A Systematic Review and Meta-Analysis on the Management and Outcome of Isolated Skull Fractures in Pediatric Patients.

BACKGROUND: The impact of traumatic brain injury (TBI) on the pediatric population is profound. The aim of this study is to unveil the state of the evidence concerning acute neurosurgical intervention, hospitalizations after injury, and neuroimaging in isolated skull fractures (ISF). MATERIALS AND METHODS: This systematic review was conducted in accordance with PRISMA guidelines. PubMed, Cochrane, Web of Science, and Embase were searched for papers until April 2023. Only ISF cases diagnosed via computed tomography were considered. RESULTS: A total of 10,350 skull fractures from 25 studies were included, of which 7228 were ISF. For the need of acute neurosurgical intervention, the meta-analysis showed a risk of 0% (95% CI: 0-0%). For hospitalization after injury the calculated risk was 78% (95% CI: 66-89%). Finally, for the requirement of repeated neuroimaging the analysis revealed a rate of 7% (95% CI: 0-15%). No deaths were reported in any of the 25 studies. CONCLUSIONS: Out of 7228 children with ISF, an almost negligible number required immediate neurosurgical interventions, yet a significant 74% were hospitalized for up to 72 h. Notably, the mortality was zero, and repeat neuroimaging was uncommon. This research is crucial in shedding light on the outcomes and implications of pediatric TBIs concerning ISFs.

External Validation of a Clinical Nomogram for Predicting Intracranial Hematoma Following Head Computed Tomography in Pediatric Traumatic Brain Injury / Validação externa de um nomograma clínico para previsão de hematoma intracraniano após tomografia computadorizada de cabeça em lesão cerebral traumática pediátrica

Introduction Over-investigation of head computed tomography (CT) has been observed in children with TBI. Long-term effects from a head CT brain scan have been addressed and those should be balanced. A nomogram is a simple prediction tool that has been reported for predicting intracranial injuries following a head CT of the brain in TBI children in literature. This study aims to validate the performance of the nomogram using unseen data. Additionally, the secondary objective aims to estimate the net benefit of the nomogram by decision curve analysis (DCA). Methods We conducted a retrospective cohort study with 64 children who suffered from traumatic brain injury (TBI) and underwent a CT of the brain. Nomogram's scores were assigned according to various variables in each patient; therefore sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and F1 score were estimated by the cross-tabulation of the actual results and the predicted results. Additionally, the benefits of a nomogram were compared with "None" and "All" protocols using DCA. Results There were 64 children with TBI who underwent a head CT in the present study. From the cross-tabulation, the nomogram had a sensitivity of 0.60 (95%CI 0.29­ 0.90), specificity of 0.96 (0.91­1.0), PPV of 0.75 (0.44­1.0), NPV of 0.92 (0.86­0.99), accuracy of 0.90 (0.83­0.97), and an F1 score of 0.66 (0.59­0.73). Also, the area under the curve was 0.78 which was defined as acceptable performance. For the DCA at 0.1 high-risk threshold, the net benefit of the nomogram was 0.75, whereas the "All" protocol had the net benefit of 0.40 which was obviously different. Conclusion A nomogram is a suitable method as an alternative prediction tool in general practice that has advantages over other protocols.

Introdução A investigação excessiva da tomografia computadorizada (TC) de crânio tem sido observada em crianças com TCE. Os efeitos a longo prazo de uma tomografia computadorizada de crânio foram abordados e devem ser equilibrados. Um nomograma é uma ferramenta de predição simples que foi relatada na literatura para prever lesões intracranianas após uma tomografia computadorizada de crânio em crianças com TCE. Este estudo tem como objetivo validar o desempenho do nomograma usando dados não vistos. Adicionalmente, o objetivo secundário visa estimar o benefício líquido do nomograma por meio da análise da curva de decisão (DCA). Métodos Realizamos um estudo de coorte retrospectivo com 64 crianças que sofreram traumatismo cranioencefálico (TCE) e foram submetidas a tomografia computadorizada de crânio. As pontuações do Nomograma foram atribuídas de acordo com diversas variáveis em cada paciente; portanto, sensibilidade, especificidade, valor preditivo positivo (VPP), valor preditivo negativo (VPN), acurácia e escore F1 foram estimados pela tabulação cruzada dos resultados reais e dos resultados previstos. Além disso, os benefícios de um nomograma foram comparados com os protocolos "Nenhum" e "Todos" usando DCA. Resultados Houve 64 crianças com TCE que foram submetidas a tomografia computadorizada de crânio no presente estudo. A partir da tabulação cruzada, o nomograma apresentou sensibilidade de 0,60 (IC95% 0,29­0,90), especificidade de 0,96 (0,91­ 1,0), VPP de 0,75 (0,44­1,0), VPN de 0,92 (0,86­0,99), acurácia de 0,90 (0,83­0,97) e uma pontuação F1 de 0,66 (0,59­0,73). Além disso, a área sob a curva foi de 0,78, definida como desempenho aceitável. Para o DCA no limiar de alto risco de 0,1, o benefício líquido do nomograma foi de 0,75, enquanto o protocolo "Todos" teve o benefício líquido de 0,40, o que foi obviamente diferente. Conclusão Um nomograma é um método adequado como ferramenta alternativa de predição na prática geral que apresenta vantagens sobre outros protocolos.

L-Carnitine and Acetyl-L-carnitine Roles and Neuroprotection in Developing Brain.

L-Carnitine functions to transport long chain fatty acyl-CoAs into the mitochondria for degradation by ß-oxidation. Treatment with L-carnitine can ameliorate metabolic imbalances in many inborn errors of metabolism. In recent years there has been considerable interest in the therapeutic potential of L-carnitine and its acetylated derivative acetyl-L-carnitine (ALCAR) for neuroprotection in a number of disorders including hypoxia-ischemia, traumatic brain injury, Alzheimer's disease and in conditions leading to central or peripheral nervous system injury. There is compelling evidence from preclinical studies that L-carnitine and ALCAR can improve energy status, decrease oxidative stress and prevent subsequent cell death in models of adult, neonatal and pediatric brain injury. ALCAR can provide an acetyl moiety that can be oxidized for energy, used as a precursor for acetylcholine, or incorporated into glutamate, glutamine and GABA, or into lipids for myelination and cell growth. Administration of ALCAR after brain injury in rat pups improved long-term functional outcomes, including memory. Additional studies are needed to better explore the potential of L-carnitine and ALCAR for protection of developing brain as there is an urgent need for therapies that can improve outcome after neonatal and pediatric brain injury.

Fatores associados à hipertensão intracraniana em crianças e adolescentes vítimas de traumatismo crânio-encefálico grave / Factors associated with intracranial hypertension in children and teenagers who suffered severe head injuries

Objetivo: Analisar fatores associados à ocorrência de hipertensão intracraniana em pacientes pediátricos vítimas de traumatismo crânio-encefálico (TCE) grave. Métodos: Coorte com coleta retrospectiva do período de 1998 a 2003. Incluídos pacientes entre 0 e 16 anos com TCE, pontuação < 9 na escala de Glasgow e submetidos a monitoração da pressão intracraniana (PIC) (n = 132). A hipertensão intracraniana (HIC) foi definida como episódio de PIC > 20 mmHg com necessidade de tratamento e HIC refratária, acima de 25 mmHg, com necessidade de coma barbitúrico ou craniectomia descompressiva. Foi realizada análise univariada, seguida de multivariada, sendo consideradas significativas as variáveis com p < 0,05. Resultados: A idade variou entres 2 meses e 16 anos, mediana de 9,7 (6,0-2,3) anos. A pontuação de Glasgow foi de 3 a 8, mediana de 6 (4-7). O trânsito respondeu por 79,5 por cento dos eventos. A instalação do monitor ocorreu, em média, 14 h após o trauma, mediana de 24 h. Cento e três pacientes (78 por cento) apresentaram HIC, e 57 (43,2 por cento), HIC refratária. Na análise multivariada, a menor faixa etária foi associada a HIC risco relativo = 1,67 (1,03-2,72); p = 0,037, e a presença de posturas anormais foi associada a HIC refratária risco relativo = 2,25 (1,06-4,78). A mortalidade do grupo foi de 51,5 por cento e foi relacionada a uso de barbitúrico na HIC refratária e a baixa pressão de perfusão encefálica na unidade de terapia intensiva. Conclusões: HIC e HIC refratária foram eventos frequentes em pacientes pediátricos com TCE grave. Quanto menor a idade do paciente, maior a chance de desenvolvimento de HIC. A presença de posturas anormais foi fator associado a maior ocorrência de HIC refratária.

Objective: To analyze factors associated with intracranial hypertension in pediatric patients who suffered severe head injuries. Methods: Retrospective cohort study, with data collected from September 1998 through August 2003, including patients aged 0 to 16 who suffered severe head injuries, Glasgow score < 9, and submitted to intracranial pressure (ICP) monitoring (n = 132). Intracranial hypertension (IH) was defined as an episode of ICP > 20 mmHg requiring treatment, while refractory IH was ICP over 25 mmHg requiring barbiturates or decompressive craniectomy. Univariate analysis was followed by multivariate analysis; variables were considered significant if p < 0.05. Results: Ages ranged from 2 months to 16 years, median age 9.7 (6.0-2.3) years. Glasgow scores ranged from 3 to 8, median 6 (4-7). Traffic accidents were responsible for 79.5 percent of events. Monitoring devices were installed, on average, 14 hours after trauma, median time 24 hours. One hundred and three patients (78 percent) had IH, while 57 (43.2 percent) had refractory IH. In multivariate analysis, younger age ranges were associated with IH relative risk = 1.67 (1.03-2.72); p = 0.037, and abnormal postures were associated with refractory IH relative risk = 2.25 (1.06-4.78). The group mortality rate was 51.5 percent; it was correlated with use of barbiturates in refractory IH and low cerebral perfusion pressure at the intensive care unit. Conclusions: IH and refractory IH were frequent events in pediatric patients who suffered severe head injuries. The younger the patient, the greater the chance of developing IH. The presence of abnormal postures was found to be a risk factor for refractory IH.