Melissa G. Chung

Delirium in Critically Ill Children: An International Point Prevalence Study*

Objectives: To determine prevalence of delirium in critically ill children and explore associated risk factors. Design: Multi-institutional point prevalence study. Setting: Twenty-five pediatric critical care units in the United States, the Netherlands, New Zealand, Australia, and Saudi Arabia. Patients: All children admitted to the pediatric critical care units on designated study days (n = 994). Intervention: Children were screened for delirium using the Cornell Assessment of Pediatric Delirium by the bedside nurse. Demographic and treatment-related variables were collected. Measurements and Main Results: Primary study outcome measure was prevalence of delirium. In 159 children, a final determination of mental status could not be ascertained. Of the 835 remaining subjects, 25% screened positive for delirium, 13% were classified as comatose, and 62% were delirium-free and coma-free. Delirium prevalence rates varied significantly with reason for ICU admission, with highest delirium rates found in children admitted with an infectious or inflammatory disorder. For children who were in the PICU for 6 or more days, delirium prevalence rate was 38%. In a multivariate model, risk factors independently associated with development of delirium included age less than 2 years, mechanical ventilation, benzodiazepines, narcotics, use of physical restraints, and exposure to vasopressors and antiepileptics. Conclusions: Delirium is a prevalent complication of critical illness in children, with identifiable risk factors. Further multi-institutional, longitudinal studies are required to investigate effect of delirium on long-term outcomes and possible preventive and treatment measures. Universal delirium screening is practical and can be implemented in pediatric critical care units.

Noninvasive Brain Stimulation: The Potential for Use in the Rehabilitation of Pediatric Acquired Brain Injury

Noninvasive brain stimulation (NIBS) offers the potential to modulate neural activity and recovery after acquired brain injury. There are few studies of NIBS in children, but a survey of those studies might provide insight into the potential for NIBS to modulate motor rehabilitation, seizures, and behavior in children. We surveyed the published literature prior to July 2014 for articles pertaining to children and NIBS with a focus on case series or trials. We also reviewed selected articles involving adults to illustrate specific points where the literature in children is lacking. A limited number of articles suggest that NIBS can transiently improve motor function. The evidence for an effect on seizures is mixed. Two open-label studies reported improvement of mood in adolescents with depression. NIBS may serve as a tool for pediatric neurorehabilitation, but many gaps in our knowledge must be filled before NIBS can be adopted as a clinical intervention. To move forward, the field needs adequately powered trials that can answer these questions. Such trials will be challenging to perform, will likely require multicenter collaboration, and may need to adopt novel trial designs that have been used with rare disorders.

Prevalence of Early Posttraumatic Seizures in Children With Moderate to Severe Traumatic Brain Injury Despite Levetiracetam Prophylaxis.

Objectives: To evaluate the prevalence of early seizures after levetiracetam prophylaxis in children with moderate to severe traumatic brain injury. Design: Prospective observational study. Setting: Level 1 pediatric trauma center. Patients: We enrolled 34 patients between the ages of 0–18 years with moderate to severe traumatic brain injury admitted to the PICU at a level 1 trauma center who received levetiracetam for early posttraumatic seizure prophylaxis. Measurements and Main Results: Primary outcome was the prevalence of early posttraumatic seizures that were defined as clinical seizures within 7 days of injury. In 6 of 34 patients (17%), clinical seizures developed despite levetiracetam prophylaxis. An additional two patients had nonconvulsive seizures. This prevalence is similar to that reported in the literature in this patient population who do not receive seizure prophylaxis (20–53%) and is higher than that in patients who receive phenytoin prophylaxis (2–15%). Patients with early posttraumatic seizures were younger (median age, 4 mo) (p < 0.001) and more likely to have suffered from abusive head trauma (p < 0.0004). Conclusions: Early clinical posttraumatic seizures occurred frequently in children with moderate to severe traumatic brain injury despite seizure prophylaxis with levetiracetam. Younger children and those with abusive head trauma were at increased risk of seizures. Further studies are needed to evaluate the efficacy of levetiracetam before it is routinely used for seizure prophylaxis in these children, particularly in young children and those who have suffered from abusive head trauma.

Hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) also known as Osler-Weber-Rendu syndrome, is an autosomal dominant disorder that is characterized by multiple arteriovenous malformations (AVMs) involving the skin, mucosal surfaces, and internal organs. HHT has an age-dependent penetrance and usually initially presents with recurrent epistaxis followed by the characteristic telangiectasias of the face, oropharynx, and hands over time. Patients often have vascular malformations that involve their lungs, brain, spinal cord, and gastrointestinal tract as well, which are the main causes of morbidity in patients with HHT. The sequelae of visceral organ involvement include ischemic stroke, cerebral bacterial abscesses, intracranial hemorrhage, chronic hypoxia, dyspnea with exertion, pulmonary hypertension, high output heart failure, gastrointestinal bleeds and liver failure.

Acanthamoeba granulomatous amoebic encephalitis after pediatric hematopoietic stem cell transplant

Acanthamoeba encephalitis is a rare, often fatal condition, particularly after HSCT, with 9 reported cases to date in the world literature. Our case was originally diagnosed with ALL at age 3 years, and after several relapses underwent HSCT at age 9 years. At 17 years of age, he was diagnosed with secondary AML for which he underwent a second allogeneic HSCT. He presented with acute‐onset worsening neurological deficits on day +226 after the second transplant and a post‐mortem diagnosis of Acanthamoeba encephalitis was established, with the aid of the CDC.

Cerebral Sinovenous Thrombosis in Neonates and Children

Investigators from Erasmus University Hospital in Belgium and Gustave-Dron Hospital and Roger-Salengro Hospital in France studied the clinical and neuroradiologic characteristics of cerebral sinovenous thrombosis (CSVT) in neonates and children.

735: CEREBRAL BLOOD FLOW VELOCITY AND AUTOREGULATION IN CHILDREN AFTER A GLOBAL HYPOXIC-ISCHEMIC EVENT.

Learning Objectives: Global hypoxic-ischemic (GHI) events are a common cause of morbidity and mortality. There is a paucity of literature on the cerebrovascular response following GHI; thus, no evidence-based, goal directed therapies exist. Understanding the basic response is necessary to inform trials aimed at therapeutic options. Methods: This is a single-center, prospective, observational study of children (0–18 years) admitted to our PICU following a GHI. Those with prior pathology that would alter cerebral blood flow velocity (CBFV) were excluded. Patients underwent daily transcranial Doppler ultrasonography for 8 days, during which the bilateral middle cerebral arteries (MCA) were insonated and cerebral autoregulation was tested using the transient hyperemic response ratio. 3 month follow-up was performed using the Glasgow Outcome Score– Pediatric Extended Version (PE-GOS). Results: 18 patients met inclusion criteria, 3 declined for a sample size of 15. Median age was 3 years (0.33, 9.5), 67% male. GHI etiology included: drowning+cardiac arrest–2, asphyxia without arrest–1, asphyxia+cardiac arrest–4, and cardiopulmonary arrest–8. Median GCS 3T (3,3), initial pH 6.88 (6.66,6.99), and initial lactate 5.9 (3.9,11.3). Mean MCA CBFV was near normal for critically ill children on post-injury day (PID) 1. Hyperemia occurred on PID 2–3 with return to normal by day 8 in survivors (n=7). Non-survivors (n=8, 53%) did not follow this pattern as their CBFV was abnormal until the end of the study period. 91% of those with a bad outcome (n = 11, PE-GOS 5–8) compared to 50% in the good outcome group (n=4, PEGOS 1–4) had at least one episode of extreme CBFV (+/2 standard deviations), p=0.1538 (Fisher’s exact). Autoregulation was not reliably intact in any child. Median PE-GOS score was 8 (6,8). Conclusions: Following a GHI, survivors had a hyperemic response on PID 2–3 with normalization thereafter. Non-survivors and those with poor neurologic outcome had persistently abnormal CBFV. Abnormal cerebral autoregulation was noted in all cases. These findings may aid prognostication and encourage the use of neuroprotective measures.

Book Review: Moyamoya Disease: Diagnosis and Treatment

The first edition of Moyamoya Disease: Diagnosis and Treatment provides a succinct review of the currently available knowledge on the epidemiology, evaluation, and management of moyamoya disease and syndrome. The text is well organized into sections, with the first focusing on diagnosis, the second on treatment options, and the third on long-term outcomes. Within each section, the descriptive chapter titles, such as ‘‘genetics of moyamoya angiopathy,’’ allow the reader to quickly find information regarding a specific clinical question. Pediatric data are distributed throughout the text, but the authors thoughtfully also have included separate sections on pediatric moyamoya. Overall, the text is well written, with an impressive list of contributors composed of a mix of pediatric and adult neurologists and neurosurgeons. The contributors uniformly provide a strong emphasis on the medical literature and provide detailed references at the end of each chapter. The text is enhanced by well-organized tables and beautiful color graphics, including an array of illustrations, photographs, and examples of various imaging modalities. The book also includes online access to approximately 40 minutes of supplemental videos and animations for topics such as arterial wall pathology in moyamoya disease, EEG changes during direct bypass, etc. The book places a heavy emphasis on the surgical aspects of moyamoya disease, which is not surprising since the authors are neurosurgeons. However, given the inclusion of detailed information on the diagnosis, epidemiology, evaluation, and outcome of patients, the audience of this book should not be limited to neurosurgeons; the text also is suitable for the general child or adult neurologist, neuro-intensivist, or vascular neurologist looking for a concise review of the moyamoya disease and its management.