A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review

Abstract

Objective The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12.

Data Source We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020.

Study Selection We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI.

Data Synthesis Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9–16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower.

Conclusion We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.

Keywords

traumatic brain injury - children - Glasgow Coma Scale - trauma mechanism - hospital admission - ICU

Author Agreement

Both authors have agreed to this final version of the paper being submitted to Neuropediatrics. The manuscript was written by the first author and the successive versions were commented by the second author.

Publication History

Received: 10 February 2021

Accepted: 04 November 2021

Article published online:
08 December 2021

• References

• 1 Atabaki SM, Hoyle Jr JD, Schunk JE. et al. Comparison of prediction rules and clinician suspicion for identifying children with clinically important brain injuries after blunt head trauma. Acad Emerg Med 2016; 23 (05) 566-575
• 2 Dunning J, Daly JP, Lomas J-P, Lecky F, Batchelor J, Mackway-Jones K. Children's head injury algorithm for the prediction of important clinical events study group. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child 2006; 91 (11) 885-891
• 3 Kuppermann N, Holmes JF, Dayan PS. et al; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374 (9696): 1160-1170
• 4 Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2 (7872): 81-84
• 5 Reilly PL, Simpson DA, Sprod R, Thomas L. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst 1988; 4 (01) 30-33
• 6 Borgialli DA, Mahajan P, Hoyle Jr JD. et al; Pediatric Emergency Care Applied Research Network (PECARN). Performance of the pediatric Glasgow Coma Scale score in the evaluation of children with blunt head trauma. Acad Emerg Med 2016; 23 (08) 878-884
• 7 Mena JH, Sanchez AI, Rubiano AM. et al. Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma 2011; 71 (05) 1185-1192 , discussion 1193
• 8 Stiell IG, Wells GA, Vandemheen K. et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001; 357 (9266): 1391-1396
• 9 Kortbeek JB, Al Turki SA, Ali J. et al. Advanced trauma life support, 8th edition, the evidence for change. J Trauma 2008; 64 (06) 1638-1650
• 10 Smits M, Dippel DWJ, Steyerberg EW. et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med 2007; 146 (06) 397-405
• 11 Undén J, Dalziel SR, Borland ML. et al; Paediatric Research in Emergency Departments International Collaborative (PREDICT). External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med 2018; 16 (01) 176
• 12 Foks KA, Cnossen MC, Dippel DWJ. et al. Management of mild traumatic brain injury at the emergency department and hospital admission in Europe: a survey of 71 neurotrauma centers participating in the CENTER-TBI study. J Neurotrauma 2017; 34 (17) 2529-2535
• 13 Zuercher M, Ummenhofer W, Baltussen A, Walder B. The use of Glasgow Coma Scale in injury assessment: a critical review. Brain Inj 2009; 23 (05) 371-384
• 14 Dewan MC, Mummareddy N, Wellons III JC, Bonfield CM. Epidemiology of global pediatric traumatic brain injury: a qualitative review. World Neurosurg 2016; 91: 497-509.e1
• 15 Quayle KS, Powell EC, Mahajan P. et al. Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med 2014; 371 (20) 1945-1947
• 16 Daniëlle van Pelt E, de Kloet A, Hilberink SR. et al. The incidence of traumatic brain injury in young people in the catchment area of the University Hospital Rotterdam, The Netherlands. Eur J Paediatr Neurol 2011; 15 (06) 519-526
• 17 Trefan L, Houston R, Pearson G. et al. Epidemiology of children with head injury: a national overview. Arch Dis Child 2016; 101 (06) 527-532
• 18 Burns EC, Burns B, Newgard CD. et al. Pediatric minor traumatic brain injury with intracranial hemorrhage: identifying low-risk patients who may not benefit from ICU admission. Pediatr Emerg Care 2019; 35 (03) 161-169
• 19 Cicero MX, Cross KP. Predictive value of initial Glasgow coma scale score in pediatric trauma patients. Pediatr Emerg Care 2013; 29 (01) 43-48
• 20 Kochar A, Borland ML, Phillips N. et al. Association of clinically important traumatic brain injury and Glasgow Coma Scale scores in children with head injury. Emerg Med J 2020; 37 (03) 127-134
• 21 Osmond MH, Klassen TP, Wells GA. et al; Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ 2010; 182 (04) 341-348
• 22 Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. Performance of the pediatric Glasgow Coma Scale in children with blunt head trauma. Acad Emerg Med 2005; 12 (09) 814-819
• 23 Mannix R, Meehan WP, Monuteaux MC, Bachur RG. Computed tomography for minor head injury: variation and trends in major United States Pediatric Emergency Departments. J Pediatr 2012; 160 (01) 136-9.e1
• 24 Greenberg JK, Yan Y, Carpenter CR. 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 (04) 342-349
• 25 Wang MY, Griffith P, Sterling J, McComb JG, Levy ML. A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale score of 13-14). Neurosurgery 2000; 46 (05) 1093-1099
• 26 Nigrovic LE, Lee LK, Hoyle J. et al; Traumatic Brain Injury (TBI) Working Group of Pediatric Emergency Care Applied Research Network (PECARN). Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Arch Pediatr Adolesc Med 2012; 166 (04) 356-361
• 27 Rivara FP, Koepsell TD, Wang J. et al. Disability 3, 12, and 24 months after traumatic brain injury among children and adolescents. Pediatrics 2011; 128 (05) e1129-e1138
• 28 Huguenard AL, Miller BA, Sarda S, Capasse M, Reisner A, Chern JJ. Mild traumatic brain injury in children is associated with a low risk for posttraumatic seizures. J Neurosurg Pediatr 2016; 17 (04) 476-482
• 29 Greenberg JK, Stoev IT, Park TS. et al. Management of children with mild traumatic brain injury and intracranial hemorrhage. J Trauma Acute Care Surg 2014; 76 (04) 1089-1095
• 30 Hwang SY, Ong JW, Ng ZM. et al. Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study. Brain Inj 2019; 33 (11) 1420-1424
• 31 Amaranath JE, Ramanan M, Reagh J. et al. Epidemiology of traumatic head injury from a major paediatric trauma centre in New South Wales, Australia. ANZ J Surg 2014; 84 (06) 424-428
• 32 Boran BO, Boran P, Barut N, Akgun C, Celikoglu E, Bozbuga M. Evaluation of mild head injury in a pediatric population. Pediatr Neurosurg 2006; 42 (04) 203-207
• 33 Dayan PS, Holmes JF, Schutzman S. et al; Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med 2014; 64 (02) 153-162
• 34 Halley MK, Silva PD, Foley J, Rodarte A. Loss of consciousness: when to perform computed tomography?. Pediatr Crit Care Med 2004; 5 (03) 230-233
• 35 Güzel A, Hiçdönmez T, Temizöz O, Aksu B, Aylanç H, Karasalihoglu S. Indications for brain computed tomography and hospital admission in pediatric patients with minor head injury: how much can we rely upon clinical findings?. Pediatr Neurosurg 2009; 45 (04) 262-270
• 36 Heather NL, Derraik JGB, Beca J. et al. Glasgow Coma Scale and outcomes after structural traumatic head injury in early childhood. PLoS One 2013; 8 (12) e82245
• 37 Kocyigit A, Serinken M, Ceven Z. et al. A strategy to optimize CT use in children with mild blunt head trauma utilizing clinical risk stratification; could we improve CT use in children with mild head injury?. Clin Imaging 2014; 38 (03) 236-240
• 38 Melo JRT, Lemos-Júnior LP, Reis RC. et al. Do children with Glasgow 13/14 could be identified as mild traumatic brain injury?. Arq Neuropsiquiatr 2010; 68 (03) 381-384
• 39 El Moghier MLA. Correlation between brain imaging and Glasgow Coma Scale in traumatic head injury in pediatrics. Intern J Med Imag 2015; 3 (03) 63-68
• 40 Nigrovic LE, Schunk JE, Foerster A. et al; Traumatic Brain Injury Group for the Pediatric Emergency Care Applied Research Network. The effect of observation on cranial computed tomography utilization for children after blunt head trauma. Pediatrics 2011; 127 (06) 1067-1073
• 41 Stanley RM, Hoyle Jr JD, Dayan PS. et al; Pediatric Emergency Care Applied Research Network (PECARN). Emergency department practice variation in computed tomography use for children with minor blunt head trauma. J Pediatr 2014; 165 (06) 1201-1206.e2
• 42 Wilson CL, Tavender EJ, Phillips NT. et al; Paediatric Research in Emergency Department's International Collaborative. Variation in CT use for paediatric head injuries across different types of emergency departments in Australia and New Zealand. Emerg Med J 2020; 37 (11) 686-689
• 43 Schonfeld D, Fitz BM, Nigrovic LE. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma. Ann Emerg Med 2013; 62 (06) 597-603
• 44 Königs M, Pouwels PJW, Ernest van Heurn LW. et al. Relevance of neuroimaging for neurocognitive and behavioral outcome after pediatric traumatic brain injury. Brain Imaging Behav 2018; 12 (01) 29-43
• 45 Di G, Liu H, Jiang X. et al. Clinical predictors of progressive hemorrhagic injury in children with mild traumatic brain injury. Front Neurol 2017; 8: 560
• 46 Hollingworth W, Vavilala MS, Jarvik JG. et al. The use of repeated head computed tomography in pediatric blunt head trauma: factors predicting new and worsening brain injury. Pediatr Crit Care Med 2007; 8 (04) 348-356 , quiz 357
• 47 Ament JD, Greenan KN, Tertulien P, Galante JM, Nishijima DK, Zwienenberg M. Medical necessity of routine admission of children with mild traumatic brain injury to the intensive care unit. J Neurosurg Pediatr 2017; 19 (06) 668-674
• 48 Holmes JF, Borgialli DA, Nadel FM. et al; TBI Study Group for the Pediatric Emergency Care Applied Research Network. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?. Ann Emerg Med 2011; 58 (04) 315-322
• 49 Noje C, Jackson EM, Nasr IW. et al. Trauma bay disposition of infants and young children with mild traumatic brain injury and positive head imaging. Pediatr Crit Care Med 2019; 20 (11) 1061-1068
• 50 Foks KA, van den Brand CL, Lingsma HF. et al. External validation of computed tomography decision rules for minor head injury: prospective, multicentre cohort study in the Netherlands. BMJ 2018; 362: k3527
• 51 Lumba-Brown A, Yeates KO, Sarmiento K. et al. Diagnosis and management of mild traumatic brain injury in children: a systematic review. JAMA Pediatr 2018; 172 (11) e182847
• 52 Greenes DS, Schutzman SA. Clinical significance of scalp abnormalities in asymptomatic head-injured infants. Pediatr Emerg Care 2001; 17 (02) 88-92
• 53 Spencer MT, Baron BJ, Sinert R, Mahmoud G, Punzalan C, Tintinalli A. Necessity of hospital admission for pediatric minor head injury. Am J Emerg Med 2003; 21 (02) 111-114
• 54 Riemann L, Zweckberger K, Unterberg A, El Damaty A, Younsi A. Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Investigators and Participants. Injury causes and severity in pediatric traumatic brain injury patients admitted to the ward or intensive care unit: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. Front Neurol 2020; 11: 345
• 55 Katar S, Aydin Ozturk P, Ozel M. et al. The use of Rotterdam CT score for prediction of outcomes in pediatric traumatic brain injury patients admitted to emergency service. Pediatr Neurosurg 2020; 55 (05) 237-243
• 56 Bonow RH, Quistberg A, Rivara FP, Vavilala MS. Intensive care unit admission patterns for mild traumatic brain injury in the USA. Neurocrit Care 2019; 30 (01) 157-170
• 57 Lindsey HM, Wilde EA, Caeyenberghs K, Dennis EL. Longitudinal neuroimaging in pediatric traumatic brain injury: current state and consideration of factors that influence recovery. Front Neurol 2019; 10: 1296
• 58 Anderson V, Spencer-Smith M, Wood A. Do children really recover better? Neurobehavioural plasticity after early brain insult. Brain 2011; 134 (Pt 8): 2197-2221
• 59 Anderson VA, Catroppa C, Haritou F, Morse S, Rosenfeld JV. Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children. J Neurol Neurosurg Psychiatry 2005; 76 (03) 401-408
• 60 Catroppa C, Anderson V. Outcome and prediction of functional recovery five years following pediatric traumatic brain injury. J Pediatr Psychol 2008; 23: 1-12
• 61 Taylor HG, Dietrich A, Nuss K. et al. Post-concussive symptoms in children with mild traumatic brain injury. Neuropsychology 2010; 24 (02) 148-159
• 62 Brooks BL, Plourde V, Beauchamp MH. et al; PERC Concussion Team. Predicting psychological distress after pediatric concussion. J Neurotrauma 2019; 36 (05) 679-685
• 63 Woodrome SE, Yeates KO, Taylor HG. et al. Coping strategies as a predictor of post-concussive symptoms in children with mild traumatic brain injury versus mild orthopedic injury. J Int Neuropsychol Soc 2011; 17 (02) 317-326
• 64 Kenardy J, Le Brocque R, Hendrikz J, Iselin G, Anderson V, McKinlay L. Impact of posttraumatic stress disorder and injury severity on recovery in children with traumatic brain injury. J Clin Child Adolesc Psychol 2012; 41 (01) 5-14
• 65 Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics 2010; 126 (02) e374-e381
• 66 Zemek R, Barrowman N, Freedman SB. et al; Pediatric Emergency Research Canada (PERC) Concussion Team. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA 2016; 315 (10) 1014-1025
• 67 Hawley CA, Ward AB, Magnay AR, Long J. Outcomes following childhood head injury: a population study. J Neurol Neurosurg Psychiatry 2004; 75 (05) 737-742
• 68 Brooks BL, Daya H, Khan S, Carlson HL, Mikrogianakis A, Barlow KM. Cognition in the Emergency Department as a predictor of recovery after pediatric mild traumatic brain injury. J Int Neuropsychol Soc 2016; 22 (04) 379-387
• 69 Gardner JE, Teramoto M, Hansen C. Factors associated with degree and length of recovery in children with mild and complicated mild traumatic brain injury. Neurosurgery 2019; 85 (05) E842-E850
• 70 Levin HS, Hanten G, Roberson G. et al. Prediction of cognitive sequelae based on abnormal computed tomography findings in children following mild traumatic brain injury. J Neurosurg Pediatr 2008; 1 (06) 461-470
• 71 Goh MSL, Looi DSH, Goh JL. et al. The impact of traumatic brain injury on neurocognitive outcomes in children: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2021; 92: 847-853
• 72 Babikian T, Asarnow R. Neurocognitive outcomes and recovery after pediatric TBI: meta-analytic review of the literature. Neuropsychology 2009; 23 (03) 283-296
• 73 Lloyd J, Wilson ML, Tenovuo O, Saarijärvi S. Outcomes from mild and moderate traumatic brain injuries among children and adolescents: a systematic review of studies from 2008-2013. Brain Inj 2015; 29 (05) 539-549
• 74 Si B, Dumkrieger G, Wu T. et al. Sub-classifying patients with mild traumatic brain injury: a clustering approach based on baseline clinical characteristics and 90-day and 180-day outcomes. PLoS One 2018; 13 (07) e0198741
• 75 Crowe LM, Hearps S, Anderson V. et al. Investigating the variability in mild traumatic brain injury definitions: a prospective cohort study. Arch Phys Med Rehabil 2018; 99 (07) 1360-1369
• 76 Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med 2014; 64 (02) 145-152 , 152.e1–152.e5
• 77 Kristman VL, Borg J, Godbolt AK. et al. Methodological issues and research recommendations for prognosis after mild traumatic brain injury: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Arch Phys Med Rehabil 2014; 95 (3, Suppl): S265-S277
• 78 Malec JF, Brown AW, Leibson CL. et al. The mayo classification system for traumatic brain injury severity. J Neurotrauma 2007; 24 (09) 1417-1424