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 Diffuse 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 Premorbid personality 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 1-800-544-5243 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