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O’Brien, Nicole; Maa, Tensing
Critical Care Medicine: December 2013
doi: 10.1097/01.ccm.0000439194.60178.1d
Oral Abstract Session: Brain Injury, Repair, and Recovery: PDF Only

Introduction: Traumatic brain injury (TBI) is a major cause of death and disability in children. Cerebral vasospasm, through reduction of blood flow, may contribute to secondary ischemic injury in these patients. Studies have found a 20-60% incidence of vasospasm in adult TBI patients with worsened neurologic outcomes in that cohort. The incidence, time to onset, and duration of vasospasm following moderate to severe TBI in children remains unknown. Methods: This prospective, observational trial was conducted at a level 1 pediatric trauma center. Children admitted to the intensive care unit with moderate to severe TBI (Glasgow Coma Score (GCS) <=12) were eligible. Participants underwent transcranial doppler ultrasound (TCD) of bilateral middle cerebral arteries (MCAs) and the basilar artery (BA) within 24 hours of injury and daily thereafter. Vasospasm was diagnosed in the MCA when flow velocity was >2 standard deviations (SD) above age and gender normal value and the Lindegaard ratio >3. Vasospasm was diagnosed in the BA when flow velocity was >2 SD above age and gender normal value. Results: 67 patients were enrolled (13 falls, 16 motor vehicle accidents, 17 pedestrians vs autos, 14 abusive head traumas, 7 other). 70% were male. Mean age was 7.8 +/- 5.4 years. Mean GCS was 8.2 +/- 2.2. Vasospasm incidence was 19% in the RMCA, 25% in the LMCA, and 11% in the BA. Mean time to onset of vasospasm was 4 +/- 1 days in the MCAs and 3 +/- 2 days in the BA. Duration of vasospasm was 2 +/- 1 days in the MCA and 3 +/- 2 days in the BA. GCS <8 was identified as a risk factor for the development of vasospasm (OR 2.6, 95% CI 1.2-8.4). At discharge, 53% of children with vasospasm had good neurologic outcomes compared to 70% of children without vasospasm (GOS-E Peds score <=4). Conclusions: In this largest cohort of children with TBI studied to date, vasospasm occurred in a sizeable number of participants. Assessment of long-term neurologic outcomes in these children is underway. Vasospasm prevention and treatment may represent an important therapeutic target that has yet to be studied in this population.

(C) 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins