Factors predicting outcomes in surgically treated pediatric traumatic brain injury

Sean Lee; Yang Ming; Swati Jain; Shu Chee; Kejia Teo; Ning Chou; Sein Lwin; Tseng Yeo; Vincent Nga

doi:10.4103/ajns.AJNS_2_19

Asian Journal of Neurosurgery, Table of Contents

CC BY-NC-ND 4.0 · Asian J Neurosurg 2019; 14(03): 737-743
DOI: 10.4103/ajns.AJNS_2_19

Original Article

Factors predicting outcomes in surgically treated pediatric traumatic brain injury

Sean Lee

¹Yong Loo Lin School of Medicine, National University of Singapore

,

Yang Ming

²Neurosurgery Division, Department of Surgery, National University Health System

,

Swati Jain

²Neurosurgery Division, Department of Surgery, National University Health System

,

Shu Chee

²Neurosurgery Division, Department of Surgery, National University Health System

,

Kejia Teo

²Neurosurgery Division, Department of Surgery, National University Health System

,

Ning Chou

²Neurosurgery Division, Department of Surgery, National University Health System

,

Sein Lwin

²Neurosurgery Division, Department of Surgery, National University Health System

,

Tseng Yeo

²Neurosurgery Division, Department of Surgery, National University Health System

,

Vincent Nga

¹Yong Loo Lin School of Medicine, National University of Singapore

²Neurosurgery Division, Department of Surgery, National University Health System

› Author Affiliations

Abstract

Introduction: Traumatic brain injury (TBI) is a common presentation to the pediatric emergency department. Understanding factors that predict outcomes will be useful in clinical decision-making and prognostication. The objective of this study was to identify important clinical parameters predictive of outcomes in pediatric TBI patients who underwent surgery. Materials and Methods: This retrospective study included 43 pediatric TBI patients who underwent surgery from January 2011 to January 2017. Clinical parameters, including presenting signs and symptoms, mechanism of injury, intracranial pressure (ICP), need for inotropes, and computed tomography findings were collected. Outcomes were assessed using the Glasgow outcome score (GOS) based on the latest follow-up. Outcomes were divided into favorable (GOS 4–5) and unfavorable (GOS 1–3). Results: Surgery was performed in 43 patients. The mean age was 9.6 ± 4.9. The mean follow-up period was 31 weeks. Thirty (70%) patients had favorable outcome and 13 (30%) had unfavorable outcome. On univariate analysis, mechanism of injury, vomiting, Glasgow coma scale score, pupil size and reactivity, hypotension, inotropic use, need for blood transfusion, and raised ICP (all P < 0.005) were significantly associated with outcomes. On step-wise logistic regression, only raised ICP (odds ratio [OR] = 35.6, P = 0.008) and hypotension (OR = 26.1, P = 0.01) were found to be statistically significant. Conclusion: The present study suggests that the majority of pediatric TBI patients who required neurosurgical intervention have favorable outcomes. Closer attention should be paid to raised ICP and hypotension as they were strong predictors of unfavorable outcomes. These findings also help manage expectations of patients' family and clinicians.

Key-words:

Head injury - outcomes - pediatric population - traumatic brain injury

Full Text

References

References
1 Daoud H, Alharfi I, Alhelali I, Charyk Stewart T, Qasem H, Fraser DD, et al. Brain injury biomarkers as outcome predictors in pediatric severe traumatic brain injury. Neurocrit Care 2014;20:427-35.
2 Greenberg JK, Yan Y, Carpenter CR, Lumba-Brown A, Keller MS, Pineda JA, et al. Development and internal validation of a clinical risk score for treating children with mild head trauma and intracranial injury. JAMA Pediatr 2017;171:342-9.
3 Wee JZ, Yang YR, Lee QY, Cao K, Chong CT. Demographic profile and extent of healthcare resource utilisation of patients with severe traumatic brain injury: Still a major public health problem. Singapore Med J 2016;57:491-6.
4 Araki T, Yokota H, Morita A. Pediatric traumatic brain injury: Characteristic features, diagnosis, and management. Neurol Med Chir (Tokyo) 2017;57:82-93.
5 Prasad MR, Ewing-Cobbs L, Swank PR, Kramer L. Predictors of outcome following traumatic brain injury in young children. Pediatr Neurosurg 2002;36:64-74.
6 Filley CM, Cranberg LD, Alexander MP, Hart EJ. Neurobehavioral outcome after closed head injury in childhood and adolescence. Arch Neurol 1987;44:194-8.
7 Koskiniemi M, Kyykkä T, Nybo T, Jarho L. Long-term outcome after severe brain injury in preschoolers is worse than expected. Arch Pediatr Adolesc Med 1995;149:249-54.
8 Kriel RL, Krach LE, Panser LA. Closed head injury: Comparison of children younger and older than 6 years of age. Pediatr Neurol 1989;5:296-300.
9 Bruce DA. Head injuries in the pediatric population. Curr Probl Pediatr 1990;20:61-107.
10 Astrand R, Undén J, Hesselgard K, Reinstrup P, Romner B. Clinical factors associated with intracranial complications after pediatric traumatic head injury: An observational study of children submitted to a neurosurgical referral unit. Pediatr Neurosurg 2010;46:101-9.
11 Chong SL, Barbier S, Liu N, Ong GY, Ng KC, Ong ME, et al. Predictors for moderate to severe paediatric head injury derived from a surveillance registry in the emergency department. Injury 2015;46:1270-4.
12 Flaherty BF, Moore HE, Riva-Cambrin J, Bratton SL. Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment. J Pediatr Surg 2017;52:334-9.
13 Ong L, Selladurai BM, Dhillon MK, Atan M, Lye MS. The prognostic value of the glasgow coma scale, hypoxia and computerised tomography in outcome prediction of pediatric head injury. Pediatr Neurosurg 1996;24:285-91.
14 Heather NL, Derraik JG, Beca J, Hofman PL, Dansey R, Hamill J, et al. Glasgow coma scale and outcomes after structural traumatic head injury in early childhood. PLoS One 2013;8:e82245.
15 Moran LM, Babikian T, Del Piero L, Ellis MU, Kernan CL, Newman N, et al. The UCLA study of predictors of cognitive functioning following moderate/Severe pediatric traumatic brain injury. J Int Neuropsychol Soc 2016;22:512-9.
16 Bennett TD, DeWitt PE, Greene TH, Srivastava R, Riva-Cambrin J, Nance ML, et al. Functional outcome after intracranial pressure monitoring for children with severe traumatic brain injury. JAMA Pediatr 2017;171:965-71.
17 Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, et al. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 2001;17:154-62.
18 Massagli TL, Michaud LJ, Rivara FP. Association between injury indices and outcome after severe traumatic brain injury in children. Arch Phys Med Rehabil 1996;77:125-32.
19 Lieh-Lai MW, Theodorou AA, Sarnaik AP, Meert KL, Moylan PM, Canady AI, et al. Limitations of the glasgow coma scale in predicting outcome in children with traumatic brain injury. J Pediatr 1992;120:195-9.
20 Ducrocq SC, Meyer PG, Orliaguet GA, Blanot S, Laurent-Vannier A, Renier D, et al. Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: Experience of a french pediatric trauma center. Pediatr Crit Care Med 2006;7:461-7.
21 White JR, Farukhi Z, Bull C, Christensen J, Gordon T, Paidas C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001;29:534-40.
22 Pillai S, Praharaj SS, Mohanty A, Kolluri VR. Prognostic factors in children with severe diffuse brain injuries: A study of 74 patients. Pediatr Neurosurg 2001;34:98-103.
23 Wells R, Minnes P, Phillips M. Predicting social and functional outcomes for individuals sustaining paediatric traumatic brain injury. Dev Neurorehabil 2009;12:12-23.
24 Prigatano GP, Gray JA. Predictors of performance on three developmentally sensitive neuropsychological tests in children with and without traumatic brain injury. Brain Inj 2008;22:491-500.
25 Fulkerson DH, White IK, Rees JM, Baumanis MM, Smith JL, Ackerman LL, et al. Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial glasgow coma scale score of 3 or 4. J Neurosurg Pediatr 2015;16:410-9.
26 Kamal H, Mardini A, Aly BM. Traumatic brain injury in pediatric age group; predictors of outcome in pediatric intensive care unit. Libyan J Med 2007;2:90-4.
27 Anderson V, Catroppa C, Morse S, Haritou F, Rosenfeld JV. Intellectual outcome from preschool traumatic brain injury: A 5-year prospective, longitudinal study. Pediatrics 2009;124:e1064-71.
28 Hale AT, Pekala K, Theobald B, Kelly K, Wolf M, Wellons JC, et al. Predictors of post-discharge seizures in children with traumatic brain injury. Childs Nerv Syst 2018;34:1361-5.
29 Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1:480-4.
30 Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: Observations on the use of the glasgow outcome scale. J Neurol Neurosurg Psychiatry 1981;44:285-93.
31 Beers SR, Wisniewski SR, Garcia-Filion P, Tian Y, Hahner T, Berger RP, et al. Validity of a pediatric version of the glasgow outcome scale-extended. J Neurotrauma 2012;29:1126-39.
32 Slovis JC, Gupta N, Li NY, Kernie SG, Miles DK. Assessment of recovery following pediatric traumatic brain injury. Pediatr Crit Care Med 2018;19:353-60.
33 Khan SA, Shallwani H, Shamim MS, Murtaza G, Enam SA, Qureshi RO, et al. Predictors of poor outcome of decompressive craniectomy in pediatric patients with severe traumatic brain injury: A retrospective single center study from Pakistan. Childs Nerv Syst 2014;30:277-81.
34 Carter BG, Butt W, Taylor A. ICP and CPP: Excellent predictors of long term outcome in severely brain injured children. Childs Nerv Syst 2008;24:245-51.
35 Ferrara P, Basile MC, Dell'Aquila L, Vena F, Coppo E, Chiaretti A, et al. Traumatic brain injury in children: Role of CDRs-PECARN as a clinical predictive resource for evaluation of intracranical lesions and neuropsychiatric outcomes. Pediatr Neurosurg 2016;51:249-52.