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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 39  |  Issue : 3  |  Page : 151-157

Clinical course and outcomes of complicated mild traumatic brain injury in children: A single-center series of 124 cases


1 Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital; Department of Neurosurgery, Faculty of Medicine, Hacettepe University, Ankara, Turkey
2 Division of Pediatric Emergency Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
3 Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
4 Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital; Department of Neurosurgery, University of Health Sciences, Dr. Abdurrahman Yurtaslan Ankara Oncology Training and Research Hospital, Ankara, Turkey
5 Department of Neurosurgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Department of Neurosurgery, Istanbul, Turkey

Date of Submission01-Mar-2022
Date of Decision16-Apr-2022
Date of Acceptance19-Apr-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Sahin Hanalioglu
Department of Neurosurgery, Faculty of Medicine, Hacettepe University, 06100, Sihhiye, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/nsn.nsn_35_22

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  Abstract 


Objective: Mild traumatic brain injury (mTBI) constitutes majority of TBI cases. A considerable portion of mTBI cases has intracranial imaging abnormalities (complicated mTBI), which pose challenges in the diagnosis and management to clinicians. Here, we aimed to evaluate the early clinical course and outcomes of pediatric complicated mTBI cases treated at a large-volume tertiary referral center. Materials and Methods: A single-center retrospective cohort study was conducted at a large-volume tertiary trauma referral center for 12-month period between 2017 and 2018. Pediatric mTBI cases with at least one of the following computed tomography (CT) findings were included a depressed skull fracture, pneumocephalus, intracranial hemorrhage, edema, or contusion. Demographic, clinical, and radiological data were collected and analyzed. Results: One hundred and twenty-four patients with complicated mTBI were identified. Falls were the leading mechanisms of trauma (71.8%). Most patients (90.3%) had a Glasgow coma score (GCS) of 15 at initial evaluation. Most frequent radiological findings on initial CT scan were epidural hematoma (EDH) (34.7%) and pneumocephalus (31.5%), followed by subdural hematoma (SDH) (19.4%), subarachnoid hemorrhage (16.9%), contusion (14.5%), and depressed skull fracture (8.1%). Radiological findings in the routine repeat CT scan were stable in 55.6% of the patients, whereas the findings progressed in 15.3% and improved in 29% of patients during this interval period (median 7 h). Neurosurgical operation was performed in 7 (5.6%) patients. Thirty-six (29%) patients were identified as having clinically important TBI (ciTBI). Average length of stay at emergency department was 9.7 ± 4.9 h, and the average length of hospital stay was 3.6 ± 2.3 days. Multivariate analysis revealed that age, GCS, pneumocephalus, depressed skull fracture, EDH, and SDH were independent predictors of ciTBI. Conclusion: Pediatric complicated mTBI is associated with higher rates of hospitalization and therefore ciTBI but relatively lower rates of need for neurosurgery. Effective decision-making tools and algorithms are needed to guide optimal management strategies of these patients.

Keywords: Clinically important traumatic brain injury, computed tomography, imaging abnormality, intracranial hemorrhage, mild traumatic brain injury, neurosurgery


How to cite this article:
Hanalioglu S, Hanalioglu D, Elbir C, Sahin OS, Sahin B, Turkoglu ME, Kertmen HH. Clinical course and outcomes of complicated mild traumatic brain injury in children: A single-center series of 124 cases. Neurol Sci Neurophysiol 2022;39:151-7

How to cite this URL:
Hanalioglu S, Hanalioglu D, Elbir C, Sahin OS, Sahin B, Turkoglu ME, Kertmen HH. Clinical course and outcomes of complicated mild traumatic brain injury in children: A single-center series of 124 cases. Neurol Sci Neurophysiol [serial online] 2022 [cited 2022 Dec 2];39:151-7. Available from: http://www.nsnjournal.org/text.asp?2022/39/3/151/357501




  Introduction Top


Traumatic brain injury is the leading cause of mortality and morbidity in children and adolescents. The severity of TBI is graded based on the Glasgow come score (GCS) at presentation: severe (GCS 3–8), moderate (GCS 9–12), and mild (GCS 13–15). Mild TBI (mTBI) represents majority of the cases presenting to the emergency departments (EDs). Although mTBI was once considered a self-limiting condition, mounting evidence suggests that it might be associated with long-lasting sequelae, including physical, cognitive, emotional, and behavioral problems (also referred to as “persistent postconcussive syndrome”).[1] The determinants of adverse outcomes or long-term disturbances have not been fully understood[2] despite the evidence for several predictors such as premorbid factors,[3],[4],[5] injury severity,[6] early symptom burden,[7] and pathological findings on initial computed tomography (CT).[3],[6],[8],[9]

The presence of acute intracranial imaging abnormalities on CT scan is used to further divide mTBI cases into two categories: complicated and uncomplicated. Whereas uncomplicated mTBI (also referred to as “concussion”) is almost always treated conservatively, complicated mTBI may be alarming and pose challenges to clinicians.[10] Management practices for complicated mTBI (e.g., decision for repeat CT, observation at ED, and hospitalization for prolonged observation) might differ considerably among countries, institutions, disciplines, and individual physicians.[10],[11] Hence, an optimal management strategy is not established for this subgroup of TBI patients, particularly in the pediatric population. In this study, we aimed to evaluate the early clinical course and outcomes of pediatric complicated mTBI cases treated at a large-volume tertiary referral center.


  Materials and Methods Top


Study design

This is a single-center retrospective cohort study conducted at a large-volume, tertiary trauma referral center. This study was approved by the local ethics committee and complied with the Helsinki Declaration. We included all consecutive pediatric patients who presented with blunt head trauma, underwent at least one head CT scan, and diagnosed with complicated mTBI, i.e., (a) presence of depressed skull fracture and (b) trauma-related intracranial abnormalities (e.g., hemorrhage, contusion, or edema) within the study (12 months) between 2017 and 2018. Our center is a high-volume, regional level-1 trauma center receiving approximately 20,000 pediatric trauma cases annually. CT decisions are at the discretion of the primary emergency physician and/or consulted neurosurgeon.

Eligibility criteria

Inclusion criteria were as follows: (i) mild TBI (GCS 13–15), (ii) patients with trauma-related intracranial abnormalities (e.g., depressed skull fracture, pneumocephalus, hemorrhage, contusion, and edema), and (iii) age <18 years. Exclusion criteria were as follows: (i) head CT scan at another hospital, (ii) those who underwent surgery directly after the first CT, (iii) head CT ordered due to nontraumatic causes (hydrocephalus, tumor, etc.), (iv) trauma patients with concomitant alcohol intoxication and/or substance abuse, and (v) inaccessible clinical or radiological data.

Data collection

The patients were identified through screening of institutional database. Demographic, clinical, and radiologic data for eligible patients were extracted through electronic medical records, patient charts, and institutional picture archiving and communication system. Data collected included age, sex, trauma mechanism, initial GCS, findings of the first CT, clinical worsening (i.e., neurological deterioration) in the interval period, findings of the second CT (i.e., radiological progression), patient disposition status, total number of CTs during the ED and hospital stay, length of stay (LOS) at ED (hours) and hospital (days), and neurosurgical intervention. Two qualified neurosurgeons, unaware of clinical data and radiology reports, independently evaluated CT scans to confirm imaging findings for all eligible patients.

The primary outcome was the rate of clinically important TBI (ciTBI), defined as any of the following (i) intracranial injury resulting in death, (ii) need for neurosurgical operation, (iii) hospital admission for >48 h due to head trauma, and (iv) intubation required for >24 h for management of TBI in the association of TBI on CT scan. Secondary outcomes were rates of neurosurgical operation, intensive care unit (ICU) admission, and LOS at ED and hospital.

Statistical analysis

Statistical analyses were performed by SPSS 23.0 software (IBM, New York, USA). Descriptive statistics were presented as mean ± standard deviation, median, interquartile range or number (percentage), wherever appropriate. Two-group comparisons were performed using Student's t-test for parametric, Mann–Whitney U for nonparametric, and Chi-square for categorical variables. Multiple group comparisons were performed with one-way ANOVA (with Bonferroni post hoc analysis) for parametric, Kruskal–Wallis for nonparametric, and Chi-square for categorical variables. Multivariate regression analysis was performed to determine the predictors of outcome measures. A P < 0.05 was regarded as statistically significant.


  Results Top


Demographic characteristics

There were 124 patients identified with complicated mTBI. Males dominated the study population. Average age was 8.1 ± 5.3 years. There were 24 (19.4%) patients under 2 years of age. Baseline characteristics of the study cohort are presented in [Table 1].
Table 1: Baseline characteristics of the study cohort

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Injury characteristics

Falls were the leading mechanisms of trauma 89 (71.8%). Road traffic accidents were the mechanism of injury in a total of 29 (23.4%) patients, among whom 18 (14.5%) were pedestrian versus motor vehicle and 11 (8.9%) were passenger (vehicle vs. vehicle). Assault was the least frequent trauma etiology in this cohort of patients (n = 6, 4.8%).

Clinical features

Most patients, 112 (90.3%), had a GCS of 15 at initial evaluation. There were 10 (8.1%) patients with a GCS of 14 and 2 (1.6%) patients with GCS of 13 at initial evaluation. Neurosurgery was consulted in 122 (98.4%) cases. Clinical worsening until repeat CT scan was observed only in 7 (5.6%) patients.

Initial computed tomography findings

Most frequent radiological findings on initial CT scan were epidural hematoma (EDH) (n = 43, 34.7%) and pneumocephalus (n = 39, 31.5%), followed by subdural hematoma (SDH) (n = 24, 19.4%), subarachnoid hemorrhage (SAH) (n = 21, 16.9%), contusion (n = 18, 14.5%), and depressed skull fracture (n = 10, 8.1%). No patients were identified having an ICH or IVH, however, one patient had petechial parenchymal hemorrhages. Majority of the patients (77.4%) had only one pathology. Imaging characteristics of the study cohort are summarized in [Table 2].
Table 2: Imaging characteristics of the study cohort

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Clinical course and repeat computed tomography

Only 7 (5.6%) patients had clinical worsening until repeat CT scan. The rest of the patients underwent a routine repeat CT scan to rule out radiological progression and/or surgical pathology. Time past between initial and repeat CT scans was 7 (4–10) h. Radiological findings in the repeat CT scan were stable in 69 (55.6%) patients, whereas the findings progressed in 19 (15.3%) and improved in 36 (29%) patients during this interval period. Patients had a total of 334 CT scans (median 2 [2–3]) at ED and 537 scans (median 4 [2–5]) CT scans during the entire hospital stay [Table 2].

Outcome measures

Forty-six (37.1%) patients were admitted to the hospital, among whom 15 (12.1%) received neurocritical care in ICU. Most patients were discharged from the ED after a brief period of observation. Neurosurgical interventions were performed in 7 (5.6%) patients. Thirty-six (29%) patients were identified as having ciTBI. Average LOS at ED was 9.7 ± 4.9 h, and the average length of hospital stay was 3.6 ± 2.3 days [Table 3].
Table 3: Clinical course and outcomes of the study cohort

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Subgroup analyses for progression status on repeat computed tomography

Outcome measures according to radiological progression status (three groups: progressed, stable, and improved) on repeat CT are presented in [Table 4]. Interval duration between initial and repeat CT scans and the number of CT scans done at the ED were similar among groups. However, patients with radiological progression on repeat CT had significantly more CT scans in total (progressed: 5.7 ± 2.4 vs. stable: 4.0 ± 2.5 vs. improved: 4.1 ± 1.9; P = 0.018). The presence of clinical worsening before repeat CT was also more common in the progressed group (15.8% vs. 4.3% and 2.8%), but the difference was not statistically significant (P = 0.108). Patients with radiological progression on repeat CT were more frequently admitted to the hospital and particularly to the ICU (P = 0.038 and P = 0.037, respectively). Neurosurgical intervention was deemed necessary for three patients with radiological progression and for four patients with stable findings but for none with improved radiological findings, but this difference was only marginally significant (P = 0.054). ciTBI was significantly higher in the progressed group (57.9%) when compared to the stable group (26.1%) and the improved group (19.4%) (P = 0.008). Duration of stay at ED was slightly longer for the improvement group, but the duration of hospital stay was longer in progression and stable groups; however, the differences did not reach statistical significance.
Table 4: Outcome measures according to radiological progression status on repeat computed tomography

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Predictors of clinically important traumatic brain injury

Multivariate analysis showed that age (odds ratio [OR] 1.20, 95% Confidence interval [CI] 1.07–1.32, P = 0.001), GCS (OR 0.22, 95% CI 0.05–0.97, P = 0.045), pneumocephalus (OR 3.69, 95% CI 1.09–12.47, P = 0.036), depressed skull fracture (OR 12.75, 95% CI 2.45–66.37, P = 0.002), EDH (OR 6.61, 95% CI 1.75–24.99, P = 0.005), and SDH (OR 7.14, 95% CI 1.55–32.88, P = 0.012) were independent predictors of ciTBI, while trauma mechanism, SAH, contusion, and clinical or radiological worsening were not independently associated with ciTBI [Table 5].
Table 5: Multivariate analysis of potential predictors of clinically important traumatic brain injury

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  Discussion Top


This study identified clinical course and outcomes as well as predictors of ciTBI in patients with complicated mTBI who presented at a level 1, large-volume trauma center. This study revealed that neurosurgical intervention is required in only 5.6% of patients despite the relatively high prevalence of ciTBI (29%) due to the high hospitalization rates of these patients. Furthermore, we found that the progression of imaging findings on routine repeat CT scans was associated with higher rates of hospitalization, ICU admission, ciTBI, and total CT counts. Independent predictors of ciTBI were older age, lower GCS, and certain imaging abnormalities (pneumocephalus, depressed skull fracture, EDH, and SDH).

Intracranial abnormalities on computed tomography scan

Prior studies have reported that the incidence of imaging abnormalities detected on CT scan range from 1% to 33% of all pediatric mTBI cases.[2],[12],[13] These abnormalities include but are not limited to intracranial hemorrhages, contusions, and brain edema.[14],[15] The role of isolated, depressed skull fractures and pneumocephalus has not been widely explored in the literature, particularly in the pediatric population.[16] We opted to include these pathologies as well because they are apparently important for clinical decision-making. The majority of our patients had only a single type of intracranial imaging abnormality, which is an expected finding due to milder nature of trauma. Consistent with previous studies in the literature, we found that extra-axial hematomas (EDH and SDH) were the most common imaging pathologies identified in our complicated mTBI cohort, followed by SAH and contusions.[13],[17] We also found that pneumocephalus was one of the leading pathologies identified. Petechial hemorrhage was uncommon and none of the patients had cerebral edema in this cohort.

Repeat computed tomography: Routine or selective?

Due to the benign course of pediatric mTBI, it is debated in the literature whether a follow-up CT scan should be performed routinely or in selected patients.[18],[19],[20],[21],[22],[23],[24] There is a tendency toward a more selective repeat CT scan strategy in recent years due to concerns regarding increased malignancy risk associated with radiation.[20],[23],[24] On the other hand, reliance on only clinical observation could lead to increased anxiety among caregivers and families, unnecessary prolonged hospitalizations, and missed or delayed diagnosis of progression in clinically stable or not closely monitored patients with mild TBI.[19] In our institution, routine follow-up CT scan was part of our clinical practice at the time of this study which allowed us to detect progression before clinical worsening.

Optimal duration of observation

The current guidelines recommend the use of clinical decision support tools to identify patients with low risk of intracranial injury.[2] Patients without radiological, neurological, and cognitive abnormalities after a minor head injury and a GCS of 15 can be discharged home safely (PECARN). However, there are no clear recommendations for the optimal duration of observation for patients with complicated mTBI. A study found that since 30% of patients with complicated mTBI had progression in radiologic findings, a routine head CT within 8 h is indicated.[19] Indeed, a routine follow-up CT scan performed a median of 7 h after the initial scan showed radiological progression in 15.3% of the patients in our cohort. Accordingly, the median LOS at the ED was 9 h, and the median length of hospital stay was 3 days.

Outcomes of complicated versus uncomplicated mild traumatic brain injury

It is intuitive that complicated mTBI is associated with increased likelihood of hospitalization and vigilant clinical observation. A decision-making tool (Children's Intracranial Injury Decision Aid (CHIIDA) was validated as a triage tool to decrease unnecessary ICU admissions for pediatric complicated mTBI cases.[25] Despite the higher incidence of hospitalization, whether complicated mild TBI cases have different long-term outcomes than uncomplicated mTBI (or merely “concussion” cases) is a matter of debate.[9],[14],[26],[27] Gardner et al. found that older age and complicated versus uncomplicated mTBI were associated with a lower degree and longer period of recovery.[28] However, Hansen et al. showed that no pattern of imaging abnormality other than multiple hemorrhagic contusions seemed to be associated with a degree or length of recovery, pointing to a heterogeneity among complicated mTBI cases.[13] Those subjects with complicated mTBI show more MRI-positive lesions and may have some deficits in certain neurocognitive domains.[29],[30] However, according to a meta-analysis, limited evidence suggests that postconcussion symptoms may persist in those with intracranial pathology on neuroimaging.[31] Possibly, a wide heterogeneity among the patients with imaging abnormalities, leads to distinct brain injury patterns and differences in functional outcomes.[28],[32],[33]

Strengths and limitations

This study is one of the few studies evaluating the early clinical course and outcomes of pediatric complicated mTBI cases treated at a large-volume tertiary referral center. The main limitation to this study is due to its retrospective nature. CT decisions were at the discretion of the primary emergency physician and/or consulted neurosurgeon. There is a possibility that the number of patients diagnosed with complicated mTBI would be higher if all mTBI patients were imaged. On the other hand, the risk of delayed occurrence of intracranial injuries among patients having normal initial CT scans who were discharged without obtaining a follow-up CT based on the existing literature is low.


  Conclusion Top


In pediatric patients presenting with a complicated mild TBI to a tertiary large-volume level 1 trauma center, neurosurgical intervention was indicated in only 5.6% of patients despite the relatively high prevalence of ciTBI (29%). Progression of imaging findings on routine repeat CT scans was observed in 15.3% of patients and was associated with higher rates of hospitalization, ICU admission, ciTBI, and total CT counts. Independent predictors of ciTBI were older age, lower GCS, and certain imaging abnormalities (pneumocephalus, depressed skull fracture, EDH, and SDH). Effective decision-making tools and algorithms are needed to guide optimal management strategies (e.g., observation period, need for repeat CT scan, and triage for admission) of these patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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