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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 2  |  Page : 126-135

Closed traumatic brain injury in children


Department of Neurosurgery, Al-Azhar University Hospital, Cairo, Egypt

Date of Submission08-Jan-2020
Date of Decision15-Mar-2020
Date of Acceptance19-Apr-2020
Date of Web Publication24-Jul-2020

Correspondence Address:
MBBCH Ahmed B Nagy
26 July Street, Malawi, El-Minia, 61631
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_1_20

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  Abstract 


Background Accidental injuries are the most common reason for death among children. Of all the types of traumatic injuries, brain injuries are the most cause of death or permanent disability.
Aim The aim of this study is to evaluate posttraumatic hospital-admitted children to reach better management, outcome, and prognosis and to achieve the best possible care for closed-head injury patients.
Patients and methods This prospective study (May 2018–May 2019), conducted at Luxor International Hospital and Al-Azhar University Hospital, includes all children aged 0–14 years with exclusion of children older than 14 years and penetrating head injuries. All the case records were reviewed and the pertinent data (clinical history, age, sex, mode of injury) were analyzed. We categorized them into mild, moderate, and severe head injuries based on the Glasgow coma scale (GCS) at the time of admission.
Results Out of 30 children with traumatic brain injury (TBI), 17 (56.7%) were of mild, nine (30%) moderate, and four (13.3%) severe TBI. In the group of patients in the category of GCS less than or equal to 8, poor outcome was seen in 50%, followed by patients in group GCS 9–12 at 0%, succeeded by group of patients with GCS 13–15 at 0%, which was statistically significant.
Conclusion This study has shown that the reason for TBI in children we managed was age dependent. Falls were widespread in toddlers, pedestrian accidents more common in preschool and school-age groups. This study has shown that the outcome of head injury in children we managed depended on the severity of the injury.

Keywords: brain, children, injury, management, traumatic


How to cite this article:
El Khadrawy SM, Abu-Elkhir MM, Nagy AB. Closed traumatic brain injury in children. Al-Azhar Assiut Med J 2020;18:126-35

How to cite this URL:
El Khadrawy SM, Abu-Elkhir MM, Nagy AB. Closed traumatic brain injury in children. Al-Azhar Assiut Med J [serial online] 2020 [cited 2020 Aug 9];18:126-35. Available from: http://www.azmj.eg.net/text.asp?2020/18/2/126/290595




  Introduction Top


Trauma, despite many preventative measures, remains a very important societal and public health issue. It is the main cause of death and disability accounting for more than 50% of the morbidity in the pediatric population [1]. Of all the types of traumatic injuries, brain injuries are the most common cause of death or permanent disability [2].

The most common cause of head trauma in children is fall, while more severe head injuries are related to traffic accidents. Thus, the most common causes of head trauma in the first year of age are falls from parental arms, from tables or chairs, and are usually low-impact injuries. As the child learns to walk, falls from heights happens. In older children, there is an increase in bicycle accidents, sports injuries, car accidents with the child as a passenger in a motor-car, and suicide accidents [3].

Atypical neurologic examination implications for the increase in intracranial tension have signs and symptoms of headache, vomiting, drowsiness, irritability, amnesia, visual disturbance, focal neurologic signs, dizziness, altered consciousness, or signs of a fractured skull base. An abnormal mental status in pediatric blunt head trauma should be considered if the patient has a Glasgow coma scale (GCS) of less than 15 or if the patient is confused, sleepy, or slow to respond to verbal communication [4].

Contributors to traumatic brain injuries (TBI) include focal damage due to direct tissue injury and diffuse injury due to acceleration/deceleration, resulting in cerebral edema and diffuse axonal injury. TBI) occurs in two phases: primary injury, which is the tissue or mechanical damage occurred at the time of trauma and secondary injury or delayed damage, caused by inflammatory and excite-toxic processes, causes cerebral edema, and elevated intracranial pressure (ICP). Secondary injury is also caused by physiologic injuries, most commonly due to hypoxemia and hypotension [5].

Computed tomography (CT) can easily identify fractures and intracranial complications [6].

The treatment of closed-head injuries concentrates on the protection of secondary brain injury by increasing the oxygen delivery and nutrients to the injured brain, while decreasing neuronal metabolic indigence. Treatment is intended to decrease secondary brain injury, such as cerebrospinal fluid (CSF) drainage, hypertonic saline infusion, barbiturate coma induction, brain cooling, and decompressive craniotomy [6].

Complications include the following: posttraumatic seizures, hydrocephalus, deep vein thrombosis, heterotopic ossification, spasticity, and gastrointestinal and genitourinary complications [7].

Long-term follow-up is often required to evaluate both physical and mental disability outcomes. The significance of early and regular contact between rehabilitation specialists, family members, and educators is strongly recommended. Pupillary response at admission, occurrence of hypothermia, and mechanism of injury were associated with survival and outcomes [2].


  Aim Top


The aim of this study is to evaluate posttraumatic hospital-admitted children to reach better management, outcome, and prognosis and to achieve the best possible care for closed-head injury patients.


  Patients and methods Top


This prospective study (May 2018–May 2019), conducted at Luxor International Hospital and Al-Azhar University Hospital, includes all children 0–14 years with exclusion of children older than 14 years old and penetrating head injuries. All the case records were reviewed and the pertinent data (clinical history, age, sex, mode of injury) were analyzed. In this study, head injuries were categorized into mild, moderate, and severe head injury based on GCS at the time of admission as shown in [Table 1].
Table 1 Classification of severity of head injury according to Glasgow coma scale

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In this study, injuries were categorized by type such as skull fracture, epidural hemorrhage (EDH), subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), intraventricular hemorrhage, pneumocephalus, diffuse axonal injury, brain contusion, and parenchymal hemorrhage.

First-aid measures (primary survey)

Th first-aid measures include the following:
  1. Assess airway: for patency and patient’s ability to maintain airway.
  2. Assess breathing: for air entry, chest movement, respiratory rate, oxygen saturation. Chest wall tenderness, bruising, lacerations, deformity may herald the underlying thoracic injury.
  3. Assess circulation: skin color and temperature, heart rate, peripheral and central pulses, capillary refill, and blood pressure.
  4. Assess the level of consciousness: determine GCS ([Table 2] and [Table 3]), pupil size, form and reaction to light, and observe for signs of seizures/abnormal movements. Look for focal neurological signs.
    Table 2 Glasgow coma scale

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    Table 3 Number of patients according to mode of trauma

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  5. Measure temperature and assess for marks/signs of injury (bruises, wounds, swelling, etc.).


Secondary survey

Secondary survey includes the following:
  1. Complete neurological examination as follows:
    1. Level of consciousness: scaled according to GCS.
    2. Cranial nerve examination.
    3. Motor system: muscle state, tone, and power were graded according to the Frankel grading system.
    4. Reflexes: superficial and deep reflexes.
    5. Sensory system: superficial and deep sensations.
    6. Assess the pupils: pupils should be examined for their response to light and their symmetry. Note if the reaction is reactive, sluggish, or unreactive.
  2. Whole body examination: through this examination, any injuries detected should be precisely mentioned and the required treatment should given like covering wounds, controlling nonlife-threatening bleeding and splinting fractures.
  3. Head and neck:
    1. Inspect the scalp. Look for any bleeding or lacerations.
    2. Examine the patient’s neck for point tenderness or deformity of the cervical spine.
    3. Lacerations can bleed much; control bleeding with direct pressure and bandaging.
    4. Inspect the face. Look for any lacerations or bruising.
    5. Look in the eyes for any foreign body, subconjunctival hemorrhage with no posterior limit, hyphemia, irregular iris, penetrating injury, or contact lenses ([Figure 1]).
      Figure 1 Raccoon eye.

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    6. Assess the ears for any bleeding or blood behind the tympanic membrane, as well as any CSF leak ([Figure 2]).
      Figure 2 Battle sign.

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    7. Check the nose for any deformities, bleeding, nasal septal hematoma, or CSF leak.
    8. Look in the mouth for any lacerations to the gums, lips, tongue, or palate.
  4. Test eye movements, vision, and hearing.
  5. Feel for point tenderness, deformity, and other signs of injury.
  6. Examine the chest for cuts, bruises, penetrations, and impaled objects.
  7. Examine the abdomen for cuts, bruises, penetrations, and impaled objects.
  8. Feel the pelvis for injuries and possible fractures.


Investigations

  1. Routine laboratory investigations: complete blood count, prothrombin time, prothrombin concentration (PC), international normalized ratio (INR), renal function tests.
  2. Abdominal ultrasound.
  3. Chest radiograph.
  4. Pelvis radiograph.
  5. Cervical CT.
  6. Brain CT: is the preferred method of imaging if available and should be performed early in the severe-to-moderate TBI group.
  7. Thoracic and lumbosacral radiographs.
      Decision regarding if the patient will be admitted to hospital or to discharge depends on his general condition and diagnosis:
    1. If the patient is neurologically and vitally stable, he can be discharged from the emergency room (ER) after completing his full investigations.
    2. If the patient has a neurological finding in brain CT, neurological deficit, or disturbed conscious level, he must be admitted under observation for more than or equal to 24 h or for surgical intervention according to radiological findings and GCS.


Management after patient admission

  1. Therapeutic use of sedatives, analgesics, and neuromuscular blockade.
  2. Hyperosmolar therapy.
  3. CSF drainage.
  4. Hyperventilation.
  5. Barbiturates.
  6. Temperature control.
  7. Corticosteroids.
  8. Nutritional management.
  9. Anticonvulsants.


Surgery for severe traumatic brain injury

  1. Decompressive craniectomy as a primary treatment of refractory ICP.
  2. Evacuation of EDH with a volume greater than 30 ml regardless of whether GCS or less than 30 ml with GCS 8 or less with anisocoria.
  3. Evacuation of SDH with thickness greater than 10 mm and midline shift greater than 5 mm or thickness less than 10 mm and mid-line shift (MLS) less than 5 mm if GCS decreased by two points or more since presentation.
  4. Evacuation of intraparenchymal hematoma with elevated ICP refractory to medical management, signs of mass effect on CT, lesion volume is 50 ml or more or with signs of deterioration referable to the lesion, GCS 6–8 and more than 20 ml of frontal or temporal contusions, and MLS of 5 mm or more and/or cisternal compression.
  5. Evacuation posterior fossa hematoma with mass effect in the posterior fossa (evidence of fourth ventricular distortion, effacement of basal cisterns, hydrocephalus) or any deterioration that may be attributed to the hematoma.
  6. Surgery for depressed fractures if the depressed bone is greater than skull thickness.
    1. After the discharge from hospital, regular follow-up was done at our outpatient department for 6 months.


Statistical analysis

Categorical factors, according to outcome (i.e. adverse outcome or recovery) were compared by the use of the c2 test or Fisher’s exact test. Time to diagnosis, according to outcome, was compared by Wilcoxon rank-sum test. The 1-year cumulative mortality rate and 1-year rate of relapse with SEs were estimated by means of the Kaplan–Meier method. The equality of relapse and mortality curves between groups were tested with the log-rank test. The 95% confidence intervals were provided for the 1-year mortality and relapse rates.


  Results Top


Out of total 30 cases, 19 (57%) were men and 11 (43%) with a male : female ratio of 1.73 : 1 ([Figure 3]).
Figure 3 Pie chart showing sex distribution.

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Of 30 children, nine (30%) were at the age of 0–5 years, 12 (40%) were at the age of 6–10 years, and nine (30%) were at the age of 11–14 years ([Figure 4]).
Figure 4 Histogram showing distribution of age groups.

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Out of 30 children, 17 (56.7%) were of mild, nine (30%) moderate, and four (13.3%) severe TBI. Overall, fall from height (15, 50%) is the most common mode of injury followed by road traffic accidents (8, 26.7%). Fall of heavy objects (moving fan, television set, and stones) overhead was found in seven (23.3%) cases ([Figure 5]).
Figure 5 Histogram showing severity of injury.

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Clinical evaluation revealed sleepiness (28 patients, 93.33%), headache (28 patients, 93.33%), amnesia (20 patients, 66.7%), loss of consciousness in (22 patients, 73.33%), vomiting (27 patients, 90%), confusion (17 patients, 56.67%), neurological deficit (21 patients, 70%), difficulty with coordination and movement (balance problems) (seven patients, 23.33%), cognitive impairment (six patients, 20%), tinnitus (eight patients, 26.67%), ENT bleeding (eight patients, 26.67%) and seizure (22 cases, 73.33%) ([Figure 6]).
Figure 6 Histogram showing clinical evaluation at admission.

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CT scan findings showed extradural hematoma (EDH) (four, 13.3%), skull fracture (six, 20%) with three of them of pneumocephalus or aerocele, contusion (four, 13.33%), SDH (three, 10%), brain edema (15, 50%), SAH (0%), and brain hemorrhages (three, 10%) as the radiological injury patterns ([Figure 7]).
Figure 7 Histogram showing the number of patients according to radiological findings in brain CT.

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Out of 30 cases, 24 (80%) cases managed conservatively, and surgical intervention was done in six (20%) cases ([Table 4]).
Table 4 Number of patient according to the type or management

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Of six surgical cases, debridement followed by duraplasty of the skull fracture skull was done in 3/30 (10%) cases, evacuation of EDH in 2/30 (6.67%) cases, and evacuation of acute SDH in 1/30 (3.33%) cases ([Table 5]).
Table 5 Number of patients according to surgical intervention

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Case 1: male patient 5-year old, admitted to ER postroad traffic accident, presented by GCS: 10/15, full motor power, CT brain shows left temporoparietal extradural hemorrhage ([Figure 8]).
Figure 8 CT brain of the studied patient showed left temporoparietal extradural hemorrhage.

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The case was admitted to hospital and immediately presented to operative room to evacuate hemorrhage.

Postoperative, the patient improved, GCS became 15/15 with no neurological deficit and the postoperative brain CT is shown in [Figure 9].
Figure 9 Postoperative brain CT of the studied patient.

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Case 2: case of male patient of 4-year old, admitted to ER postfall from height, presented by disturbed conscious level with GCS 12/15, full motor power, and bleeding per nose. CT brain showed right and left frontal multiple fissure fractures and left orbital roof fissure fracture with multiple right and left brain contusions and SAH ([Figure 10]).
Figure 10 CT brain of the studied patient showed right and left frontal multiple fissure fractures and left orbital roof fissure fracture with multiple right and left brain contusions and subarachnoid hemorrhage (soft tissue and bone window).

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Patient took medications like dexamethasone, adequate antibiotics (ceftriaxone and unistam) and mannitol to decrease brain edema around contused tissues; after 24 h, the patient improved, GCS became 15/15, CT brain follow-up showed a marked decrease in contusions size with edema decrease ([Figure 11] and [Figure 12]).
Figure 11 Follow-up brain CT of the studied patient after dehydrating measures.

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Figure 12 Histogram showing the relationship between Glasgow coma scales with outcome.

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Outcome

In the group of patients in the category of GCS less than or equal to 8, poor outcome was seen in 50%, followed by patients in group GCS 9–12 at 0%, succeeded by group of patients with GCS 13–15 at 0%, which was statistically significant.

The overall mortality was 2/30 (6.67%). All were occurred in severe head injury (2/4, 50%).


  Discussion Top


TBI is a type of acquired brain injury that arises from external trauma. Acceleration–deceleration forces act upon the skull, following the traumatic event, and causes brain contusions and injuries.

Most of the patients were men 19 (57%) as compared with women (11, 43%) which is comparable to Astrand et al. [8] In this series, there is no difference in poor outcome in children below 5 years or above 5 years as reported by Suresh et al. [9].

In this series, the most common modes of TBI were fall (15, 50%) with good outcome in 13/15 (86.67%) patients, followed by RTAs (eight, 26.7%) with good outcome in 8/8 (100%), followed by fall of heavy objects (moving fan, television set, and stones) overhead (with seven, 23.3%) with good outcome in 100%.

Astrand et al. [8] reported 50% were injured due to road traffic accident (RTA), 36% due to fall, assault 4%, and others 10% and RTA had good outcome of 86% and fall had good outcome of 94%. Yi et al. [10] reported in their study that fall were the most common type of injury (73.2%), followed by RTA (16%), followed by assault (7%), followed by others (3.6%).

The patients with low GCS had a poor outcome as is expected. The patients who had a GCS of 13–15 (mild head injury) [17 (56.67%)] had a poor outcome in 0 (0%), followed by GCS of 9–12 (moderate head injury) [nine (30%)] who had a poor outcome in 0 (0%), followed by GCS of eight or less (severe head injury) [four (13.33%)] who had a poor outcome in two (50%).

Suresh et al. [9] reported poor outcome in the group of GCS 3–5 as 58.5%, GCS 6–8 had 35.2%, GCS 9–12 had 11.4%, and GCS 13–15 had 1.3%. Beca et al. [11] found that the initial GCS score was the single most important factor affecting the outcome [1].

Astrand et al. [8] reported poor outcome in GCS 14–15 in 0%, in 9–13 as 6.2%, and less than 8 had 22% poor outcome. Ong et al. [12] and Aldrich et al. [13] reported that low GCS did not always accurately predict the outcome in the absence of hypoxia or ischemia.

Out of the 30 patients, 25 (83.33%) patients had normal pupils, three (10%) had anisocoria, and two (6.7%) patients had fixed dilated pupils. Poor outcome in patients with normal pupils was 0%, patients with anisocoric pupils was 0%, and with fixed dilated pupils was 100%.

Astrand et al. [8] reported 100% poor outcome in dilated pupils unresponsive to light. Suresh et al. [9] reported poor outcome of 49.3% in patients of abnormal pupils and 7.4% in normal pupils. Jennett [14] reported a poor outcome of 96% in fixed dilated and 50% in normal pupils. Francel et al. [15] stated that pupillary response is not a good predictor of outcome. In this series, atypical pupillary response is the strongest predictor of outcome.

Out of the 30 patients in our series, CT scan findings were noted as the following:
  1. Isolated skull fracture in six (20%) patients with good outcome in 100% and poor outcome in 0%. Suresh et al. [9]. had 17% patients with isolated skull fracture with good outcome in 94.1% and poor outcome in 5.9%. The probability of associated intracranial hematoma with skull fracture in children is half of that of adults [16].
  2. EDH in four (13.33%) patients with good outcome in 100% and poor outcome in 0%. EDH reported by Suresh et al. [9] was at 28% with poor outcome in 8.4%. Astrand et al. [8] reported 48% of patients of EDH with good outcome in 98% and poor outcome in 2%. The mortality rate in children with EDH ranged from 7 to 15%; 5–10% of patients also had residual neurological deficits [16].
  3. Contusions/hematoma was seen in seven (23.3%) with good outcome in 100% and poor outcome in 0%. Suresh et al. [9] reported 16.7% with poor outcome in 18.2% and Lobato et al. [17] reported that outcome was better in EDH. The outcome was unfavorable in patients with intracerebral hematomas and hemorrhagic contusions [18].
  4. SDH was seen in three (10%) patients and out of those poor outcome was noted in 0 (0%) patients. Suresh et al. [9] had recorded SDH in 10.33% of patients out of whom 35.3% had poor prognosis. Yi et al. [10] and Tomberg et al. [18] recorded 25% and 17.1% of patients having SDH and none of them had good prognosis.
  5. Diffuse brain edema was observed in nine (30%) with poor outcome in two (6.67%) patients. Suresh et al. [9] reported the incidence of diffuse brain edema as 30% with poor outcome in 25%.


Total clinical outcomes, according to the GCS in this study, were 56.67% (n=17) had good recovery, 30% (n=9) had moderately disabled, and 13.33% (n=4) were severely disabled (6.67% (n=2) remained in vegetative and 6.6% (n=2) were dead). Yi et al. [10] reported a GCS of 37 (77.1%) good recovery, four (8.3%) moderately disabled, one (2.1%) vegetative, and six (12.5%) dead.


  Conclusion Top


This study showed that in children with TBI, fall is the most common cause, more common in men than women and severity of injury is the most common factor that determine the outcome of management.

Recommendations

We recommend studying closed TBI in children to reach the most appropriate management for TBI and to improve the outcome in posthospital-admitted cases.

Acknowledgements

The author extends his gratitude to Dr Shehab El Khadrawy, Professor of Neurosurgery, Faculty of Medicine, Al-Azhar University for his guidance and kind directions throughout this study. In every phase of this study, his supervision and guidance shaped this study to be completed perfectly. Also, the author is grateful to Dr Mostafa Abo El-Kheer, Lecturer of Neurosurgery, Faculty of Medicine, Al-Azhar University for his consistent guidance, ample time spent, and consistent advices that helped me to bring this study into success.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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