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Rain Does Not Fall On One Roof Alone: The Worldwide Burden of Pediatric TBI & Its Sequelae

Post-traumatic headaches, pain, seizures & epilepsy: Good & Bad Plasticity
Christopher Giza

Persistent post-traumatic symptoms occurs when symptoms of TBI last longer than expected after an injury. These symptoms may include headaches, seizures, dizziness, and problems with concentration and memory. They can last weeks to months.  There are about twenty-two frequent symptoms making the management very challenging.  This talk will focus on the new updates in the evaluation and management, priorities, and clinical pearls. Dr. Giza will review new concepts of post-TBI neuroplasticity and pathophysiology.  In addition will review under recognized post-traumatic syndromes with predominant autonomic, neck pain, vertigo, or visual symptoms. 
The International Headache Society as defines post-traumatic headache (PTH): “a headache developing within seven days of the injury or after regaining consciousness.” Different types of headache have been described, but the most common headache resembles migraine and tension-type headache.  Headaches is one of the most debilitating symptoms after trauma and interfere with physical, academic, sports activity and social life.  Other posttraumatic symptoms might interfere with the treatment and recovery.  
Trauma can lead to various outcomes from simple seizures and debilitating post-traumatic epilepsy (PTE). Multiple changes occur after a head injury that can lead to these attacks and several mechanisms are involved such as mTOR via TLR-1. Adenosine and several new neuroprotective agents may be effective preventing brain damage.

 

Cognitive, Psychiatric sequelae & Outcome assessments in low resource settings including chronic neurobehavioral deficits (ADHD, memory, learning)
Alcy Torres

The evaluation of cognitive and behavioral symptoms play an important role in the recovery of many children and adolescents who have sustained TBI. This presentation will discuss new approaches for assessments during the acute, sub-acute, and chronic phases. Issues of baseline testing and validity assessment will be reviewed. Typical clinical recommendations arising from the neuropsychological evaluation will be discussed, with an emphasis on the relationship between test findings and common academic accommodations.
Neuropsychology has been at the forefront of developments in clinical assessment of traumatic brain injury as focus on these injuries has received increasing public and professional attention over the last two decades. While much of the research and clinical practice in this area has grown out of evaluation and treatment of sports-related concussion, advances in assessment and management of cognitive and psychological aspects of recovery are applicable to the full range of patients suffering of brain injury symptoms.  Clinical practice and research has led to the recognition of cognitive and psychiatric sequelae including ADHD.  About 15-20% of patients suffer from persistent symptoms, but guidelines for management have not been established. These patients have been lumped together as a suffering from post-concussion syndrome, a unifying diagnosis.  I will propose new algorithms for evaluation and management, practical for LMIC countries.

 

Intensive care and neurosurgical management of pediatric TBI with focus on sequelae
Anthony Figaji

A significant number of children who are admitted to the hospital have TBI symptoms. Yet, the optimal or standard pathway of care for children with TBI in the hospital setting is not known. Diagnosing TBI in hospital is important because planning of therapies and perioperative anesthetic care is needed in order to minimize risks that could impede recovery. So too is a clinical practice guideline that enables triage, diagnosis, management, and continuity of care. In this presentation, Dr. Figaji will provide a practical approach to the diagnosis and management of severe TBI in the ICU, and emphasize the importance of a standardized neurological and multidisciplinary care to identify posttraumatic deficits and its comorbidities. 
In the ICU, TBI symptoms may be less clinically recognizable in a few scenarios: 1) the pre-verbal or non-verbal child; 2) those with distracting injuries, such as orthopedic or visceral trauma; and 3) those admitted to the Pediatric Intensive Care Unit (PICU) with more severe forms of TBI or systemic injuries. In these scenarios there is often no way of knowing whether a child has concussion-like deficits unless clinical scores such as the Glasgow Coma Scale (GCS) are abnormal (e.g. < 14 of maximum score of 15), or if the history or neurologic examination suggest this possibility.  Dr. Figaji aims to provide a practical clinical and neurosurgical approach to the diagnosis and management of TBI in the hospital.

 

Neurorehabilitation of patients with TBI sequelae in limited resource settings.  The burden of TBI in the world and in particular in the Sub Saharan Africa is massive and there is an urgent need for research, education and training
Biju Hameed

A complex diagnosis such as concussion requires a multidisciplinary patient-centered approach to maximize health outcomes. There is growing evidence to support the role of Rehabilitation in managing children and adolescents with a protracted recovery following TBI. Symptoms such as headache, dizziness, neck pain, gaze instability, balance dysfunction, and fatigue can be addressed through a multi-model approach. This presentation provides an overview of the targeted pathways of examination and treatment of individuals after TBI through vestibular rehabilitation, cervicogenic rehabilitation, exertional training, and patient education. 

Individuals with persistent symptoms affecting their function will benefit from management from a multidisciplinary rehabilitation team, experienced in TBI.  Initial rest following concussion is recommended but research suggests that strict or prolonged rest has been linked to slower symptom resolution while exercise and cervico-vestibular rehabilitation facilitate return to function and recovery. The management of TBI can be challenging due to the heterogeneity of patient presentations. Current best practice unique to rehabilitation includes the ability to provide an individualized, patient centered approach to best differentiate disorders of the cognitive, mood, behavior, autonomic, vestibular and cervicogenic systems. Dr. Hameed will provide a framework of the key and new components of Rehabilitation approach to patients with TBI.