Management of children with mild traumatic brain injury and intracranial hemorrhage

Abstract

BACKGROUND Traumatic brain injury (TBI) is a significant public health problem affecting tens of thousands of children each year, and an important subset of these patients sustains intracranial hemorrhage (ICH). The purpose of this study was to test the hypothesis that we could identify a subset of children with traumatic ICH who could be monitored on a general neurosurgery ward with a low risk of clinical deterioration. METHODS We performed a retrospective review of pediatric patients ≤18 years of age with mild TBI (Glasgow Coma Scale score 14–15) and traumatic ICH admitted to Saint Louis Children’s Hospital between 2006 and 2011. We excluded patients with injuries unrelated to the TBI that would require ICU admission and those with penetrating intracranial injuries. RESULTS We identified 118 patients meeting inclusion criteria. Repeat neuroimaging was obtained in 69/118 patients (58%). Radiologic progression was noted in 6/69 (8.7%) patients, with a trend toward more frequent progression in patients with epidural hematoma (EDH) versus other ICH (3/15 (20%) vs. 3/54 (5.6%); p=0.11). Eight of 118 patients (6.8%) experienced clinically important neurological decline (CIND), and 6/118 (5.1%) required neurosurgical intervention. Both CIND and need for neurosurgical intervention were significantly higher in patients with EDH (21% each) compared to those with other types of ICH (4% and 2% respectively) (P=0.02; P<0.01). Based on these results, we developed a preliminary management framework to assist in determining which patients can be safely observed on a neurosurgery ward without an intensive care unit (ICU) admission. Specifically, those patients without EDH, intraventricular hemorrhage, coagulopathy, or concern for a high-risk neurosurgical lesion (e.g. arteriovenous malformation) may be safely observed on the ward. CONCLUSIONS These results demonstrate that few children with mild TBI and ICH experience CIND, and the preliminary framework we developed assists in identifying which patients can safely avoid ICU admission. This framework should be validated prospectively and externally. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Monitoring Criteria of Intracranial Lesions in Children Post Mild or Moderate Head Trauma

“…Only 4 of 113 children required emergency surgery or more intensive care, which is similar to published data for mild head trauma. 15 Only 2.6% of our patients received secondary surgical management compared with a higher rate of secondary surgical management reported by authors of other studies, ranging from 10 14 to 13.1% 13 in children with ICLs, but the initial severity of the head trauma was not specified.…”

“…There are no recommendations on the management and clinical or iconographic monitoring for delineation of risk factors for clinical deterioration in children with intracranial lesions following minor or moderate head trauma. [10][11][12][13][14][15] We wanted to study the management of these children with non-critical intracranial lesions to optimize the approach adopted. The children were hospitalized in the neuropediatric and neurosurgery departments of Toulouse University Hospital.…”

Evaluating the Role of a Neurosurgery Consultation in Management of Pediatric Isolated Linear Skull Fractures

“…Our data answers a specific question that previous papers have alluded to, but not emphasized, in their results [6, 7, 10, 12, 14, 15]. To briefly summarize, Arrey et al [6] determined that there was no need to hospitalize 326 patients with ILSF with a median age of 19 months unless there was a pending nonaccidental trauma workup.…”

“…Addioui et al [14] showed that of 180 patients, only 4.4% required intervention for dural repair or elevation of depressed fractures despite 32% having subdural, epidural, or subarachnoid hemorrhage, or intracranial contusions. Greenberg et al [15] found that the presence of epidural hemorrhage, intraventricular hemorrhage, coagulopathy, or significant comorbid neurosurgical lesion confers a higher risk for clinically important neurologic decline and need for neurosurgical intervention. Interestingly, Tavor et al [17] retrospectively demonstrated that severe mechanism of injury (running, biking, fall onto protruding instrument) combined with clinically evident skull fracture, neurological deficit, and severe headache identified almost all 182 patients who required intervention in their study.…”

Clinical and ultrasonographic evaluation of the neurological status of children with mild brain injury in acute phase

“…По данным литературы, в 1,5-8 % случаев у детей с клиническими критериями ЛЧМТ вы-являют следующие значимые травматические структурные внутричерепные изменения (СВИ): эпидуральные гематомы (16 %), субдуральные гематомы (37 %), паренхиматозные кровоизлия-ния (44 %), субарахноидальные кровоизлияния (24 %) и внутрижелудочковые кровоизлияния (4 %) [2,3]. Транзиторный характер общемозго-вой и очаговой неврологической симптоматики в детском возрасте уменьшает значимость кли-нической оценки при выявлении ослож ненного течения ЛЧМТ и требует использования методов нейровизуализации для уточнения тяжести ЧМТ [4,5].…”