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Prevalence, Evolution, and Extent of Impaired Cerebral Autoregulation in Children Hospitalized With Complex Mild Traumatic Brain Injury*

Lele, Abhijit V., MBBS, MD, MS, FNCS1,2; Watanitanon, Arraya, MD3; Lakireddy, Viharika, MBBS3; Clark-Bell, Crystalyn, BS3; Moore, Anne, BSN, RVT2; Zimmerman, Jerry J., MD, PhD4; Chesnut, Randall M., MD2; Armstead, William, PhD5; Vavilala, Monica S., MD6

Pediatric Critical Care Medicine: April 2019 - Volume 20 - Issue 4 - p 372–378
doi: 10.1097/PCC.0000000000001824
Neurocritical Care

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.

1Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, WA.

2Department of Neurological Surgery, University of Washington, Seattle, WA.

3Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.

4Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA.

5Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.

6Harborview Injury Prevention and Research Center, Department of Anesthesiology and Pain Medicine, Harborview Medical Center, Seattle, WA.

*See also p. 389.

Supported, in part, by the National Institutes of Neurological Diseases and Stroke (R21NS095321-02: to Dr. Vavilala).

Dr. Lele’s institution received one funding from Aqueduct Critical Care (research support from Aqueduct Critical Care for A Study Evaluate Aqueduct's Smart External Drain clinical trial and for External Ventricular Drain Aware study). Dr. Clark-Bell received funding from University of Washington (the data was collected as part of her salaried position). Dr. Zimmerman’s institution received funding from the National Institutes of Health (NIH) (R21 award and R01 funding) and Immunexpress, Seattle, WA (research funding), and he received funding from Elsevier Publishing (royalties for editing the textbook Pediatric Critical Care) and the Society of Critical Care Medicine (travel reimbursement for attend board meetings). Drs. Clark-Bell, Moore, Zimmerman, and Vavilala received support for article research from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest

This study was conducted at Harborview Medical Center, Seattle, WA.

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©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies