Epidemiological and Clinico-radiological Evaluation of Head Injury in Pediatric Population

ABSTRACT

Background:

Head injury in infancy and childhood has been documented as the single most common cause of death. In India, children aged <15 years constitute 35% of the total population and contribute to 20–30% of all head injuries. In this study, we attempted to analyze the epidemiological factors, management, and outcome of traumatic brain injury (TBI). The objective of this study were to find the causes of head injury in children and its pattern of distribution in this population and to analyze the efforts required to prevent the injury and management focusing on limiting the progression of primary brain injury and minimizing secondary brain insult.

Results:

A total of 2714 patients with head injury were admitted at our hospital during the study period and, out of them, 508 (18.17%) were pediatric patients with age less than 18 years. Of the 508 patients, only 497 patients were included in this study. In the present study, 357 (71.83%) were males and 140 (28.16%) were females. In total, 351 cases were managed conservatively whereas surgical intervention was conducted in 146 cases (P < 0.001). In this study, the most common mode of injury was a road traffic accident (RTA) (46.88%; n=233), followed by fall from height (34.8%; n=173) (P < 0.001). It was also seen that epidural hematoma and fracture hematoma were the most common computed tomography findings in pediatric patients with head injury followed by parenchymal contusion or contusion with or without fracture followed by diffuse axonal injury. A total of 344 cases out of 497 cases were discharged with Glasgow outcome score (GOS)-5 whereas nine cases remained in a persistent vegetative state (GOS-2).

Conclusion:

Early intervention aimed at the primary lesion in TBI in children generally carries a good outcome, and limits as much as possible the ongoing biomechanical, physiological, and pathological sequelae post-TBI. In teenagers, the importance of proper self-care along with adequate safety gears while doing any TBI-prone activity should be emphasized.

INTRODUCTION

Head injury is an insult to the brain, not of a degenerative or congenital nature, but caused by external physical force that may produce a diminished or altered state of consciousness, which is responsible for impairment of cognitive abilities or physical functioning. Head injury in infancy and childhood has been documented as the single most common cause of death.[1]

Moreover, the modes of injury, the mechanisms of damage, and the management of specific problems differ significantly between the adult and pediatric populations. Most of the road traffic accidents (RTAs) happen in pedestrians; out of which, majority are children.[2,3]

The mortality rate varies from 10% to 60%.[4] Poor prognosis is noticeable in the age group <4 years with better outcomes in the age group of 5–15 years.[5] In India, children aged <15 years constitute 35% of the total population[6] and contribute to 20–30% of all head injuries.[7]

According to the Centre for Disease Control (CDC), in the USA, almost half a million (473,947) emergency department visits for traumatic brain injury (TBI) are made annually by children aged 0 to 14 years.[8] TBI is a leading source of childhood injury and, although most of these are classified as mild, this level of injury is associated with ongoing problems.[9]

Falls from height and motor vehicle collisions are common noninflicted causes, whereas child abuse in infants and young children are unfortunate inflicted causes of traumatic brain injury. Children’s maturing brains pass through maximal synaptogenesis, pruning, and refinement circuitry, in experience-dependent fashion with increased levels of glucose metabolism,[10] higher neurotrophic factors,[11] and elevated excitatory amino acid receptor binding and expression.[12] Posttraumatic depression of neuronal activity may result in lost developmental potentials[13] and increased levels of apoptosis.[14]

Head injury is the commonest cause of trauma-related deaths in children,[15] so efforts should be geared toward the prevention and management focusing on limiting the progression of the primary brain injury and minimizing secondary brain injury. In this study, we attempted to analyze epidemiological factors, management, and outcome of TBI.

Aims and objectives

1. To study the quantum of TBI in the pediatric age group in our institution.

2. To study various epidemiological factors, management, and outcome of TBI in the pediatric age group.

MATERIALS AND METHODS

The present study was a prospective, observational study, conducted in the Department of NeuroSurgery from March 2015 to August 2016 on the pediatric population with head injuries.

Inclusion criteria

1. Head injury patients below 18 years of age.

2. Family or next-of-kin available to provide written informed consent.

Exclusion criteria

1. Age ≥18 years

2. Lack of informed consent

3. Patients with absent brainstem reflexes and spontaneous respiration at the time of admission

4. Poly-trauma patients, patient with congenital diseases, and other systemic disease were excluded from the study

Besides demographic information, data including epidemiological factors, mode of injury, clinical findings, radiological findings, and type of intervention done were recorded and analyzed, and the outcome was assessed using GOS (Glasgow outcome score) at the time of discharge from hospital and after 3 months at follow-up in the outpatient department. At our center, in an emergency, patients are managed using primary and secondary survey methods of Advanced Trauma Life Support. In this study, patients were classified into mild, moderate, and severe head injury using GCS (Glasgow Coma Score). All patients were divided into three age groups as 0 to <2 years, 2 to <12, and 12 to 18 years.

Pediatric patients with mild head injuries without any radiological abnormalities and neurological deficits were observed for 24h and discharged with instructions to parents/guardians to report to the hospital immediately if they have any warning signs like loss of consciousness, seizure, vomiting, increasing headache, or neurological deficit. When surgical intervention was required, patients were operated, while others those were managed conservatively. Associated injuries were treated accordingly. Patients were followed up at 3 months post-injury on the outpatient basis upon discharge using the GOS to determine the functional outcome of the patients. GOS score 4 and 5 was considered as a good outcome and GOS 1–3 was considered as poor outcome. Ethical committee clearance was taken before conducting the study. Data were analyzed statistically using SPSS Statistics 20 software (IBM Analytics, India 2015).

OBSERVATION

A total of 2714 patients of head injury were admitted to our hospital during the period March 2015 to August 2016 (18 months) and, out of them, 508 (18.17%) were pediatric patients aged between 0 and 18 years. Of the 508 patients, complete data of 11 patients was not available, thus only 497 patients were included in this study.

In the present study, 357 (71.83%) were males and 140 (28.16%) were females. In our study, the children from 0 to 18 years were divided into three groups based on age group, i.e., 0 to <2, 2 to<12, and 12 to 18 years for more specific age-wise analysis for better understanding of clinic pathology among the pediatric head trauma population.

Sex distribution

Sex-wise distribution ratio showed that the male-to-female ratio is 0 to <2, 2 to <12 and 12 to 18 years were 1:1.42, 2.6:1, and 3.2:1, respectively. In all categories, male preponderance (P <0.001) was found, except in 0–2 years age group.

Course in hospital

We managed all patients of head injury in the emergency department, intensive care unit (ICU), and ward as per our protocol.

Mode of injury

In this study, the most common mode of injury was an RTA (46.88%; n=233), followed by fall from height (34.8%; n=173) (P < 0.001). Interestingly, three cases of head injury in children were due to injury with agriculture fan blade. Twenty cases had a head injury due to fall of objects on the head; out of which, five cases were due to cement slab, two cases were due to branch of a tree, eight cases were due to fall of the muddy wall due to heavy rain and wall under construction, five cases were due to fall of television or radio from a stand on the head. RTA was the most common cause of head injury in the age group of 12 to 18 years (n=156). Fall from a height like fall from bed/fall from stairs/roof was the commonest cause of head injury in the children below 2 years. Two cases of the battered baby syndrome were found in children <2 years and four cases in the age group 2–12 years [Table 1].

Table 1.

Distribution of mode of injury

Mode of injury	0 to <2 years	2 to <12 years	12–18 years	Total	%	P-value
Road traffic accident	6	71	156	233	46.88%	<0.001
Fall from height/roof	27	119	27	173	34.8%	<0.001
Assault/battered baby	2	4	9	15	3.0%	0.267
Sports injury	0	7	6	13	2.6%	0.48
Injury due to household articles/ agriculture fan blade	4	16	3	23	4.6%	0.011
Fall on ground/fall from bed	5	8	7	20	4%	0.068
Fall of an object over head/wall/grill	5	10	5	20	4%	0.040
Total	49	235	213	497		<0.001

Presenting features

In our study, it was found that the most common presenting feature (P <0.01) was vomiting in 271 (54.52%) cases followed by altered sensorium which accounted for 132 (27.56%) cases [Table 2]. Headache was found in 110 cases (22.13%) (P < 0.001) which was statistically significant in the age group 12 to 18 years.

Table 2.

Age-wise analysis of multiple parameters with their statistical significance

Parameters	0 to <2 years	2 to <12 years	12 to 18 years	Total	Percentage	P-value
Admission GCS (Glasgow coma score)
Severe (3–8)	4	29	27	60	12.07%	0.794
Moderate (9–13)	14	93	74	181	36.41%	0.276
Mild (14–15)	31	113	112	256	51.50%	0.141
Other clinical features
Altered sensorium	13	66	53	132	26.56%	0.457
Vomiting	35	144	92	271	54.52%	<0.001
Headache	0	24	86	110	22.13%	<0.001
Convulsion	4	18	15	37	7.44%	0.852
Hemiparesis/monoparesis	2	5	8	15	3.01%	0.602
Visual disturbance	0	5	3	8	1.60%	0.506
Glasgow outcome score (GOS)
Good recovery (5)	34	178	132	344	69.21%	0.006
Moderate disability (4)	11	32	38	81	16.29%	0.226
Severity disability (3)	1	3	12	16	3.2%	0.029
Vegetative state (2)	0	3	6	9	1.8%	0.287
Dead (1)	3	19	25	47	9.45%	0.294

Early posttraumatic convulsion was found more in young children between 2 to 12 years age. A total of only 37 (7.44%) patients presented with features of early posttraumatic epilepsy; of which, 18 cases belonged to age between 2 and 12 years. Around 15 cases presented with hemiparesis/monoparesis; out of which, eight cases were in the age group 12 to 18 years.

In our study, eight cases had vision disturbances; out of which, a single case was due to direct penetrating injury to the eye causing complete blindness in that eye. The remaining cases had reduced vision due to raised intracranial pressure (ICP), frontal, or occipital lobe injury.

We adopted the standard GCS for children more than 2 years and PGCS for pediatric patients below 2 years to evaluate the severity of the injury. In our study, 256 (51.50%) patients presented to casualty with GCS of 14 to 15, suggesting mild head injury in the pediatric population. Moderate head injury with GCS of 9 to 13 was found in 181 (36.41%) cases. Sixty cases with severe head injury had GCS of 3 to 8 (12.07%).

In radiological findings, epidural hematoma (EDH) and fracture hematoma were the most common computed tomographic finding in pediatric head injury found in 133 cases (26.76%) followed by intraparenchymal contusion or hematoma. There were 132 cases (26.55%) of contusion with or without fracture. Compound fracture with underlying contusion was seen in 26 cases and isolated contusion was found in 106 cases. In total, 226 (45.47%) cases had a skull fracture and 65.7% cases of EDH had at least a single linear skull fracture. The diffuse axonal injury was found in 62 (12.47%) cases. In our study, it was seen that 54.53% of head injury cases were without a skull fracture [Figure 1].

Figure 1.

Bar diagram showing the type of injury in the different age group of pediatric head injury patients

In total, 351 cases were managed conservatively whereas surgical intervention was conducted in 146 cases (P<0.001) [Table 3]. Eleven patients left the hospital against medical advice; these all were managed conservatively.

Table 3.

Type of injury and management of patients

Type of injury	0 to <2 years	2 to <12 years	12 to 18 years	Total	P-value
EDH	5	76	52	133	0.003
CD# NO DURA	12	37	30	79	0.198
CD# P	3	15	14	32	0.992
CD# C	4	10	12	26	0.504
CONT	4	53	49	106	0.059
ASDH	7	12	24	43	0.022
DAI	12	23	27	62	0.017
MISC	2	9	5	16	0.631
Total	49	235	213	497
Management
Operative	6	75	65	146
Conservative	43	160	148	351
P-value	0.005	0.239	0.628	0.020

ASDH = acute subdural hematoma, CD# P = compound depressed fracture with pneumocephalus, CD# NO DURA = compound depressed fracture without dural breach, CD#C = compound depressed fracture with underlying contusion, CONT = parenchymal contusion, DAI = diffuse axonal injury, EDH = extradural hematoma, MISC = miscellaneous

Mortality and outcome

Out of 497 cases, 344 cases were discharged with a good outcome (GOS 5), 81 patients had a moderate disability (GOS 4), 16 patients had severe disability (GOS 3) whereas nine cases were in the vegetative state (GOS 2). Out of the total 47 deaths (GOS 1), there were only three and 19 deaths in the age group of 0 to 2 and 2–12 years, respectively. Maximum mortality (n = 25 cases) was in the age group 12 to 18 years. Patients with a moderate disability with GOS 4 (n = 38) were relatively more in the age group of 12 to 18 years than other age groups.

Out of 497 patients, 47 died during the period of hospitalization (9.45%) with male preponderance (M:F = 2:1). In total, 450 patients were treated successfully and discharged. The total number of deaths during this period in the hospital due to head trauma irrespective of age was 312 (11.49%) out of 2714 patients (P <0.01). It shows that the mortality rate among the pediatric head injury patients was quite less (P<0.01) than that of general head trauma victims. The most fatal outcome was in patients who presented in GCS 3 to 6 with pupillary abnormalities. During the hospital stay, the most common cause of death among 27 patients out of 47 deaths was aspiration pneumonia and septicemia. Twelve patients died within 72h of admission as a result of the direct cause of head injury.

DISCUSSION

Head injury is one of the most common causes of mortality and morbidity in the pediatric population.[16] In this series, out of all head injury patients admitted to our institution, 497 (18.31%) were pediatric patients. In this study, we found that the number of head injury cases increased with an increase in age[17] (P < 0.001). As the age increases, mobility and outdoor activities increase, such as increased vehicular usage, playing outdoor games, increase in child labor, which increased the likelihood of sustaining a head injury. Male preponderance (P < 0.001) in our study was quite comparable to a study by Schutzman and Greenes.[18]

In our study, the most common mechanism of injury was an RTA (46.88%), followed by fall from height (34.80%) (P<0.001). RTA as a common cause of head injury in the pediatric population was also found in another study by Yousefzadeh et al.[19,20] whereas few studies reported fall from height as the most common cause of head injury.[4,21] Taking the pediatric age group as 0 to 18 years may explain the reason for RTA being the most common cause. In our study, fall from height was the most common mode of injury in children in the age group 0 to 2 years and 2 to <12 years and was comparable with other studies.[20,22,23]

The mean duration of hospitalization in our study was 4.0615 days. Most of the patients spent 3 to 7 days in the hospital with 68% of patients staying <7 days (P <0.001). The children in the age group 12 to 18 years spent more days in hospital than any other group. Importantly, the high school and intermediate college-going children lost a significant number of days due to head injury.

In our study, we found that operative intervention (146 cases) was relatively lower compared to conservative management (351 cases) (P < 0.001) [Figure 2] and these results were comparable with other study by Jeevaka et al.[24]

Figure 2.

Bar diagram showing management procedure done in different age groups

In the second edition of Brain Trauma Foundation Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents, there is Level III evidence regarding hyperosmolar therapy with hypertonic saline in the treatment of severe traumatic pediatric TBI associated with intracranial hypertension; Level II evidence in moderate hypothermia (32–33 C) beginning within 8h after severe TBI for up to 48h duration to reduce intracranial hypertension; Level III evidence to avoid prophylactic severe hyperventilation to a PaCO₂ < 30 mmHg in initial 48h after injury.[25] In our study in the management of severe head injury patients using hyperosmolar therapy and hyperventilation to reduce intracranial hypertension, we found suboptimal results. Despite improvements, the recommendations are limited in many areas, reflecting persisting gaps in the evidence for severe TBI management.[26]

Due to the scarcity of resources, we have not done ICP monitoring in any case to measure the ICP. Although some recent studies support the use of ICP monitoring in TBI and consider it as beneficial, many studies describe that the use of ICP monitoring does not have any impact on the outcome. Haddad and Arabi mentioned that although there is no randomized, controlled trial that demonstrates that ICP monitoring improves outcome or supports its use as a standard but still ICP monitoring has become an integral part of the management of patients with severe TBI in most trauma centers.[27] However, there is no substantial evidence about whether ICP monitoring improves the outcome or not.[27] Several studies have demonstrated that ICP monitoring reduces the overall mortality rate of severe TBI.[23,28,29] Other studies have not shown any benefits from ICP monitoring.[20,23,30] Moreover, a few studies have demonstrated that ICP monitoring was associated with worsening of survival.[31,32] Potential complications of ICP monitoring included infection, hemorrhage, malfunction, obstruction, or malposition. In the Cochrane database, a recent systematic review, no randomized control trials were found signifying the role of ICP monitoring in acute coma whether traumatic or nontraumatic.[32] Most clinicians agree to support the use of ICP monitoring in severe TBI patients at risk for intracranial hypertension. In a recent larger study done by Alkhoury and Kyriakides, it was mentioned that ICP monitoring was used infrequently in the pediatric population despite current Brain Trauma Foundation guidelines. The data suggested that there was a small, yet statistically significant, survival advantage in patients who had ICP monitoring and a GCS score of 3. However, all patients with ICP monitoring experienced longer length of hospital stay, longer ICU stay, and more ventilator days compared with those without ICP monitoring.[33]

In this study, the mortality rate among the pediatric head injury patients was quite less (P =0.01) than that of general head trauma victims which were also comparable with other study by Mitra et al.[22]

Of 497 cases, 344 were discharged with GOS-5 whereas nine cases remained in persistent vegetative (GOS-2). A fair number of good recovery suggested that majority of head trauma cases were mild to moderate in severity. The better survival outcome may be due to the anatomical characteristics in pediatric age (open fontanelle and skull stability which is dependent on ligamentous structures than bony structures) which allow it to tolerate the raised ICP better than adults. But, the brain of a child is more vulnerable to hypoxic injury, thus making the functional outcome often unpredictable. Also outcome depends on age at injury, severity, and time since injury, premorbid child characteristics, socioeconomic status, lack of co-morbid factors such as alcoholism hypertension, diabetes mellitus, and absence of age-related risk factors which are responsible for a good outcome in the pediatric population. Also, early recognition and timely intervention yields good results.

CONCLUSION

Early intervention in TBI in children generally carries a good outcome, with efforts aimed at the primary lesion to limit as much as possible the ongoing biomechanical, physiological, and pathological sequelae owing to TBI. The general population should be made more aware of the preventive aspects because most of the TBI can be prevented in infancy and childhood by active vigilance and focused care by the parents/guardian. In teenagers, the importance of proper self-care along with adequate safety gear while doing any TBI-prone activity should be emphasized.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.