Abstract
Objective
Substantial practice variation exists in the management of children with non-severe traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification.
Methods
We conducted a single center retrospective cohort study of children <18-years-old evaluated in the ED from 05/01/2014-02/28/2020 with tICH and initial Glasgow Coma Scale (GCS) score of >8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models.
Results
Our sample included 135 children. Clinically important tICH was observed in 13.3% (n=18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n=127) presented with an initial GCS≥14, including all children who later deteriorated. Initial GCS (p=0.001) and non-accidental trauma (p=0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥14, isolated, non-epidural hemorrhage after accidental injury developed clinically important tICH.
Conclusion
Clinically important tICH occurred in 13% of children with non-severe tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS≥14. However, a subgroup of children was identified as low-risk based on clinical and neuroradiographic characteristics.
Keywords: Traumatic brain injury, intracranial hemorrhage, critical interventions, clinical deterioration, pediatric trauma
Introduction
Most children with intracranial hemorrhage after traumatic brain injury (TBI), particularly those presenting with non-severe TBI (initial Glasgow Coma Scale (GCS) score >8), do not require immediate emergency department (ED) interventions.1-3 Once a hemorrhage is identified, nearly all children are admitted to the hospital for close monitoring, although rates of clinically important deterioration are generally low. Moreover, between 40-80% of children undergo repeat neuroimaging to monitor for neuroradiographic hemorrhage progression.4-14 There is significant practice variation in terms of where children with non-severe traumatic intracranial hemorrhage (tICH) are monitored, how long they are monitored, and whether they receive routine re-imaging.12,15
A likely source for this institutional and practitioner variability in management relates to uncertainty in the rates and timing of clinically important tICH, including lesions requiring immediate ED interventions or that result in delayed clinical deterioration due to hemorrhage progression. Neurosurgical interventions are relatively uncommon, although previous studies have reported varying rates and timing of these interventions.2-11,13,16-20 Data on critical medical interventions such as hyperosmotic agent administration and intubation are more limited,12,19 as are data on other forms of clinically important deterioration, such as a decline in GCS resulting in a floor to intensive care unit (ICU) transfer.20 A comprehensive understanding of both the rates and timing of these outcomes will improve accurate risk stratification. Therefore, our objectives were to report rates and timing of clinically important tICH, including immediate ED interventions and deterioration, in children with non-severe tICH, and to describe associated clinical and neuroradiographic characteristics and outcomes.
Materials and Methods
Design, Participants, and Data Source
We conducted a single center, retrospective cohort study of children <18 years old presenting to the ED from May 1st, 2014 to February 28th, 2020 with neuroradiographic evidence of intracranial hemorrhage secondary to known or suspected blunt head trauma and an initial ED GCS score of >8. Patients were excluded from enrollment if they met the following criteria: head trauma without intracranial injury (e.g., skull fracture without hemorrhage), penetrating (non-blunt) trauma, history of neurologic disorders (e.g., epilepsy, developmental delay, history of intracranial mass, etc.), presence of a ventriculoperitoneal shunt (or equivalent intracranial device), history of a bleeding disorder or currently on anti-coagulants (e.g., aspirin, warfarin, etc.), known recent (within 30 days) neuroimaging (brain CT or full or limited brain MRI) diagnosed skull fracture and/or tICH, and if the patient presented as an interfacility transfer. Transfers were excluded because of the variability in quality of outside records being uploaded to our electronic health record.
Data were abstracted from our site’s electronic health record and local trauma registry. Our site is an urban, Level 1 Pediatric Trauma Center and tertiary care children’s hospital. The trauma registry is maintained in compliance with American College of Surgeons requirements for trauma centers and captures all children with tICH at our site. Trained registrars enter demographic and clinical data that are manually abstracted from the electronic health record using standardized and established methods. Using our local trauma registry, we identified all potentially eligible patients with tICH. We then determined patient eligibility and abstracted study data directly from the electronic health record by manual review. Confirmation of tICH was determined based on review of the initial attending neuroradiology CT report performed in the ED.
We collected and managed study data using Research Electronic Data Capture (REDCap) electronic data capture tools21,22 hosted at our study institution. REDCap is a secure, web-based software platform designed to support data capture for research studies. All statistical analyses were performed using Stata/SE version 17.0 (Stata Corp, College Station, Texas). The study was determined to be exempt by our Institutional Review Board. We reported our findings in concordance with the The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) Statement,23 which is an extension to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.24
Data Abstraction
Prior to study start, a standardized manual of procedures was finalized. Eligibility criteria and variable and outcome definitions were determined a priori based on previous literature, clinical plausibility, and study team consensus. Data collection instruments were pilot tested with test cases for clarity and consistency. Prior to data entry, the four study data abstractors reviewed the manual of procedures and underwent video-conference trainings to review study procedures and conduct mock chart reviews. Abstractors then conducted structured chart reviews to abstract data to the standardized REDCap form, following our study manual of procedures.
Prior to beginning study data abstraction, abstractors independently abstracted data on the same 10% of charts, which were co-reviewed by the study principal investigator (P.C.) to confirm accuracy and uniformity. We performed an interrater reliability analysis on key variables (primary outcome and important secondary outcomes) of this proportion of charts prior to independent abstraction. Prior to abstraction, interrater reliability for the primary outcome and relevant secondary outcomes was calculated for all abstractors, and all abstractors had good agreement (kappa >0.8) for all key variables.
Outcomes and Study Variables
Our primary outcome was clinically important tICH occurring after head injury and up to 96 hours after ED arrival. Our composite primary outcome was defined by (1) receipt of immediate critical ED interventions within 4 hours from ED arrival, or (2) development of any clinically important deterioration 5-96 hours after ED arrival. Immediate critical ED interventions were defined as any TBI-related critical medical or neurosurgical interventions or mortality within 4 hours of ED arrival. Critical medical interventions included hyperosmotic agents (mannitol, hypertonic saline) and/or emergent non-operative intubation for airway protection for TBI. Neurosurgical interventions included neurosurgical operations, external ventricular drains, and/or intracranial monitors.
Clinically important deterioration was defined as any TBI-related critical medical or neurosurgical intervention, mortality, and/or clinician documentation of new or worsening clinical signs/symptoms (e.g., decline in GCS) 5-96 hours after ED arrival resulting in an acute (within 4 hours of signs/symptoms) change in management. Change in management was defined as any of the following in response to the deterioration: (i) critical medical or neurosurgical intervention, (ii) non-routine repeat neuroimaging, (iii) change in monitoring status (e.g., floor to ICU transfer, nursing neurologic checks changed from every 4 hours to every 1 hour), or (iv) emergent antiepileptic drug administration. Our secondary outcomes included clinically important deterioration, critical medical interventions, neurosurgical interventions, mortality, neuroradiographic hemorrhage progression, ICU admission, routine repeat neuroimaging (i.e., not obtained for a clinical change), ED, hospital, and ICU length-of-stay, and 30-day TBI-related ED revisits post discharge.
To classify neuroimaging findings including presence of neuroradiographic progression, we reviewed all clinical neuroradiology reports for any neuroimaging obtained within 96 hours of ED arrival. All neuroimaging findings on imaging reports were classified into relevant categories (e.g., hemorrhage subtype, multiple versus isolated hemorrhage, skull fracture location, etc.) and hemorrhage size was recorded. All attending neuroradiology reads were independently reviewed by 2 study investigators to establish consensus on the neuroradiology interpretation. For repeat neuroimaging reports, we reviewed if each traumatic finding changed compared to the previous imaging. To define neuroradiographic hemorrhage progression, we further classified repeat neuroimaging into presence or absence of hemorrhage progression. We classified the findings as no hemorrhage progression if the report outlined no increase in the measured size of any reported hemorrhage and/or if there was a summary interpretation which indicated no progression in size of any hemorrhage. Conversely, we classified hemorrhage progression as an increase in size of any hemorrhage (by any raw measurement), or if the summary interpretation indicated progression in the size of any hemorrhage compared to the previous image.
We collected additional variables related to our research question based on relevant literature4-11,17 and clinical and biological plausibility. We collected data on demographic information, relevant past medical history, TBI symptoms (e.g., loss of consciousness, altered mental status, etc.), GCS, mechanism of injury, time since injury, clinical, laboratory, and medication data, timing of interventions and imaging, and indication for imaging (routine vs clinical change).
Statistical Analysis
To describe our study sample, we calculated frequencies and proportions for categorical variables and described continuous variables as medians with interquartile ranges (IQR). We determined rates and timing of our primary and secondary outcomes. To measure the association between relevant clinical and neuroradiographic variables and the primary outcome, we performed bivariate regression analyses by generating simple logistic regression models with each clinical variable and the primary outcome. We performed a subgroup analysis by repeating the analysis among the subgroup of children who did not undergo immediate ED interventions. Multivariable modeling was not performed because of the limited numbers of patients with the primary outcome compared to the number of potential predictors. To evaluate the association between relevant laboratory variables and the primary outcome, we used the Mann-Whitney U test. Finally, we described the clinical course of children with clinically important deterioration.
Results
Study Sample
During the study period of May 1st, 2014 to February 28th, 2020, 862 children with head trauma and potential tICH were identified in our trauma registry (Figure 1). After eliminating patients based on our exclusions, 135 children evaluated in the ED with tICH constituted the study sample. Demographic and clinical characteristics, stratified by presence of clinically important tICH, are displayed in Table 1. Median [IQR] age was 0.9 [0.5, 3.1] years and for children with a known injury time, the median [IQR] time from injury to ED arrival was 4.9 [1.0, 48.0] hours. Median [IQR] hospital length of stay was 1.8 [1.1, 3.6] days and 42.2% (n=57) were admitted to the ICU.
Figure 1:
Study Flowchart
Table 1.
Characteristics of children with traumatic intracranial hemorrhage, stratified by development of clinically important traumatic intracranial hemorrhage (among all patients) and clinically important deterioration (among subgroup who did not undergo immediate emergency department interventions)
| All | Subgroup (no Immediate ED Interventions) | |||||||
|---|---|---|---|---|---|---|---|---|
| No Clinically Important tICH (n=117, 86.0%) |
Clinically Important tICH (n=18, 13.3%) |
All (n=135) |
OR (95% CI) |
No Deterioration (n=117, 92.1%) |
Deterioration (n=9, 7.1%) |
All (n=126) |
OR (95% CI) |
|
| Demographics | ||||||||
| Age [IQR], years | 0.8 [0.4, 2.9] | 1.4 [0.6, 7.7] | 0.9 [0.5, 3.1] | 1.0 (1.0, 1.0)a | 0.8 [0.4, 2.9] | 0.8 [0.6, 7.7] | 0.8 [0.4, 2.9] | 1.0 (1.0, 1.0)c |
| Female Sex | 49 (41.9) | 6 (33.3) | 55 (40.7) | * | 49 (41.9) | 4 (44.4) | 53 (42.1) | * |
| Race/Ethnicity | * | * | ||||||
| Asian | 9 (7.7) | 3 (16.7) | 12 (8.8) | 9 (7.7) | 1 (11.1) | 10 (7.9) | ||
| Black | 5 (4.3) | 3 (16.7) | 8 (5.9) | 5 (4.3) | 2 (22.2) | 7 (5.6) | ||
| Hispanic-Latino | 73 (62.4) | 9 (50.0) | 82 (60.7) | 73 (62.4) | 4 (44.4) | 77 (61.1) | ||
| White | 12 (10.3) | 1 (5.6) | 13 (9.6) | 12 (10.3) | 1 (11.1) | 13 (10.3) | ||
| Other | 18 (15.4) | 2 (11.1) | 20 (14.8) | 18 (15.4) | 1 (11.1) | 19 (15.1) | ||
| Historical Findings | ||||||||
| Time [IQR] from injury to ED arrival, hours | 6.6 [1.0, 70.6] | 2.9 [0.7, 23.4] | 4.9 [1.0, 48.0] | 1.0 (1.0, 1.0)b | 6.6 [1.0, 70.6] | 1.8 [0.7, 168.0] | 6.1 [1.0, 70.6] | 1.0 (1.0, 1.0)d |
| Missing | 14 | 2 | 16 | 14 | 2 | 16 | ||
| Severe Mechanism of Injury | 31 (27.9) | 4 (23.5) | 35 (27.3) | 0.8 (0.2, 2.6) | 31 (27.9) | 2 (25.0) | 33 (27.7) | 0.9 (0.2, 4.5) |
| Missing | 6 | 1 | 7 | 6 | 1 | 7 | ||
| Non-Accidental Trauma | 14 (12.0) | 6 (33.3) | 20 (14.8) | 3.7 (1.2, 11.4) | 14 (12.0) | 5 (55.6) | 19 (15.1) | 9.2 (2.2, 38.4) |
| Post-Traumatic Seizure | 8 (6.8) | 1 (5.6) | 9 (6.7) | 0.8 (0.1, 6.8) | 8 (6.8) | 1 (11.1) | 9 (7.1) | 1.7 (0.2, 15.4) |
| Altered Mental Status | 63 (53.9) | 15 (83.3) | 78 (57.8) | 4.3 (1.2, 15.6) | 63 (53.9) | 7 (77.8) | 70 (55.6) | 3.0 (0.6, 15.1) |
| Focal neurologic deficit | 7 (6.0) | 2 (11.1) | 9 (6.7) | 2.0 (0.4, 10.3) | 7 (6.0) | 0 (0.0) | 7 (5.6) | 0.8 (0.0, 14.6) |
| Vomiting | 38 (32.5) | 11 (64.7) | 49 (36.6) | 3.8 (1.3, 11.1) | 38 (32.5) | 6 (66.7) | 44 (34.9) | 4.2 (1.0, 17.5) |
| Missing | 0 | 1 | 1 | |||||
| Loss of Consciousness | 19 (16.8) | 4 (28.6) | 23 (18.1) | 2.0 (0.6, 7.0) | 19 (16.8) | 2 (33.3) | 21 (17.7) | 2.5 (0.4, 14.5) |
| Missing | 4 | 4 | 8 | 4 | 3 | 7 | ||
| Physical Exam Findings | ||||||||
| Initial Glasgow Coma Scale Score | ||||||||
| Mild, ≥14 | 113 (96.6) | 13 (72.2) | 126 (93.3) | 0.1 (0.0, 0.4) | 113 (96.6) | 9 (100.0) | 122 (96.8) | 0.8 (0.0, 15.1) |
| Moderate, 9-13 | 4 (3.4) | 5 (27.8) | 9 (6.7) | 10.9 (2.6, 45.6) | 4 (3.4) | 0 (0) | 4 (3.2) | 1.3 (0.1, 26.6) |
| Palpable skull fracture | 10 (8.6) | 0 (0) | 10 (7.4) | 0.3 (0.0, 4.9) | 10 (8.6) | 0 (0.0) | 10 (7.9) | 0.5 (0.0, 9.9) |
| Signs of basilar skull fracture | 3 (2.6) | 1 (5.6) | 4 (3.0) | 2.2 (0.2, 22.7) | 3 (2.6) | 1 (11.1) | 4 (3.2) | 4.8 (0.4, 51.0) |
| Distracting injury | 1 (0.9) | 2 (11.1) | 3 (2.2) | 14.5 (1.2, 169.2) | 1 (0.9) | 1 (11.1) | 2 (1.6) | 14.5 (0.8, 253.9) |
| Substantial non-head co-injury | 2 (1.7) | 3 (16.7) | 5 (3.7) | 0.1 (0.0, 0.6) | 2 (1.7) | 2 (22.2) | 4 (3.2) | 0.1 (0.0, 0.5) |
| Hospital Course and Revisits | ||||||||
| Hospital Length of Stay [IQR], days | 1.7 [1.1, 2.4] | 8.6 [4.0, 11.9] | 1.8 [1.1, 3.6] | 1.4 (1.2, 1.6) | 1.7 [1.1, 2.4] | 9.1 [5.9, 20.0] | 1.8 [1.1, 2.8] | 1.4 (1.2, 1.6) |
| Intensive Care Unit Admission | 42 (35.9) | 15 (83.3) | 57 (42.2) | 8.9 (2.4, 32.6) | 42 (35.9) | 6 (66.7) | 48 (38.1) | 3.6 (0.8, 15.0) |
| Repeat Neuroimaging | 57 (48.7) | 17 (94.4) | 74 (54.8) | 17.9 (2.3, 138.9) | 57 (48.7) | 9 (100.0) | 66 (52.4) | 20.0 (1.1, 351.4) |
| Progression/ new findings on repeat imaging | 11 (19.3) | 5 (29.4) | 16 (21.6) | 1.7 (0.5, 6.0) | 11 (19.3) | 3 (33.3) | 14 (21.2) | 2.1 (0.5, 9.7) |
| Prophylactic anti-epileptics | 4 (3.4) | 5 (27.8) | 9 (6.7) | 10.9 (2.6, 45.6) | 4 (3.4) | 1 (11.1) | 5 (4.0) | 3.5 (0.4, 35.4) |
| 30-day TBI-related ED revisits post discharge | 10 (8.6) | 2 (11.1) | 12 (8.9) | 1.3 (0.3, 6.7) | 10 (8.6) | 0 (0) | 10 (7.9) | 0.5 (0.0, 9.9) |
Values in the table represent median [interquartile range] or frequency (proportion)
Proportions are out of column total minus missing data; Proportions might not sum to 100% because of rounding
not calculated because variable association not clinically relevant
OR (95% CI) 1.000284 (0.9999709, 1.000598)
OR (95% CI) 1.000236 (0.9998182, 1.000655)
OR (95% CI) 1.001382 (0.9931719, 1.009660)
OR (95% CI) 1.007174 (0.9979751, 1.016458)
Abbreviations: CI, confidence interval; ED, emergency department; IQR, interquartile range; OR, odds ratio; TBI, traumatic brain injury; tICH, traumatic intracranial hemorrhage
Clinically Important tICH
Thirteen percent (n=18) of children had clinically important tICH after injury and within 96 hours of ED arrival (Table 1). Children were more likely to have clinically important tICH when presenting with altered mental status (Odds Ratio (OR) 4.3 (95% Confidence Interval (CI), 1.2, 15.6), vomiting (OR 3.8 (95% CI, 1.3, 11.1)), moderate GCS of 9-13 (OR 10.9 (95% CI, 2.6, 45.6), and a non-accidental trauma mechanism (OR 3.7 (95% CI, 1.2, 11.4). Among the 126 children who did undergo immediate ED intervention, 7.1% (n=9) later deteriorated (Table 1). Median [IQR] time to clinically important deterioration was 19.8 [9.7, 47.5] hours. Ninety-three percent (n=126) of children presented with an initial mild GCS score of 14 or 15, including all 9 children who later developed clinically important deterioration.
Nine children (6.7%) underwent neurosurgical intervention, with a median [IQR] time to intervention of 8.1 [2.7, 19.8] hours. Eight children (5.9%) received either hypertonic saline or mannitol, with a median [IQR] time to first administration of 0.1 [0.0, 0.1] hours. One child (0.7%) underwent emergent non-operative intubation for TBI, which occurred 1.4 hours after ED arrival. No mortality was observed in our sample of children with non-severe tICH. Laboratory results obtained within 6 hours of ED arrival are displayed in Table 2. Children with clinically important tICH had higher glucose levels on ED arrival compared to children who did have the outcome (p=0.003).
Table 2.
Laboratory results within 6 hours of emergency department arrival of children with traumatic intracranial hemorrhage, stratified by development of clinically important traumatic intracranial hemorrhage
| Laboratory Results | All | |||
|---|---|---|---|---|
| No Clinically Important tICH (n=117, 86.0%) |
Clinically Important tICH (n=18, 13.3%) |
All (n=135) |
p-valuea | |
| Glucose | 100 [91, 116] | 124 [107, 150] | 105 [92, 124] | 0.003 |
| Missing | 52 | 1 | 53 | |
| Sodium | 139 [138, 141] | 141 [139, 144] | 140 [138, 141] | 0.012 |
| Missing | 43 | 0 | 43 | |
| Hemoglobin | 11.4 [10.5, 12.2] | 11.0 [9.7, 12.1] | 11.3 [10.4, 12.2] | 0.089 |
| Missing | 15 | 0 | 15 | |
| Hematocrit | 34.1 [31.6, 36.0] | 32.7 [28.3, 35.9] | 34.0 [31.3, 36.0] | 0.332 |
| Missing | 15 | 0 | 15 | |
| Prothrombin Time | 11.3 [10.6, 12.1] | 12.4 [11.8, 12.8] | 11.4 [10.8, 12.3] | 0.001 |
| Missing | 14 | 1 | 15 | |
| Partial Thromboplastin Time | 33.0 [29.5, 35.0] | 32.0 [29.0, 33.0] | 33.0 [29.0, 35.0] | 0.233 |
| Missing | 17 | 1 | 18 | |
| International Normalized Ratio | 1.0 [1.0, 1.1] | 1.1 [1.1, 1.2] | 1.0 [1.0, 1.1] | 0.122 |
| Missing | 14 | 1 | 15 | |
Values in the table represent median [interquartile range] or frequency (percent)
Mann-Whitney U test between no clinically important tICH and clinically important tICH
Abbreviations: tICH, traumatic intracranial hemorrhage
Neuroimaging
Initial neuroradiographic findings, stratified by clinically important tICH, are displayed in Figure 2. No specific hemorrhage type was found to be statistically associated with clinically important tICH. Among isolated hemorrhages, 21.9% of isolated epidural hemorrhages (OR 2.3 (95% CI, 0.8, 6.7)) and 21.6% of isolated subdural hemorrhages (OR 2.4 (95% CI, 0.9, 6.7)) developed clinically important tICH. Children with initial CT findings of hemorrhage mass effect (OR 3.7 (95% CI, 1.3, 11.0) and midline shift (OR 28.3 (95% CI, 7.3, 110.0)) were more likely to develop the primary outcome. The maximum median [IQR] hemorrhage width on initial CT was higher for children who developed clinically important tICH compared to children who did not (11.7 [5.0, 20.0] versus 4.0 [1.6, 7.0] millimeters respectively; OR 1.2 (95% CI, 1.1, 1.3)).
Figure 2:
Initial neuroradiographic findings of children with traumatic intracranial hemorrhage, stratified by development of clinically important traumatic intracranial hemorrhage
Repeat neuroimaging within 96 hours of ED arrival was obtained in 54.8% (n=74) of children in our sample. Of the repeat neuroimaging performed, 40.5% (n=30) were repeat CTs, 35.1% (n=26) were limited brain (fast) MRIs, and 24.3% (n=18) were full brain MRIs. The repeat neuroimaging performed was obtained in response to a clinical change in 8.1% (n=6) of children; the remainder of repeat neuroimaging (91.9% (n=68)) was performed routine. Median [IQR] time to obtaining the first CT was 0.6 [0.2, 1.3] hours and median [IQR] time to obtaining the repeat neuroimaging was 15.3 [7.2, 22.1] hours.
Neuroradiographic hemorrhage progression and/or new clinically important neuroradiographic findings were noted on 21.6% (n=16) of repeat neuroimaging performed. One of the 6 children who were reimaged due to a clinical change had neuroradiographic progression. None of the 71 (52.6%) children with initial GCS ≥14, isolated, non-epidural hemorrhage after accidental injury had clinically important tICH after injury, however 35.2% (n=25) received repeat neuroimaging. A narrative description of the clinical course and details of clinically important deterioration is displayed in Table 3.
Table 3.
Detailed narrative description of children with traumatic intracranial hemorrhage who developed clinically important deterioration
| Agea | Initial CT findings |
Time to Deterioration (hours)b |
ED Disposition |
Hospital LOS |
Details of Clinical important Deterioration |
Accidental or NAT |
|---|---|---|---|---|---|---|
| 5 months | Subdural | 20 | Floor | 24 | No clinical change was noted, persistent bulging fontanelle noted → Bedside subdural tap performed |
NAT |
| 5 months | Subdural Diastasis of skull |
164 | Floor | 21 | No clinical change was noted → Subdural-peritoneal shunt was placed |
NAT |
| 7 months | Epidural Skull fracture |
12 | ICU | 11 | Drop in hemoglobin (9 to 7) and increased head circumference → Repeat head CT performed (no change) and hemoglobin monitored every 6 hours |
NAT |
| 7 months | Subdural Midline shift |
48 | Floor | 8 | Generalized seizures and increased emesis → repeat CT performed (no change), subdural fontanelle tap performed, levetiracetam given, transferred from floor to ICU |
NAT |
| 9 months | Subdural | 40 | ICU | 20 | Generalized seizures → Lorazepam given, repeat CT performed (no change), transferred from floor to ICU |
NAT |
| 10 months | Epidural with mass effect Midline shift |
10 | Operating Room | 5 | No clinical change was noted → Craniotomy was performed |
Unclear, but NAT workup completed |
| 7 years | Epidural with mass effect Midline shift Skull fracture |
6 | ICU | 6 | Waxing and waning mental status noted → Repeat CT performed (epidural size increased), which led to hematoma evacuation in the operating room |
Accidental |
| 11 years | Extra-axial Subarachnoid Skull fracture Diastasis of skull |
2 | ICU | 3 | Increased somnolence → Non-routine imaging (no change) |
Accidental |
| 12 years | Epidural Subarachnoid Skull fracture Diastasis of skull |
89 | ICU | 9 | New right sided facial droop developed → Repeat head CT performed (no change). Facial droop resolved, likely secondary to focal seizure. |
Accidental |
all patients presented with an initial Glasgow Coma Scale Score of 15
from ED arrival
Abbreviations: CT, computed tomography; ED, emergency department; LOS, length of stay; ICU, intensive care unit; NAT, non-accidental trauma
Discussion
In our sample of children with non-severe tICH, we found 13% had clinically important tICH resulting in immediate ED interventions or development of deterioration during acute hospitalization. Among the children who did not undergo immediate interventions upon ED arrival, 7% later deteriorated. Most children in our sample presented with mild GCS scores of 14-15, including all children who deteriorated after their initial ED management. We identified several clinical and neuroradiographic characteristics of children with clinically important tICH, including initial GCS, non-accidental trauma mechanism, epidural hemorrhage, and non-isolated hemorrhage. Among children who received repeat neuroimaging, hemorrhage progression and/or new neuroradiographic findings were identified in nearly a quarter of patients; however, only one of the 6 children who had repeat neuroimaging obtained due to deterioration were found to have hemorrhage progression or new findings on CT.
Children with tICH are often admitted for close clinical monitoring and repeat neuroimaging to screen for hemorrhage progression resulting in clinical deterioration. The specifics of management, including monitoring location (inpatient floor versus ICU), duration of monitoring, and use, timing, and modality of repeat neuroimaging (CT versus MRI), varies significantly by institution.12,15 In our sample, we identified measurable rates of interventions and deterioration after injury, and found that care was driven by a combination of factors including clinical course and neuroradiographic findings. The variability in management not only highlights the need for improved risk stratification, but also the need for a more granular understanding of clinical course to guide management decisions.
Previous literature has most commonly used the need for neurosurgical interventions, and more recently neurosurgical intervention or emergent intubation, as the outcome for risk stratification2-11,13,16-19 in the development of clinical scores.17,19 Although retrospectively derived without prospective validation to date, these scores nevertheless likely identify children at very low risk for deterioration. However, from the perspective of bedside clinicians, identifying patients who are low risk for not only critical interventions, but also deterioration not requiring critical interventions is important when attempting to risk stratify and optimize healthcare utilization. Importantly, in our sample we identified that deterioration without emergent neurosurgical or critical medical interventions is not uncommon compared to deterioration requiring those interventions, a result that has important implications for management recommendations if these events are not also factored into clinical risk stratification decisions. Because deterioration without critical interventions were not included as outcomes in the derivation of these existing scores, a future target for additional research will include building on these existing scores to identify a broader sample of low-risk patients.
Previous literature has also understandably excluded children with concern for non-accidental trauma from risk stratification using these clinical scores.17,19 Because injury mechanism (accidental versus non-accidental) is often unknown to the clinicians providing initial management for the nonverbal younger than 2-year-olds, in our cohort, we examined the clinical course of all eligible children regardless of mechanism. Our findings support that children who present after non-accidental trauma are at higher risk for deterioration. We found a high percentage of children with non-accidental trauma mechanisms underwent ED interventions or had deterioration. Yet, in all but one of these patients, their initial CT results showed hemorrhage patterns consistent with non-accidental trauma (e.g., bilateral subdural hemorrhages). The additional patient presented with findings highly suggestive of non-accidental trauma and was found to have an epidural on initial CT without any reported trauma. Together, these findings suggest that characteristics on initial neuroimaging and history may be able to be incorporated into decision making for a broader, undifferentiated group of head injured children.
Initial neuroradiographic findings are important components for risk stratification of children with tICH. Nearly a quarter of children with isolated epidural hemorrhage, isolated subdural hemorrhage, and multiple hemorrhages on initial neuroimaging in our sample developed our primary outcome. This finding is consistent with previous literature19,20 revealing a percentage of children with these initial neuroradiographic findings will require interventions or deteriorate and are therefore considered higher risk. However, within these hemorrhage subtypes, the majority do not require interventions or deteriorate. In our sample, combining relevant clinical and neuroradiographic characteristics, we found that no child with initial GCS ≥14, isolated, non-epidural hemorrhage after accidental injury required interventions or deteriorated after injury. This group consisted of more than half of our sample, highlighting an opportunity for a more targeted management approach for low-risk children.
Importantly, we were able to collect time from injury data on most patients with accidental injury mechanisms. Although intuitively important, in our clinical experience, it is less common to routinely take into account time from injury into decisions around clinical observation time (i.e., when to discharge a patient from the hospital), observation type (floor versus ICU), and time to repeat neuroimaging. For patients with accidental injuries, we found that the majority of interventions for patients occur early after injury, supporting that time from injury should be more routinely incorporated into clinical decision making. Of the children with deterioration, the majority sustained non-accidental injuries, two deteriorated within 6 hours of ED arrival, and one deteriorated later but was identified early in the ED course as higher risk by clinicians due to multiple hemorrhages on initial neuroimaging. Our findings support previous literature17,19,20 that risk stratification of children with non-severe tICH is achievable and lend further support that a broader definition of low risk is possible with additional research in this domain. We plan to next explore clinical course and predictors of clinically important tICH in a multicenter sample of children.
Our investigation has several important limitations. Because of the limited number of patients with the primary outcome, we did not have sufficient power to model predictors in a multivariable model. We therefore presented our results descriptively with narrative details of the clinical course of these patients and will use findings from this study to support further multicenter research using a larger sample of patients. As with any study using existing data in the form of electronic health record review, variable data capture is a limitation. Because we focused our data collection on variables that are commonly documented in the health record for patients with tICH, such as loss of consciousness, the rates of missing data were reflectively limited. Incorrectly recorded data in the health record may have also impacted our study findings. To attempt to mitigate potential bias, our data abstractors were trained extensively on how to review all relevant clinical documentation from different clinician types (e.g., emergency medicine, trauma surgery, and neurosurgery clinical notes), and abstractors all had relevant, previous experience with interpretation of clinical documentation in the electronic health record. Although primary neuroradiology reports were used rather than a study radiologist re-reviewing imaging, the use of the clinical neuroradiology read for our study is likely adequate because the clinical report findings were used in clinical practice at the time of the patient visit, mirroring the clinical course and decision-making process by clinicians. And finally, we excluded many patients at our institution who were transferred to our facility because of variability in the quality of outside facility documentation of initial management and neuroimaging reviews. However, this improves the generalizability of our findings as the transferred patient population at our hospital is more severely injured, and our current sample is likely more reflective of other trauma centers evaluating injured children at the first point of hospital contact.
Conclusions
Clinically important tICH occurred after injury and within 96 hours of ED arrival in 13% of children with non-severe tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all 9 of whom had an initial GCS≥14. However, in our sample, we found that none of the 71 children with initial GCS ≥14, isolated, non-epidural hemorrhage after accidental injury underwent interventions or deteriorated. We therefore plan to next explore the clinical course and risk factors for interventions and deterioration in a multicenter sample of children to better understand clinically important tICH in this population.
Acknowledgements:
Samantha Lozano BS (Research Assistant), Saamia Masoom MD (Research Assistant), Sara Valadez BA (Trauma Registrar)
Source of Funding:
This work is supported by grant KL2TR001854 (P.C, study Principal Investigator) and UL1TR001855 and UL1TR000130 (REDCap Data Management Platform hosted by the Southern California Clinical and Translational Science Institute) from the National Center for Advancing Translational Science (NCATS) of the U.S. National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Abbreviations:
- CI
confidence interval
- CT
computed tomography
- ED
emergency department
- GCS
Glasgow Coma Scale
- ICU
intensive care unit
- IQR
interquartile range
- MRI
magnetic resonance imaging
- OR
odds ratio
- RECORD
The REporting of studies Conducted using Observational Routinely-collected health Data Statement
- REDCap
Research Electronic Data Capture
- STROBE
Strengthening the Reporting of Observational Studies in Epidemiology reporting guideline
- TBI
traumatic brain injury
- tICH
traumatic intracranial hemorrhage
Footnotes
Conflicts of Interest: No conflicts of interests or sources of funding
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