy following severe traumatic brain injury in children and adolescents has not been established. ⋯ The pretrial clinical evaluation phase was useful to ensure compliance with complex hypothermia therapy and consensus-based clinical management guidelines of care successfully implemented across 17 of 18 centers. This study maneuver allowed us to complete a subsequent RCT in 225 children following severe traumatic brain injury.
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In this review, five questions serve as the framework to discuss the importance of age-related differences in the pathophysiology and therapy of traumatic brain injury (TBI). The following questions are included: (1) Is diffuse cerebral swelling an important feature of pediatric TBI and what is its etiology? (2) Is the developing brain more vulnerable than the adult brain to apoptotic neuronal death after TBI and, if so, what are the clinical implications? (3) If the developing brain has enhanced plasticity versus the adult brain, why are outcomes so poor in infants and young children with severe TBI? (4) What contributes to the poor outcomes in the special case of inflicted childhood neurotrauma and how do we limit it? (5) Should both therapeutic targets and treatments of pediatric TBI be unique? Strong support is presented for the existence of unique biochemical, molecular, cellular and physiological facets of TBI in infants and children versus adults. Unique therapeutic targets and enhanced therapeutic opportunities, both in the acute phase after injury and in rehabilitation and regeneration, are suggested.
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Review
Use of advanced neuroimaging techniques in the evaluation of pediatric traumatic brain injury.
Advanced neuroimaging techniques are now used to expand our knowledge of traumatic brain injury, and increasingly, they are being applied to children. This review will examine four of these methods as they apply to children who present acutely after injury. (1) Susceptibility weighted imaging is a 3-dimensional high-resolution magnetic resonance imaging technique that is more sensitive than conventional imaging in detecting hemorrhagic lesions that are often associated with diffuse axonal injury. (2) Magnetic resonance spectroscopy acquires metabolite information reflecting neuronal integrity and function from multiple brain regions and provides sensitive, noninvasive assessment of neurochemical alterations that offers early prognostic information regarding the outcome. (3) Diffusion weighted imaging is based on differences in diffusion of water molecules within the brain and has been shown to be very sensitive in the early detection of ischemic injury. ⋯ An important aspect of these advanced methods is that they demonstrate that 'normal-appearing' brain in many instances is not normal, i.e. there is evidence of significant undetected injury that may underlie a child's clinical status. Availability and integration of these advanced imaging methods will lead to better treatment and change the standard of care for use of neuroimaging to evaluate children with traumatic brain injury.
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Traumatic brain injury (TBI) is the leading cause of death and disability in children. Evidence-based guidelines for the management of this population are available; however, the data highlight significant deficiencies with few treatment standards or guidelines. Considering the limited availability of resources, it is necessary to define realistic goals. Attention should be given to injury prevention, developing standardized pediatric admission and outcome evaluations, increasing the utility and spectrum of physiological and biochemical testing, and defining the evolving role of imaging in TBI.