Spontaneous Intracranial Hypotension in Childhood and Adolescence

Authors: Schievink WI, Maya MM, Louy C, Moser FG, Sloninsky L.

OBJECTIVES: To describe the clinical and radiographic manifestations of spontaneous intracranial hypotension, a rarely diagnosed cause of headache in children.
STUDY DESIGN: This study included patients 19 years of age or younger evaluated between January 1, 2001, and June 30, 2012, for spontaneous intracranial hypotension.
RESULTS: We evaluated 24 children (18 girls and 6 boys) with spontaneous intracranial hypotension (age at onset of symptoms: 2-19 years, mean 14.3 years). Twenty-three patients presented with orthostatic headaches and 1 presented with a nonpositional headache. A generalized connective tissue disorder was diagnosed in 54% of patients. Magnetic resonance imaging showed the typical changes of spontaneous intracranial hypotension in most patients (79%). Spinal imaging demonstrated a cerebrospinal fluid (CSF) leak with or without an associated meningeal diverticulum in 12 patients (50%) and with dural ectasia or meningeal diverticula in 10 patients (42%), and it was normal in 2 patients (8%). Twenty-three patients initially underwent epidural blood patching, but 8 patients also were treated with percutaneous injections of fibrin glue and 11 patients eventually required surgical correction of the underlying CSF leak. There was no morbidity or mortality associated with any of the treatments, but 5 patients required acetazolamide for rebound high intracranial pressure headache. Overall, outcome was good in 22 patients (92%) and poor in 2 patients (8%).
CONCLUSIONS: Spontaneous intracranial hypotension in childhood is rare. Most patients can be treated effectively using a combination of epidural blood patching and percutaneous injections of fibrin glue or surgical CSF leak repair in refractory cases.

Hypothermia Decreases Cerebrospinal Fluid Asymmetric Dimethylarginine Levels in Traumatic Brain Injury Children

Authors: Thampatty BP, Klamerus MM, Oberly PJ, Feldman KL, Bell MJ, Tyler-Kabara EC, Adelson PD, Clark RS, Kochanek PM, Poloyac SM.

OBJECTIVES:: Pathological increases in asymmetric dimethylarginine, an endogenous nitric oxide synthase inhibitor, have been implicated in endothelial dysfunction and vascular diseases. Reduced nitric oxide early after traumatic brain injury may contribute to hypoperfusion. Currently, methods to quantify asymmetric dimethylarginine in the cerebrospinal fluid have not been fully explored. We aimed to develop and validate a method to determine asymmetric dimethylarginine in the cerebrospinal fluid of a pediatric traumatic brain injury population and to use this method to assess the effects of 1) traumatic brain injury and 2) therapeutic hypothermia on this mediator. 

Teacher-Reported Behavioral Disturbances in Children With Traumatic Brain Injury: An Examination of the BASC-2

Authors: Thaler NS, Mayfield J, Reynolds CR, Hadland C, Allen DN.

Pediatric traumatic brain injury (TBI) is associated with behavioral disturbances that can interfere with adjustment in the classroom. As such, standardized assessments of behavioral disturbances following TBI are useful in treatment planning and rehabilitation, although few studies have examined the sensitivity of standardized behavior assessments to behavioral abnormalities in this population. The present study compared the Behavior Assessment System for Children-Second Edition Teacher Rating Scale (BASC-2 TRS) profiles of 25 children who sustained TBI to those of 25 matched controls and to the BASC-2 standardization sample. Results indicated that teachers endorsed externalizing and school-related problems more severely and frequently than internalizing problems, with the greatest elevations on the Hyperactivity, Attention Problems, and Learning Problems subscales. In addition, BASC-2 scores appeared unrelated to IQ but were influenced by achievement functioning. Findings are consistent with previous studies of behavioral abnormalities in children with TBI and provide support for the usefulness of the BASC-2 TRS in evaluating behavioral disturbances in children that result from TBI.

Delayed extradural haemorrhage: a case for intracranial pressure monitoring in sedated children with traumatic brain injury within tertiary centres

Authors: Hughes A, Lee C, Kirkham F, Durnford AJ.

A 15-year-old girl sustained a mild isolated traumatic brain injury  following a pedestrian road traffic accident. She was ventilated for head computed tomography (CT) scan which revealed no intracranial abnormalities. Ventilation was not withdrawn until 15 h later when poor neurological recovery prompted urgent repeat CT, which demonstrated a delayed extradural haemorrhage (EDH). She underwent surgical evacuation, and intracranial pressure (ICP) monitoring was initiated postoperatively. She developed persistently raised ICP resistant to medical therapy, prompting further CT. This showed a recurrence of the delayed EDH requiring further surgical drainage. She made a good neurological recovery. There should be a low threshold for repeat CT to exclude delayed EDH when neurological status is poor despite normal CT soon after initial primary injury. ICP monitoring should be undertaken in children and adolescents who have normal initial CT, but in whom serial neurological assessment is not possible owing to sedation.

Pretreatment With Midazolam Blunts the Rise in Intracranial Pressure Associated With Ketamine Sedation for Lumbar Puncture in Children.

Authors: Michalczyk K, Sullivan JE, Berkenbosch JW.

OBJECTIVE:: Ketamine has a long history of use during pediatric procedural sedation. Concerns about raising intracranial pressure may limit use in certain situations. Whereas some data suggest that benzodiazepine coadministration may blunt this response, pediatric data during procedural sedation do not exist. We evaluated the effects of midazolam pretreatment on intracranial pressure during ketamine sedation in children. DESIGN:: Prospective, randomized clinical study. SETTING:: Outpatient Medical Observation unit at Kosair Children's Hospital. PATIENTS:: A total of 25 oncology patients in whom sedated lumbar puncture was scheduled. INTERVENTIONS:: Patients alternated between sedation in Group A (midazolam/ketamine prior to lumbar puncture) or Group B (ketamine only prior to lumbar puncture). Opening pressure, medication doses, sedation depth, and complications were recorded. A control group of non-ketamine-sedated patients (Group C) was added to differentiate drug vs. disease-specific opening pressure changes. Between-group differences were compared by linear mixed effects model or contingency table with p < 0.05 considered significant. MEASUREMENTS AND MAIN RESULTS:: Twenty-five patients aged 82 ± 49 months were sedated 84 times. Thirty-five sedations were in Group A, 39 in Group B, and 10 in Group C. Mean (95% confidence interval) adjusted opening pressure in Group A (22.0 cm H2O) was lower than Group B (26.5 cm H2O, p = 0.013). Opening pressure in Group C (17.3 cm H2O) was lower than in Group B (p = 0.002) but not in Group A (p = 0.096). Ketamine doses were similar between Groups A and B (1.4 ± 0.6 mg/kg vs. 1.4 ± 0.4 mg/kg, p = NS). Mean midazolam pretreatment dose was 0.09 ± 0.02 mg/kg and did not correlate with measured opening pressure. Four patients, all in Group B, experienced significant emergence reactions. CONCLUSION:: While pretreatment with midazolam is associated with a reduction in intracranial pressure compared with sedation with ketamine alone, ketamine-containing regimens are associated with higher opening pressures than non-ketamine-containing regimens.

Cognitive, affective, and conative theory of mind (ToM) in children with traumatic brain injury

Authors: Dennis M, Simic N, Bigler ED, Abildskov T, Agostino A, Taylor HG, Rubin K, Vannatta K, Gerhardt CA, Stancin T, Yeates KO.

We studied three forms of dyadic communication involving theory of mind (ToM) in 82 children with traumatic brain injury (TBI) and 61 children with orthopedic injury (OI): Cognitive (concerned with false belief), Affective (concerned with expressing socially deceptive facial expressions), and Conative (concerned with influencing another's thoughts or feelings). We analyzed the pattern of brain lesions in the TBI group and conducted voxel-based morphometry for all participants in five large-scale functional brain networks, and related lesion and volumetric data to ToM outcomes. Children with TBI exhibited difficulty with Cognitive, Affective, and Conative ToM. The perturbation threshold for Cognitive ToM is higher than that for Affective and Conative ToM, in that Severe TBI disturbs Cognitive ToM but even Mild-Moderate TBI disrupt Affective and Conative ToM. Childhood TBI was associated with damage to all five large-scale brain networks. Lesions in the Mirror Neuron Empathy network predicted lower Conative ToM involving ironic criticism and empathic praise. Conative ToM was significantly and positively related to the package of Default Mode, Central Executive, and Mirror Neuron Empathy networks and, more specifically, to two hubs of the Default Mode Network, the posterior cingulate/retrosplenial cortex and the hippocampal formation, including entorhinal cortex and parahippocampal cortex.


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