Intrapleural alteplase decreases parapneumonic effusion volume in children more than saline irrigation.

OBJECTIVE: In this prospective, double-blind, randomized crossover trial, we determined the effect of intrapleural fibrinolysis with alteplase compared to that of normal saline irrigation on the thoracostomy tube output and pleural effusion volume in children with complicated parapneumonic effusion. METHODS: Twenty seven children, median age 3.5 years, referred to the interventional radiology service for thoracostomy tube drainage of a parapneumonic effusion were studied. Seventeen patients with pleural fluid thickness greater than 2 cm or >20% ipsilateral chest volume after 8 hr of thoracostomy tube drainage entered the treatment arm. They were randomized to receive alteplase 0.1 mg/kg twice a day on days 1 and 3, or on days 2 and 4, with normal saline irrigation on the alternate days. Daily pleural fluid volume measured by low dose chest computed tomography (CT) and thoracostomy tube output was compared between the saline and alteplase groups. RESULTS: Compared to normal saline irrigation, alteplase irrigation resulted in increased thoracostomy tube drainage and to a greater decline in pleural fluid volume. Earlier alteplase administration resulted in increased fluid mobilization compared to administration later in the hospital course. There were no bleeding complications. CONCLUSIONS: Intrapleural fibrinolysis with alteplase safely increases pleural drainage and decreases the volume of pleural inflammatory debris compared to intrapleural administration of normal saline. The benefit of intrapleural alteplase on decreasing the volume of pleural inflammatory debris occurs for up to 72 hr with repeated twice daily dosing.

Traumatic low attenuation subdural fluid collections in children younger than 3 years.

OBJECTIVE: To determine the time course for the development of posttraumatic nonhemic subdural fluid collections in infants and young children. DESIGN: Retrospective consecutive case series during 16 years. Patients Fifty-five head trauma patients younger than 3 years with low attenuation subdural fluid on computed tomography. MAIN OUTCOME MEASURE: Time after head trauma when low attenuation fluid first becomes visible. SETTING: Regional pediatric medical center. RESULTS: The initial visualization of low attenuation subdural fluid was within 4 days of the trauma for 44 of the patients. The mean +/- SD size of the subdural fluid collections when first identified was 4.6 +/- 2.0 mm (range, 2-12 mm), and the maximum observed size was 7.7 +/- 3.5 mm (range, 3-21 mm). The mean +/- SD time after injury until the maximum observed size was 16 +/- 18 days (range, 0-87 days). Low attenuation subdural fluid and high attenuation intracranial hemorrhage coexisted on at least 1 computed tomographic study during the first week after the trauma in 42 (81%) of the 52 patients with hemorrhage. CONCLUSION: Low attenuation subdural fluid collections (distinct from clotted blood) in infants and young children with head injuries most often develop during the first week after the traumatic event.

Intracranial hemorrhage in children younger than 3 years: prediction of intent.

OBJECTIVE: To determine whether certain computed tomographic imaging patterns in infants and young children with intracranial hemorrhage help predict intentional compared with unintentional injuries. DESIGN: Retrospective consecutive case series over a 10-year period. PATIENTS: Two hundred ninety-three children younger than 3 years with intracranial hemorrhage. MAIN OUTCOME MEASURES: The sensitivity and specificity of computed tomographic imaging patterns for intentional head injury. SETTING: Regional pediatric medical center. RESULTS: Four variables used in the multiple logistic regression analysis for predicting intentional head injury were statistically significant (P<.05): subdural hematoma located over the cerebral convexities, hematoma within the interhemispheric subdural space, hygroma (nonhemic subdural fluid) with intracranial hemorrhage, and absence of a skull fracture with intracranial hemorrhage. The prediction model for the diagnosis of intentional head trauma using combinations of these 4 variables and a.45 probability cutoff point indicated a sensitivity of 84% (95% confidence interval, 78%-90%) and a specificity of 83% (95% confidence interval, 74%-89%). CONCLUSION: Computed tomographic imaging patterns of intracranial hemorrhage in children younger than 3 years help predict whether the injury was intentional.

Serum neuron-specific enolase as a predictor of short-term outcome in children with closed traumatic brain injury.

BACKGROUND: Closed traumatic brain injury (cTBI) is a significant cause of mortality and morbidity in children. The natural course and extent of recovery from cTBI in children are poorly understood. Neuron-specific enolase (NSE), an enzyme detected in serum following structural damage of neuronal brain cells, appears to be a good marker for intracranial injury. However, to the best of the authors' knowledge, the usefulness of NSE as a predictor of disability in children with cTBI has not been reported. OBJECTIVES: To examine the association between posttraumatic serum NSE level and short-term physical disability in children with cTBI. METHODS: This was a retrospective analysis of a prospectively enrolled cohort of children aged 0-18 years with isolated cTBI presenting to the emergency department (ED) within 24 hours of injury, and having a cranial computed tomography (CT) scan as part of the evaluation. The NSE level was obtained at the time of ED evaluation. Physical disability was measured using the Glasgow Outcome Scale (GOS). The GOS score was assigned retrospectively for enrolled patients by a single investigator blinded to NSE level. Patient outcomes were categorized as good (GOS = 5) or poor (GOS < 5). A single radiologist reviewed all cranial CT scans. RESULTS: Ninety eligible subjects with NSE levels were identified; 86 met the enrollment criteria. Seven subjects (8%) had poor outcome. There was a significant difference in NSE levels between the poor and good outcome groups, even within high-risk subgroups. The area under the curve (AUC) for NSE prediction of poor vs. good outcome was 0.83. A serum NSE level of 21.2 ng/dL was 86% sensitive and 74% specific in predicting poor outcome. CONCLUSIONS: It appears that the serum NSE level can be used as a predictor of global short-term physical disability in children following cTBI.

Intrapleural fibrinolysis for parapneumonic effusion and empyema in children.

PURPOSE: To assess the safety and efficacy of urokinase and alteplase for intrapleural fibrinolysis in children with parapneumonic pleural fluid collections. MATERIALS AND METHODS: A retrospective review was performed of 71 children with parapneumonic pleural fluid accumulations who were treated with thoracostomy tube placement and intrapleural instillation of either urokinase or alteplase. The procedures were performed with urokinase between September 2, 1995, and March 27, 1998, and with alteplase between March 30, 1998, and January 2, 2002. The medical records and daily chest radiographs were reviewed by a pediatric radiologist to ascertain demographic information, signs and symptoms, laboratory results, thoracostomy tube output, treatment details, and radiographic pleural thickness and lung opacification. Multiple variables were compared for the alteplase and urokinase groups by using univariate and multivariate statistics. We defined primary treatment success as resolution of signs and symptoms at the time of discharge, without surgical intervention. RESULTS: Primary treatment success was 98% for alteplase and 100% for urokinase, with no major complications. Greater pleural fluid drainage occurred with alteplase than urokinase during the 1st (P =.001) and 2nd (P =.002) days of fibrinolytic therapy, and for the duration of thoracostomy drainage (P <.001). Multivariate models showed greater total drainage with alteplase (P <.001), greater patient age (P <.001), larger tube size (P =.002), and greater volume of drainage during the 24 hours prior to fibrinolysis (P <.001). CONCLUSION: Intrapleural fibrinolysis with urokinase or alteplase facilitates thoracostomy tube drainage of parapneumonic pleural fluid. With the dosing regimen used in this study, alteplase produces greater thoracostomy tube output than does urokinase.