Moderate-to-Severe Traumatic Brain Injury in Children: Complications and Rehabilitation Strategies.

Traumatic brain injury (TBI) is the leading cause of death in children in the United States. Each year 37,200 children sustain a severe TBI, with up to 1.3 million life-years potentially adversely affected. Severe pediatric TBI is associated with significant mortality and morbidity. Of the children who survive their injury, more than 50% experience unfavorable outcomes 6 months after the injury. Although TBI-associated death rates decreased between 1997-2007, disabilities for TBI survivors continue to have both a direct and indirect impact on the economic and human integrity of our society. The degree of disability varies with the severity and mechanism of the injury, but a realm of physical and emotional deficits may be evident for years after the injury occurs. This article describes the pathophysiology of moderate to severe TBI, its associated complications, and opportunities to improve patient outcomes through use of acute management and rehabilitation strategies. To address the many challenges for TBI survivors and their families, including significant financial and emotional burdens, a collaborative effort is necessary to help affected children transition seamlessly from acute care through long-term rehabilitation.

How does dysautonomia influence the outcome of traumatic brain injured patients admitted in a neurorehabilitation unit?

BACKGROUND: Patients surviving severe traumatic brain injury (TBI) may suffer from symptoms presumed to be related to an excessive sympathetic production known as paroxysmal sympathetic hyperactivity (PSH). While this condition is more common in the acute phase, prognosis is less clear in rehabilitation settings. AIM: The goal of this study is to describe the functional status of patients with PSH admitted in a rehabilitation hospital and to determine its prognostic influence during rehabilitation. METHODS: A cohort study was undertaken of all the patients admitted in a neurorehabilitation hospital suffering from PSH. Functional outcomes were reported according to the Glasgow outcome scale-extended (GOSE), the Disability Rating Scale (DRS) and the Functional Independence Measure (FIM). RESULTS: Thirteen out of 39 patients suffered symptoms compatible with PSH. Neuroimaging of PSH patients showed more diffuse lesions. The FIM at admission was lower in the PSH group who was transferred for rehabilitation at an earlier stage. At discharge no differences were seen using the FIM, DRS and GOS-E. CONCLUSIONS: Functional status is similar and PSH does not appear to influence recovery during the rehabilitation, although PSH patients are more likely to undergo psychoactive medications and special care is needed to approach their caregivers that perceive PSH as a complication for rehabilitation.

Comparison of long-term outcomes of patients with severe traumatic or hypoxic brain injuries treated with intrathecal baclofen therapy for dysautonomia.

PRIMARY OBJECTIVE: To compare the long-term outcome of patients with severe traumatic brain injury and patients with hypoxic brain injury with dysautonomia and hypertonia treated with intrathecal baclofen therapy. METHODS AND PROCEDURES: Fifty-three patients with severe traumatic (n = 43/53) or hypoxic (n = 10/53) brain injuries treated by intrathecal baclofen therapy were included to be evaluated with the Coma Recovery Scale-Revised, the Barthel Index, the Glasgow Outcome Scale, the Ashworth scale, the scores of hypertonic attacks, of sweating episode and of voluntary motor responses. A retrospective analysis highlighted patients' characteristics at admission and before surgery and their complications. MAIN OUTCOMES AND RESULTS: After a mean follow-up time of 9.6 years, 13/53 (24.5%) patients had died. Alive patients with traumatic brain injury had a higher level of consciousness recovery (p < 0.02) and more abilities in activities of daily living (p < 0.008) in the long-term. Their dysautonomia and limb hypertonia also significantly improved, contrary to patients with hypoxic brain injury who needed higher doses of baclofen (p < 0.03). CONCLUSIONS: At long-term follow-up, patients with hypoxic brain injury had a poorer functional outcome than patients with traumatic brain injury with persistent symptoms of dysautonomia associated with uncontrolled hypertonia, despite the use of intrathecal baclofen.

A 10-year follow-up study of patients with severe traumatic brain injury and dysautonomia treated with intrathecal baclofen therapy.

PRIMARY OBJECTIVE: To describe the long-term disorders of consciousness in patients with dysautonomia and hypertonia treated with intrathecal baclofen therapy (IBT). METHODS AND PROCEDURES: Forty-three patients with severe traumatic brain injuries who were previously implanted with an intrathecal baclofen pump were included to be evaluated in the long-term with the Coma Recovery Scale-Revised. The Barthel Index, the Glasgow Outcome Scale, the Ashworth scale, the scores of hypertonic attacks, of sweating episodes and of voluntary motor responses were used to describe functional abilities and residual impairments. A retrospective analysis highlighted patients' characteristics at admission, before surgery and their complications. MAIN OUTCOMES AND RESULTS: After a mean follow-up of 10 years, nine of 43 (20.9%) patients had died, 13/43 (30.2%) patients were severely disabled or in an unresponsive wakefulness syndrome and 21/43 (48.8%) patients had good recovery of consciousness. The latter patients tended to receive IBT later, suggesting a later development of uncontrolled symptoms of dysautonomia and hypertonia. They needed lower doses of baclofen, suggesting that they had less severe symptoms. Their dysautonomia, limb hypertonia and voluntary motor responses improved significantly compared to patients with poor outcome. CONCLUSIONS: Recovery of good long-term consciousness is possible. A low level of consciousness recovery and the early development of severe and persistent symptoms of dysautonomia associated with hypertonia could be linked to poor long-term outcome.

Diagnosing dysautonomia after acute traumatic brain injury: evidence for overresponsiveness to afferent stimuli.

OBJECTIVE: To differentiate between traumatic brain injury (TBI) subjects with normal and elevated autonomic activity by quantifying cardiac responsivity to nociceptive stimuli and to determine the utility of heart rate variability (HRV) and event-related heart rate changes in diagnosing dysautonomia. DESIGN: Prospective cohort study. SETTING: Intensive care unit in a tertiary metropolitan trauma center. PARTICIPANTS: Adults (N=27) with TBI recruited from 79 consecutive TBI admissions comprising 16 autonomically aroused and 11 control subjects matched by age, sex, and injury severity. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Immediate: pattern of autonomic changes indexed by HRV and event-related heart rate after nociceptive stimuli. Six months: length of stay, Glasgow Coma Scale, and Disability Rating Scale. RESULTS: Heart rate changes (for both HRV and event-related heart rate) were associated with the diagnostic group and 6-month outcome when evaluated pre- and poststimulus but not when evaluated at rest. When assessed on day 7 postinjury, the comparison of HRV and heart rate parameters suggested an overresponsivity to nociceptive stimuli in dysautonomic subjects. These subjects showed a 2-fold increase in mean heart rate relative to subjects with sympathetic arousal of short duration (16% vs 8%), and a 6-fold increase over nonaroused control subjects. Data suggest that post-TBI sympathetic arousal is a spectrum disorder comprising, at one end, a short-duration syndrome and, at the other end, a dramatic, severe sympathetic and motor overactivity syndrome that continued for many months postinjury and associated with a significantly worse 6-month outcome. These findings suggest that it is not the presence of reactivity per se but rather the failure of processes to control for overreactivity that contributes to dysautonomic storming. CONCLUSIONS: This study provides empirical evidence that dysautonomic subjects show overresponsiveness to afferent stimuli. Findings from this study suggest an evidence-driven revision of diagnostic criteria and a simple clinical algorithm for the improved identification of cases.