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Perioperative Care for Pediatric Patients With Penetrating Brain Injury: A Review
Marco Mikhael1, Elizabeth Frost2, Maria Cristancho1
1Department of Anesthesiology and Pain Management, Cook County Hospital, Chicago, IL.
Insights
Penetrating brain injury (PBI) in children, though less common than blunt traumatic brain injury (TBI), is more lethal and requires distinct management strategies. Further research and clinical trials are essential for effective PBI treatment.
Area of Science:
- Pediatric neurosurgery
- Trauma surgery
- Pediatric critical care
Background:
- Traumatic brain injury (TBI) is a major cause of death and disability in children.
- Penetrating brain injury (PBI), a subset of TBI, is less common but more lethal than blunt TBI.
- Existing TBI guidelines often do not differentiate PBI, potentially leading to suboptimal management.
Purpose of the Study:
- To provide an overview of PBI in children, including its features, epidemiology, and causes.
- To analyze existing case series and literature on PBI.
- To highlight the need for PBI-specific research and clinical trials.
Main Methods:
- Review of existing literature, including case reports and case series on PBI.
- Analysis of epidemiological data and presenting features of PBI.
- Comparison of PBI management with blunt TBI management guidelines.
Main Results:
- PBI requires different neuroimaging, ICP monitoring, and surgical approaches compared to blunt TBI.
- PBI was excluded from major pediatric TBI management guidelines, indicating a knowledge gap.
- Case series suggest unique aspects of PBI pathophysiology and outcomes.
Conclusions:
- Penetrating brain injury (PBI) management necessitates distinct protocols separate from blunt traumatic brain injury (TBI).
- There is a critical need for dedicated clinical trials and research focusing on PBI in pediatric populations.
- Current understanding and guidelines for PBI are insufficient, underscoring the urgency for further investigation.
Abstract:
Traumatic brain injury (TBI) continues to be the leading cause of death and acquired disability in young children and adolescents, due to blunt or penetrating trauma, the latter being less common but more lethal. Penetrating brain injury (PBI) has not been studied extensively, mainly reported as case reports or case series, due to the assumption that both types of brain injury have common pathophysiology and consequently common management. However, recommendations and guidelines for the management of PBI differ from those of blunt TBI in regards to neuroimaging, intracranial pressure (ICP) monitoring, and surgical management including those pertaining to vascular injury. PBI was one of the exclusion criteria in the second edition of guidelines for the acute medical management of severe TBI in infants, children, and adolescents that was published in 2012 (it is referred to as "pediatric guidelines" in this review). Many reviews of TBI do not differentiate between the mechanisms of injury. We present an overview of PBI, its presenting features, epidemiology, and causes as well as an analysis of case series and the conclusions that may be drawn from those and other studies. More clinical trials specific to penetrating head injuries in children, focusing mainly on pathophysiology and management, are needed. The term PBI is specific to penetrating injury only, whereas TBI, a more inclusive term, describes mainly, but not only, blunt injury.
