Predicting Brain Damage in Children with Acute Brain Injuries

Dr John Beca

Clinical Director

Paediatric Intensive Care

Starship Children’s Hospital

Auckland

Background to Research

Acute injury to the brain is the number one cause of death and morbidity in children, and in fact it exceeds all other causes combined.  About 70% of brain injuries in children are caused by the heart stopping, breathing problems or trauma such as a car accident.  Young children who survive severe brain injury commonly have multiple life long disabilities.  Between 35-50% of those with severe brain injury die or are left with such severe brain damage that they will never be able to live independently.

When the brain is injured some permanent damage occurs at that time.  However damage also often continues for some days afterward.  It is now well established that there is therefore a short window of opportunity to treat brain injuries.  There are also potential treatments available.  Adult studies have shown that ‘silent seizures’, where there is no outward sign of it happening, are common with acute brain injuries and probably make the damage worse.  We suspect that this is also true in children and we hope to find the answer.

What are your research objectives?

We currently lack the ability to determine how severely the brain is damaged and whether ongoing damage is occurring.  Our primary aim is to determine whether advanced monitoring of the brain, including monitoring of the electrical activity (EEG) and oxygen levels and early MRI scans, can reliably improve predictions of brain damage, when compared with currently established clinical factors.  The outcome will be assessed by an MRI scan three months later and functional and neuropsychological assessment another year on.  During our research we also want to find out how often ‘silent’ seizures occur in children with brain injury, the effect of sedative drugs on the brain’s electrical activity and determine the validity of a new simplified EEG monitor, known as the BrainZ monitor, when compared to conventional EEG.

How will you conduct your research?

We propose to enroll 57 children admitted to the Paediatric Intensive Cardiac Unit (PICU) at Starship Hospital with a severe acute brain injury caused either by trauma or cardiorespiratory arrest.  Within one to two hours of admission we will attach sensors to the head and monitor continuous three channel EEG and brain oxygen levels.  These will be continued for 96 hours or until the child starts to be weaned from mechanical ventilation.  We will also perform overnight standard EEG monitoring for the first three nights and an MRI scan as soon as possible after admission.  Extensive data will be collected about the child including demographic data, the type of injury, clinical and physiological data while in PICU and the type of drugs administered in hospital, such as those given for pain and agitation, which act on the brain.

To see if we can separate the effects of these drugs from that of brain injury, we will also study a control group of 57 children admitted to PICU with respiratory failure but without brain injury, and who also require mechanical ventilation and the administration of the same drugs. 

Are there others in your field in NZ or globally conducting similar research?

The Paediatric Intensive Care Unit at Starship is the only children’s intensive care unit in New Zealand.  There are no others pursing the same end for children in NZ but there are others investigating monitoring of acute brain injury in newborn intensive care units.  Internationally others are looking at various techniques in an attempt to improve our monitoring and understanding of children’s brain injuries.

What is innovative about the approach you are taking?

There is very limited or no data about any of these techniques used with children in intensive care.  There are no studies where all three techniques have been used.  There is little MRI information and no-one has looked at how early changes relate to evidence of permanent damage on subsequent MRI or how these permanent changes relate to development.  Our study is innovative because we are using the simplified EEG monitor which has been developed locally in New Zealand (BrainZ monitor).  While this monitor has been used extensively in newborn intensive care units it has not been used on older children.  But we consider that if it could reliably detect seizures this would provide enormous advances in our care of children. 

If you achieve your objectives what will that mean to those suffering from the disease or to the knowledge advancement of this disease?

This research will provide information about the ability of electrical and oxygen monitoring of the brain and early MRI scans to predict the severity of brain damage and indicate ongoing damage.  If more advanced monitoring could identify these things, it could be used to select children for trials of new treatments.  The detection and treatment of ‘silent’ seizures might also improve the outcomes for children with brain damage.  Obviously reliable information about the severity of brain damage and the likely outcome would provide invaluable information for both parents and medical staff.

Is there national or international collaboration on your research project?

There is no collaboration.