Scanning for Answers

Researcher explores secrets of traumatic brain injury in children

Karin Reuter-Rice, right, conducts a pediatric Transcranial Doppler scan. Photo by Jared Lazarus/Duke University Photography
Karin Reuter-Rice, right, conducts a pediatric Transcranial Doppler scan. Photo by Jared Lazarus/Duke University Photography

Working as a nurse practitioner in the Pediatric Intensive Care Unit, Karin Reuter-Rice, couldn't help but notice that some children who came in with traumatic brain injuries, such as those resulting from automobile accidents, improved rapidly and made full recoveries, while others who came in with very similar injuries suffered grave and permanent damage.

"You'll have one child come in with a significant head injury who is up and walking, talking, recovering, and ready to go home within a week or two, and another child with the same type of injury to the same general part of the brain who may never leave the hospital," says Reuter-Rice, an assistant professor in the School of Nursing and the School of Medicine's Department of Pediatrics.

"Why do these brain injuries look so similar and yet the outcomes are so different, and what else is happening in the brain that will help us answer that question?"

She has embarked on a multi-year research project to try to find those answers. Reuter-Rice, faculty coordinator for the neonatal and pediatric instructional areas in the master of science in nursing degree program, is gathering ultrasound, genetic and other data from children with traumatic brain injuries (TBI) admitted to the pediatric units in the Duke University Health System.

TBI accounts for about one-third of all injury-related deaths in the U.S. and is the leading cause of morbidity and mortality in children. This past September, Reuter-Rice was one of just 12 nurse researchers in the nation to receive a $350,000 Robert Wood Johnson Foundation Nurse Faculty Scholars grant to support her research.

Reuter-Rice, who is also the 2013 recipient of the National Association of Pediatric Nurse Practitioners' Henry K. Silver Memorial Award for significant contributions to the improvement of pediatric health care, is especially interested in what happens during the secondary phase of a head injury, after the initial trauma and associated bleeding or bruising occurs. She is exploring the possible role that a rather mysterious phenomenon known as vasospasm, the sudden contraction of blood vessels in the brain after a traumatic injury, might play in determining how well, or how poorly, individual children recover from TBI.

"Vasospasm can occur within minutes after the primary injury, or up to months later," Reuter-Rice says. "When that blood vessel contracts, it restricts the flow of blood to the injured brain, as well as the uninjured part of the brain. Therefore, you have the potential for more injury."

scanning for answers

Deprived of blood, brain cells quickly deteriorate and die. The causes and effects of vasospasms, which frequently accompany subarachnoid hemorrhage from aneurysms, are not well understood, Reuter-Rice says. It's not known what stimulates the blood vessels, which themselves generally are undamaged, to constrict, or why it happens in some patients and not others.

To try to unlock the answers to some of those questions, she has begun using a diagnostic Transcranial Doppler (TCD) to do ultrasound images of the larger blood vessels in the brains of children who come into Duke with traumatic brain injuries. Such ultrasounds, which can pinpoint the occurrence and location of vasospasms, are the standard of care in adult patients with severe head injuries, but they are not routinely performed in pediatric patients.

"We don't understand it very well, especially in children," Reuter-Rice says. "I'm trying to get some inkling of the processes that drive it. We may not find answers that will apply to every patient, but we will at least know more than we do now, and that will help inform our next steps. And that, to me, is what we need for brain injury research. We need it for our wounded warriors. We need it for our wounded athletes. We need it for our wounded children."

Some of the keys may lie in specific biological markers and genetic variations that may be associated with pediatric TBI. So Reuter-Rice is also collecting DNA swabs and analyzing biological data -- biomarker levels, and so on -- from the participating patients, with an eye toward identifying biomarkers or genetic factors that may predispose some children to suffer vasospasms or, conversely, that may confer some protective mechanism. The results ultimately could lead to improved care, not only for children with TBI, but also for those who suffer other sorts of oxygen deprivation to the brain, as in suffocation, stroke, or submersion injuries.

"This is all very new, very foundational, but if we were more informed about how the brain reacts to injury we might be able to intervene more effectively," Reuter-Rice says. "If we could identify a biomarker or a polymorphic gene that we know suggests a worse outcome, for example, we could treat those children more proactively."

Reuter-Rice, who came to Duke three years ago from Rady Children's Hospital in San Diego, began the study with a three-year grant from the National Institutes of Health's National Institute of Nursing Research. The new Robert Wood Johnson Foundation award allows her to expand and extend the project, so that by 2016 she expects to have data from 60 children. She has a large, multidisciplinary team of colleagues assisting her with the project, including senior faculty such as Marilyn Hockenberry, the Bessie Baker Professor of Nursing, and neurologist Dr. Daniel Laskowitz; nurses and physicians in the Pediatric ICU; Duke nursing graduate students and undergraduates; and even a high school senior at the North Carolina School of Science and Mathematics.

"Dean Catherine Gilliss took a bit of a leap of faith in bringing me here, because my research is a little bit outside what our school's traditional research has been," Reuter-Rice says. "And yet it has unfolded to be this wonderfully collaborative process, and I have found nothing but enthusiastic cooperation everywhere I've looked."

That spirit of cooperation has come from the parents of the young patients as well -- mothers and fathers who are dealing with some of the most terrible things that can happen to parents. In the first 10 months of her study, Reuter-Rice enrolled 21 young patients from four months to 15 years of age -- the majority younger than 2 -- who had suffered severe brain injuries, some from accidents and others, tragically, from abuse.

She believes her research can make that profound compassion and willingness to help bear fruit. It all goes back to the question that put her on this path to begin with.

"I've seen so many children so severely injured, and I always wonder, 'Why does this one do so well while that one does so poorly?'" she says. "Why can't they all do well? We should know. We should know so that we can help more children have better outcomes. This is something I am passionate about, and we are set up here at Duke to start making some serious leaps toward that goal."