A concussion or mild traumatic brain injury is defined as a transient neurologic change resulting from a biomechanical impact to the head. Given this broad definition, it is not surprising that concussion represents the most common type of traumatic brain injury (TBI). Concussions can be complicated and multifaceted, as patients usually present with various combinations of neurologic, cognitive and psychiatric symptoms, Drs. Sharief Taraman and Jonathan Romain said in a recent grand rounds presentation at CHOC Children’s.
Adolescents represent a commonly seen subgroup within the concussion population, most notably because of their frequent involvement in sports and higher-risk activities. Additionally, when injuries do occur at the high school and college level, the impact velocities tend to be at a higher rate than is seen in younger athletes, potentially resulting in more pronounced concussions. Further complicating the situation is that adolescents tend to have busy schedules and multiple responsibilities throughout the school year (when most concussions occur). Thus, when a concussion is sustained, the student athlete not only needs to deal with the immediate symptoms of the injury, but also the potential for academic and social derailment during the recovery process. Combine these issues with a strong body of literature suggesting adolescents tend to have slower resolution than do adults, and you have the recipe for a very bumpy recovery.
The doctors explain that cognitive symptoms manifest as slower processing speed, feeling foggy, and occasional forgetting or transient confusion. Psychiatric symptoms often include irritability, liability and sadness. A child may have one or many of these symptoms, although more often these symptoms overlap. The patient and their family may not recognize how persistent symptoms of headache and dizziness, for example, can contribute to memory problems and difficulty concentrating, irritability, and feelings of depression and hopelessness. Children with prolonged symptoms also can feel isolated from their peers while they are sitting out of play and school.
Precision medicine is changing how physicians think about treatments, with great advances coming out of the oncology field. In podcast No. 42, three CHOC experts and speakers at the upcoming Peds2040 conference, Dr. Anthony Chang,Dr. Leonard Sender and Spyro Mousses, Ph.D., discuss exciting developments impacting patients today and offering tremendous hope for the future.
Dr. Sender, medical director of the Hyundai Cancer Institute at CHOC, is determined to find a cure for cancer and prevent or reduce the toxicity associated with treatments. Under his leadership, CHOC has programs in place that bring together big data, bioinformatics and genomic sequencing. In addition to discussing what CHOC is currently doing, he and Dr. Mousses, whose interested include artificial intelligence, share plans for the near future, including offering very complex molecular profiles in collaboration with multiple specialists and institutions, including hospitals and bioinformatics companies from across the nation.
To hear more from these three thought leaders, listen to episode No. 42:
Many might picture a stroke patient as middle aged or elderly, but
the reality is that the ailment occurs across the lifespan.
A stroke affects one in every 3,500 live births and six to 13 per 100,000 children per year. At CHOC Children’s, that translates to one or two patients per month outside the newborn period.
Among many risk factors, the largest for stroke in children include cardiac disease (19 percent); coagulation disorders (14 percent); and dehydration (11 percent). Multiple risk factors are present in up to 25 percent of pediatric stroke patients.
Atherosclerosis and modifiable risk factors that dominate adult stroke mechanism and treatment were nearly non-existent in pediatric stroke. However, in the past decade and a half, traditional cardiovascular risk factors for stroke in people ages 15 to 34 have been steadily increasing.
Placental diseases can cause perinatal arterial stroke, and perinatal stroke accounts for a large proportion of pediatric stroke morbidity. The first week of life carries the most risk for stroke and the majority of survivors have lifelong morbidity, most typically, hemiparetic cerebral palsy. Cognitive or behavioral disorders and epilepsy are also common.
Acute ischemic stroke (AIS) lesions are often multifocal, even in the absence of overt cardiac disease, which lends support to proximal embolic source. Many neonates with AIS have risk factors and presentations that overlap with hypoxic ischemic encephalopathy, and the two can co-occur.
Despite these occurrences and the inherent dangers, a lack of awareness prevails and diagnosis of childhood stroke is often significantly delayed. One study found up to a 28-hour delay in seeking medical attention from the onset of symptoms and a 7.2 hour delay after presentation before any brain imaging occurred (Lenn, et al, 2002).
Further complicating matters is that presentation can be subtle, varied and non-specific, and often occurs in the setting of a systemic illness. One study found the median time to diagnose AIS in neonates was 87.9 hours and 24.8 hours in children (Mackay, et al 2009). Another study saw that 19 of 45 children with a stroke did not receive a correct diagnosis until 15 hours after initial presentation, and in some cases, up to three months afterward (DeVeber, et all 2006).
Also, many other diseases mimic a stroke: A fifth of children presenting for evaluation of suspected acute stroke have a “stroke mimic,” rather than an actual stroke (Shelhaas, Pediatrics, 2006). Stroke mimics include migraines and delirium, as well as seizure and tumor.
High-powered clinical trials that guide adult stroke management – including antiplatelet and anticoagulant strategies; chemical and mechanical thrombolysis; stroke unit care; and many others – do not yet exist for children.
Of 687 children enrolled in the International Pediatric Stroke Study (2011), 15 patients received tissue plasminogen activator (tPA): nine underwent intravenous tPA and six underwent intra-arterial tPA. The median time to treatment from onset was 3.3 hours for intravenous alteplase and 4.5 hours for intra-arterial alteplase.
Of those patients, four had intracranial hemorrhage (non-symptomatic); one died from brainstem stroke; one died from massive stroke with herniation; one was discharged without deficits; and 12 were discharged with neurological deficits.
Intravenous tissue plasminogen activator (tPA) needs more study for safety, dosing and efficacy before it can be fully applied to pediatric patients. Dosing in children cannot be extrapolated from adult data or existing pediatric data.
Limited pediatric safety and effectiveness data also exists around neurointerventional techniques like intra-arterial tPA and mechanical thromboectomy. Early intervention results in better outcomes, though success rates depend heavily on the operator’s experience.
Similar to the adult stroke population, rehabilitation is multifaceted and comprises neuropsychology; developmental monitoring; educational intervention; and physical, occupational, and speech therapies. Most of the functional recovery occurs in the first two to three months. The quality of functional recovery is better in the pediatric population; however, the prognosis worsens as the lesion size increases.
The risk of recurrence following a stroke is up to 25 percent and highest in the first three months of onset. The lowest risk of recurrence is in perinatal and cryptogenic stroke.
Like any other condition, prevention of pediatric stroke is important and many patients will be placed on antiplatelet or anticoagulation. Interestingly, children with some, few or no vaccinations are shown to be at risk of stroke seven times higher than those who received all or most vaccinations.
Palliative care in infants and children is a critical and evolving field. In this grand rounds video presentation, Dr. Sirisha Perugu, CHOC Children’s neonatologist, and Meg Mohr, FNP-BC, MSN, coordinator of CHOC’s pediatric advanced care team, provide valuable insight. More specifically, they:
define palliative care and provide a brief history of its development;
highlight the ways palliative care adds value to culturally sensitive and family- centered care;
examine the health care provider’s role in end-of- life care and patient management decisions;
and suggest how the health care provider can assist a family whose child requires the added layer of support of palliative care.
The Leapfrog Group has once again named CHOC Children’s Hospital to its annual list of Top Hospitals, distinguishing CHOC’s commitment to providing the safest, highest quality health care. CHOC is one of only 12 children’s hospitals in the nation and only two in the state to earn the respected award.
The selection is based on results of The Leapfrog Group’s annual hospital survey, which measures hospitals’ performance on patient safety and quality, focusing on three critical areas:
How patients fare
Management structures established to prevent errors
Performance across many facets of hospital care, including survival rates for high-risk procedures and ability to prevent medication errors, is considered in establishing the qualifications for the award.
“Leapfrog’s Top Hospital award is widely acknowledged as one of the most prestigious distinctions any hospital can achieve in the United States,” said Leah Binder, president and CEO of The Leapfrog Group. “Top Hospitals have lower infection rates, better outcomes, decreased length of stay and fewer readmissions. By achieving Top Hospital status, CHOC has proven it prioritizes the safety of its patients, is committed to transparency, and provides exemplary care for children and families in Orange County. I congratulate the hospital’s board, staff and clinicians whose efforts achieved these results.”