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Clinical profile, evaluation of imaging guidelines, and management of pediatric traumatic brain injury at a tertiary care center in India: A review of 269 patients

 Department of Neurosurgery, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, India

Date of Submission16-Feb-2022
Date of Decision15-Apr-2022
Date of Acceptance16-Apr-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Trimurti D Nadkarni,
Department of Neurosurgery, Room No. 203, 2nd Floor, College Building, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr. A.L. Nair Road, Mumbai Central, Mumbai 400008
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPN.JPN_30_22



Background: Traumatic brain injury (TBI) is associated with considerable morbidity and mortality in the pediatric population. Literature regarding management of TBI in children is scarce in the Indian setting. Our study aims to bridge the existing literary gap. Materials and Methods: This study is a retrospective analysis of 269 children below 12 years of age presenting to a tertiary care hospital in India with head injury between January 2018 and January 2021. Pearson’s χ2 test, Kruskal–Wallis test, and Mann–Whitney U-test were used for statistical analysis. Results: The mean age of children admitted with head injury was 4.7 years. TBI was mild in 92.2% of children. A fall from height was the most common cause of injury (81.8%). The most common finding on computed tomography (CT) was skull fracture in 38%. Ten children (3.8%) required neurosurgical intervention. The median duration of hospital stay was 4 days. Statistically significant differences in median duration of hospital stay were obtained based on skull fracture and Glasgow Coma Scale on arrival. About 43.1% (n = 116) of children received a CT scan despite lack of indication as per NICE (National Institute of Health Care and Excellence) guidelines, and positive findings were obtained in 47.4% (n = 55). Prophylactic anticonvulsants were given to 39.8% of children (n = 107), of which 86.8% (n = 92) had positive findings. Fourteen children (13.2%) with a normal CT scan received anticonvulsants due to the presence of seizures following head injury. Conclusion: Strict implementation of guidelines issued by NICE would have led to non-detection of intracranial injury in many patients. A modification of this guideline to suit the Indian perspective may be necessary. The use of anticonvulsants in children following head injury needs further characterization.

Keywords: Computed tomography, head injury, skull fracture, traumatic brain injury

How to cite this URL:
Roy JM, Balasubramaniam S, Barve PS, Nadkarni TD. Clinical profile, evaluation of imaging guidelines, and management of pediatric traumatic brain injury at a tertiary care center in India: A review of 269 patients. J Pediatr Neurosci [Epub ahead of print] [cited 2023 Sep 29]. Available from: https://www.pediatricneurosciences.com/preprintarticle.asp?id=350641

   Introduction Top

Trauma is a major cause of mortality and morbidity in all age groups. In 2017, Dewan et al.[1] reported the incidence of traumatic brain injury (TBI) across the globe between 64 and 74 million. Falls and road traffic accidents (RTAs) accounted for most cases of pediatric TBI.[2] In the USA, access to weaponry has contributed to the overall increase in penetrating TBI among adults and children.[3],[4] The American Academy of Pediatrics reported an annual incidence of 1.5 million head injuries among the pediatric population. Accidental falls, RTAs, and sports-related injuries account for these injuries. In India, falls account for the major cause of head injuries in the pediatric population, followed by RTAs.[5]

Tabish et al.[5] and Verma et al.[6] elaborated upon the epidemiology of pediatric head injuries in tertiary care hospitals in India. There is scarce information on the presence of skull fractures across different age groups. Additionally, an increased duration of hospital stay is suggestive of high morbidity and can be affected by factors such as Glasgow Coma Scale (GCS) on arrival and presence of a skull fracture.

Brain imaging following head injury is employed to assess the degree of injury. There is growing concern about radiation exposure and damage to the developing brain during computed tomography (CT) imaging.[7] Guidelines to ensure optimal implementation of brain imaging have varying sensitivities and specificities in detecting intracranial pathology.[8] Studies based on the Indian population have compared different imaging modalities in detecting intracranial injury.[9],[10] We evaluated the applicability of guidelines issued by the NICE to our cohort in a retrospective manner.[11] As the guidelines of Neurotrauma Society of India (NTSI) are similar to NICE guidelines, the data of our study regarding this variable will hold true in either scenario. The use of anticonvulsants following head injury has also been studied in the Indian population; however, a clear set of guidelines have not yet been issued.

We aim to describe these factors associated with the management of pediatric head injury.

   Materials and Methods Top

We performed a retrospective study of all children below 12 years of age who presented to our tertiary care hospital in Mumbai, India with TBI between January 2018 and January 2021. This study is a review of children who were admitted or brought for an initial consultation and does not include data on their follow-up. Children who presented with one or more cardinal symptoms of head injury (loss of consciousness, ENT bleed, vomiting, and seizures) and alleged history of head injury were included in this study. Children with poly trauma and poor GCS where radiological investigations could not be performed were excluded.

All patients received a CT scan as part of the management protocol at our hospital, and we evaluated the applicability of guidelines issued by the NICE in a retrospective manner. Use of prophylactic anticonvulsants was also studied in a retrospective manner.

Data were collected in the form of a case record proforma for every patient [Table 1]. The GCS/Pediatric GCS (depending on the age of the child) was used to categorize children on arrival into three groups, namely, mild (GCS 13–15), moderate (GCS 9–12), and severe (GCS 3–8).
Table 1: The case record proforma used during data collection

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Descriptive analytical formulae were used to calculate the mean and range for an even distribution, or median and interquartile range (IQR) for an uneven distribution. Pearson’s χ2 test was used to test for association between two categorical variables. Non-parametric analysis of the difference between median duration of hospital stay against different categories of GCS (mild, moderate, and severe) and presence or absence of skull fracture was done using the Kruskal–Wallis test and Mann–Whitney U-test, respectively. All statistical analyses were performed using SPSS ver. 26.0 (IBM, Armonk, NY, USA), and a P-value of less than 0.05 was considered significant.

   Results Top

Demographic variables

The total number of participants included in the study was 269. The mean age of children was 4.7 years, ranging from 28 days to 12 years of age. A higher incidence of head injury was seen among boys (56.8%, n = 153) when compared with girls (43.2%, n = 116). There were 118 children (43.8%) between 1 and 4 years of age [Table 2].
Table 2: Distribution of modes of injury across age groups of the pediatric population

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Mode of injury

The most common etiology of head injury was fall from height and accounted for 77.1% of the cases, n = 220. RTAs accounted for 5.9% of cases, and injuries sustained while playing accounted for 8.5% of the cases [Table 2].

Relationship between age and mode of injury

About 90% of children (n = 106) aged between 1 and 4 years were brought to the hospital after injuries sustained during fall from a height. Older children were more commonly involved in bicycle or motor vehicle accidents. Pearson’s χ2 test revealed statistical significance between age group and mode of injury (P < 0.05).

Clinical presentation

Most children (n = 248, 92.2%) presented with features of mild TBI based on the GCS. About 6.3% (n = 17) and 1.5% (n = 4) presented with moderate and severe TBI, respectively. Vomiting was the most common symptom and was present in 87.7% of the children (n = 236). Other symptoms on presentation were loss of consciousness (n = 70, 26%), ENT bleed (n = 18, 6.6%), and seizures (n = 34, 12.6%).

Imaging characteristics

Plain CT brain imaging detected abnormalities in 62.1% of children (n = 167). Skull fractures were present in about 38% of children (n = 103). Extra-axial bleed occurred in 30.8% of children (n = 83). As CT scan in infants has the risk of associated radiation exposure, ultrasound of brain through the open anterior fontanelle is an option. Detailed data on CT scan findings based on adherence or non-adherence to NICE guidelines are mentioned in [Table 3].
Table 3: CT scan findings based on adherence or non-adherence to NICE guidelines

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Relationship between age and skull fractures

CT brain revealed fractures in about 38% of children (n = 103). About 52% of children below the age of 1 had skull fractures [Table 4]. The frequency of fractures decreased with age. Pearson’s χ2 test between age group and presence/absence of fracture revealed no statistical significance (P > 0.05).
Table 4: Nature of skull fractures across age groups of the pediatric population

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Management and duration of hospital stay

Conservative management was most frequently employed (96.2%). This included a 48-h observation, keeping the child nil-by-mouth for 24 h and symptomatic treatment using analgesics and IV fluids. Ten children in our study required surgical interventions to evacuate the underlying extradural hemorrhage. The median duration of hospital stay was 4 days, IQR 3–5 days. Statistically significant difference in duration of hospital stay was observed with GCS on arrival and presence/absence of skull fracture. This statistical significance was obtained using the Kruskal–Wallis test (P = 0.036, P < 0.05) for the GCS on arrival and the Mann–Whitney U-test (P = 0.00, P < 0.01) for presence/absence of skull fracture.

Prescription of anti-epileptic medication

Prophylactic anti-epileptic medication was prescribed in 39.4% (n = 106) of children on discharge of which 86.8% of children (n = 92) had positive findings on CT scan [Table 5]. About 13.2% of children (n = 14) who had normal findings on CT received anticonvulsants due to the presence of seizures following head injury. Phenytoin was most frequently prescribed (n = 101, 37.3%), in divided doses of 5 mg/kg body weight.
Table 5: Prescription of anti-epileptic drugs based on CT scan findings

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Applicability and adherence to guidelines issued by the NICE

In our cohort, guidelines issued by the NICE had a sensitivity of 65.3% [95% confidence interval (CI) 57.53–72.46] and a specificity of 71.57% (95% CI 61.78–81.06) in detecting intracranial injury. CT brain was performed in 51.3% (n = 138) of the children in accordance with guidelines issued by the NICE [Table 3]. Non-adherence was observed in 48.7% of the children (n = 131), of which positive findings on CT scan were detected in 44.2% (n = 58). Two of these children required surgical evacuation of the underlying extradural hematoma (EDH). Hence, 58 out of 131 children (44.2%) benefited (medically or surgically) by imaging in spite of not adhering to NICE guidelines as noted in two illustrative cases presented hereafter [Figure 1].
Figure 1: A: A plain axial CT scan with a large right frontoparietal extradural hematoma (EDH) with mass effect and midline shift. B: A large left posterior fossa EDH with compression of the fourth ventricle

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Illustrative cases

Case 1

A 10-year-old child with history of low-speed RTA presented to us fully conscious (GCS 15/15) with no neurological deficit. A small swelling was present at the right frontoparietal region of scalp. Pupils were bilaterally equal and reactive to light. Pulse was 82/min. She had no positive history of vomiting, loss of consciousness, or amnesia. [Figure 1]A. Right frontoparietal craniotomy with evacuation of EDH was done. The patient was neurologically intact after surgery with no post-operative complications.

Case 2

A 5-year-old child with history of fall from a height of 2 m was brought to ER, fully conscious (GCS 15/15) with no neurological deficit. Pupils were bilaterally equal and reactive to light. Pulse was 80/min. She had one episode of vomiting and no loss of consciousness [Figure 1]B. Left suboccipital craniectomy with evacuation of EDH was done. The patient was neurologically intact after surgery with no post-operative complications.

   Discussion Top

TBI is a considerable cause of mortality and morbidity in the pediatric population. In India, head injury secondary to fall is common in the pediatric population and is associated with significant morbidity.[12] Deficits in executive functioning and behavioral changes have been reported following head injury in the pediatric population.[13],[14]

Head injury resulting from fall from stairs or from a height accounted for 81.8% of the cases (n = 220). This category comprised accidental falls from a poorly constructed upper floor, fall from a bed, chair, or stairs. RTA accounted for 6% of cases in our series. In a similar study, Verma et al.[6] found that falls and RTAs accounted for 64% and 16% of injuries, respectively.

Age influences the nature of head injury. We found statistical significance (P < 0.05) between the mode of injury across different age groups in our cohort. There is an increase in incidence of motor vehicle accidents as children grow old. Pedestrian accidents and two-wheeler accidents account for most cases of RTAs.[15] Children are often involved in two-wheeler accidents due to underage driving or even as pillion riders. A lack of legislative measures and road safety awareness account for RTAs.

Ren et al.[16] described the effect of impact velocity in different locations on type of fracture after head injury. In our series, fractures of the skull were more common among younger age groups, similar to findings reported by other authors.[17] However, this association was not statistically significant. Linear fractures were more common among all age groups in our study when compared with depressed fractures (n = 70, 26%). Satardey et al.[18] reported that outcome of patients with depressed fractures was affected by GCS on arrival, site of fracture, and intracranial bleed. In our series, we obtained statistically significant difference between median duration of hospital stay among groups of children based on the GCS on arrival and the presence or absence of skull fractures. These factors are indicative of longer duration of hospital stay, which can lead to an increase in total expenditure and morbidity. The data on interval between time of injury and presentation could not be highlighted in this paper as ours is a tertiary referral center and many patients were referred to us after being managed at local hospitals.

Positive findings were obtained on CT brain imaging in 62.1% of the cases. In our series, CT scans were performed for all children due to the presence of one or more cardinal symptoms of head injury. Guidelines issued by the NICE had a sensitivity of 65.3% (95% CI 57.53–72.46) and a specificity of 71.57% (95% CI 61.78–80.06) in detecting intracranial injury in our cohort. This low sensitivity suggests a high number of false-negative results, which would have gone undetected in the presence of strict adherence to these guidelines alone. Foks et al.[8] reported the sensitivity and specificity of these guidelines in detecting intracranial pathology following minor head injury to be 72.5% and 62.9%. We studied the applicability of these guidelines in our population in a retrospective manner. Low adherence to guidelines (51.3%) was either due to inability of the caregiver to narrate complete history regarding the nature of impact, or due to initial consultation at a different center prior to the child being brought to our institution. Non-adherence revealed significant pathology in 58 children (21.5% of the study population). Nineteen cases of extradural hemorrhage were detected on brain imaging when guidelines were not followed. Based on our experience, NICE guidelines for brain imaging are not always suitable in the Indian setting due to specific requirements such as fall from a height >3 m or a minimum of three discrete episodes of vomiting or 5 min of loss of consciousness. These guidelines depend on the temporal relationship between various factors in history and examination to determine the need for a CT scan.

Although most children presented with the above symptoms, the exact duration or number of episodes was not clearly narrated by the caregiver. In our study population, most falls occurred when the child slipped while climbing downstairs or fell from a chair/makeshift rooftop less than 3 m in height. The low literacy rate in parents visiting led to inadequate information regarding the nature of the injury or clinical symptoms such as duration of loss of consciousness and frequency/interval between episodes of vomiting. Some incidents were unwitnessed and hence the exact mechanism of injury or the height of fall could not be discerned. NICE guidelines were formulated with a sensitivity ranging from 82% to 99% and a specificity ranging from 31% to 70% based on external validation from three studies which evaluated their diagnostic accuracy in adults. In one such study, Smits et al.[19] reported a sensitivity of 82.1% and a specificity of 46.1% in detecting intracranial injury and found NICE guidelines to help minimize unnecessary brain imaging at the cost of missing potential cases of intracranial injury. Another study reported a 100% sensitivity of the NICE guidelines in detecting intracranial injury.[20] Possible explanations for their varying sensitivities are an older age group in the second study, which grouped them into a high-risk category for intracranial injury and thus CT scans were performed. The lower sensitivity in the former was perhaps due to discrepancies regarding the definition of “high energy impact.” To our knowledge, there are no studies that have validated the diagnostic accuracy of NICE guidelines in the pediatric population. This suggests the need for a revised set of guidelines on brain imaging for use in the Indian population where the nature of injury is often uncertain.

In our study population, children with a GCS of 15 were found to have positive findings on a plain CT scan in 57.65% of the cases, similar to findings reported by Wang et al.[21] This could be explained by the fact that the pediatric brain is fragile and hence head injuries manifest with significant damage as detected on a CT scan. A low threshold for performing CT scan following head injury in children may be necessary due to underlying brain injury that can only be detected radiologically, despite normal clinical examination. In our study, 2.25 CT scans had to be performed for every positive radiological finding in whom CT scan was performed without adhering to NICE guidelines. Of 269 children, only 10 required surgical management, indicating that most pediatric head injuries could be managed conservatively with promising recovery, despite significant radiological findings. Long-term studies will help clarify guidelines regarding brain imaging, following head injury in children in the Indian subcontinent.

Literatures regarding guidelines for seizure prophylaxis are scarce. A set of risk factors for seizures following head injury were identified by the Brain Trauma Foundation.[22] These include a GCS <10, seizures within 24 h following head injury, extra-axial bleed, depressed skull fracture, and cerebral contusions. In our cohort, all 39.4% of children who were discharged on anticonvulsants were retrospectively identified as being positive for the above-mentioned risk factors. Among children with a normal CT scan, 13.2% (n = 14) received anticonvulsants due to seizures following head injury. Smith et al.[23] described the adverse effects of anticonvulsants on cognitive function after brain injury. Administering prophylactic anticonvulsants after head injury is controversial, and further studies would help clarify this.

   Conclusion Top

In India, falls account for most cases of head injury among the pediatric age group. Mild TBI was the most common type of TBI encountered. Duration of hospital stay was affected by the presence of skull fracture and GCS on arrival. The adherence to NICE CT guidelines was found to be low at our center. However, significant intracranial pathology was detected following non-adherence. A revised set of guidelines for brain imaging following head injury would help detect significant head injuries in the Indian population. The present cohort of 269 pediatric cases is too small to formulate guidelines on radiological imaging in pediatric head injuries. A more extensive multi-center study needs to be performed to establish new protocols specific to Indian scenario.

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Conflicts of interest

There are no conflicts of interest.

   References Top

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Dewan MC, Mummareddy N, Wellons JC III, Bonfield CM Epidemiology of global pediatric traumatic brain injury: Qualitative review. World Neurosurg 2016;91:497-509.e1.  Back to cited text no. 2
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  [Figure 1]

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


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