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Published on: December 8, 2014
Prevalence, Evolution, and Extent of Impaired Cerebral Autoregulation in Children Hospitalized With Complex Mild
Abhijit V Lele1,2, Arraya Watanitanon3, Viharika Lakireddy3
1Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA.
Insights
Impaired cerebral autoregulation affects nearly half of children with complex mild traumatic brain injury, often persisting after discharge. This cerebrovascular dysfunction is most prevalent in the initial days post-injury.
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Cerebrovascular Physiology
Background:
- Mild traumatic brain injury (mTBI) in children can have complex presentations.
- Cerebral autoregulation (CA) is crucial for maintaining stable cerebral blood flow.
- Understanding CA in pediatric mTBI is vital for effective management.
Purpose of the Study:
- To investigate the prevalence and characteristics of impaired cerebral autoregulation in children with complex mild traumatic brain injury.
- To identify factors associated with impaired CA and its evolution over time.
Main Methods:
- A prospective observational study involving children with complex mild TBI admitted to a pediatric intensive care unit.
- Cerebral autoregulation was assessed using transcranial Doppler ultrasound and tilt testing between days 1 and 8 post-admission.
- Prevalence of impaired CA (autoregulation index < 0.4) and associated clinical factors were analyzed.
Main Results:
- Nearly half of the children (48.4%) exhibited impaired cerebral autoregulation.
- Impairment was most common within the first 5 days post-injury and frequently involved both hemispheres.
- Older children with impaired CA tended to have specific types of intracranial hemorrhages.
Conclusions:
- Impaired cerebral autoregulation is a common finding in children with complex mild TBI, even with initially reassuring neurological scores.
- Abnormal cerebrovascular hemodynamics are prevalent in the early post-injury period.
- A significant proportion of children are discharged with ongoing impaired CA, highlighting the need for continued monitoring.
Objectives:
To examine cerebral autoregulation in children with complex mild traumatic brain injury.
Design:
Prospective observational convenience sample.
Setting:
PICU at a level I trauma center.
Patients:
Children with complex mild traumatic brain injury (trauma, admission Glasgow Coma Scale score 13-15 with either abnormal head CT, or history of loss of consciousness).
Interventions:
Cerebral autoregulation was tested using transcranial Doppler ultrasound between admission day 1 and 8.
Measurements And Main Results:
The primary outcome was prevalence of impaired cerebral autoregulation (autoregulation index < 0.4),determined using transcranial Doppler ultrasonography and tilt testing. Secondary outcomes examined factors associated with and evolution and extent of impairment. Cerebral autoregulation testing occurred in 31 children 10 years (SD, 5.2 yr), mostly male (59%) with isolated traumatic brain injury (91%), median admission Glasgow Coma Scale 15, Injury Severity Scores 14.2 (SD, 7.7), traumatic brain injury due to fall (50%), preadmission loss of consciousness (48%), and abnormal head CT scan (97%). Thirty-one children underwent 56 autoregulation tests. Impaired cerebral autoregulation occurred in 15 children (48.4%) who underwent 19 tests; 68% and 32% of tests demonstrated unilateral and bilateral impairment, respectively. Compared with children on median day 6 of admission after traumatic brain injury, impaired autoregulation was most common in the first 5 days after traumatic brain injury (day 1: relative risk, 3.7; 95% CI, 1.9-7.3 vs day 2: relative risk, 2.7; 95% CI, 1.1-6.5 vs day 5: relative risk, 1.33; 95% CI, 0.7-2.3). Children with impaired autoregulation were older (12.3 yr [SD, 1.3 yr] vs 8.7 yr [SD, 1.1 yr]; p = 0.04) and tended to have subdural hematoma (64% vs 44%), epidural hematoma (29% vs 17%), and subarachnoid hemorrhage (36% vs 28%). Eight children (53%) were discharged home with ongoing impaired cerebral autoregulation.
Conclusions:
Impaired cerebral autoregulation is common in children with complex mild traumatic brain injury, despite reassuring admission Glasgow Coma Scale 13-15. Children with complex mild traumatic brain injury have abnormal cerebrovascular hemodynamics, mostly during the first 5 days. Impairment commonly extends to the contralateral hemisphere and discharge of children with ongoing impaired cerebral autoregulation is common.
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