The King's Outcome Scale for Childhood Head Injury and injury severity and outcome measures in children with traumatic brain injury

Psychometric evaluation and reference values for the German Postconcussion Symptom Inventory (PCSI-SR8) in children aged 8-12 years

Background

Post-concussion symptoms (PCS) are a common consequence of pediatric traumatic brain injury (pTBI). They include cognitive, emotional, and physical disturbances. To address the lack of age-adapted instruments assessing PCS after pTBI, this study examines the psychometric properties of the German 17-item post-TBI version of the Postconcussion Symptom Inventory (PCSI-SR8) in children aged 8-12 years. The study also aims to establish reference values based on data from a pediatric general population sample to better estimate the prevalence and clinical relevance of PCS after pTBI in clinical and research settings.

Methods

A total of 132 children aged 8-12 years from a post-acute TBI sample and 1,047 from a general population sample were included in the analyses. The questionnaire was translated from English into German and linguistically validated using forward and backward translation and cognitive debriefing to ensure comprehensibility of the developed version. Reliability and validity were examined; descriptive comparisons were made with the results of the English study. Measurement invariance (MI) analyses between TBI and general population samples were conducted prior to establishing reference values. Factors contributing to the total and scale scores of the PCSI-SR8 were identified using regression analyses. Reference values were calculated using percentiles.

Results

Most children (TBI: 83%; general population: 79%) rated at least one symptom as "a little" bothersome. The German PCSI-SR8 met the psychometric assumptions in both samples and was comparable to the English version. The four-factor structure comprising physical, emotional, cognitive, and fatigue symptoms could be replicated. The MI assumption was retained. Therefore, reference values could be provided to determine the symptom burden of patients in relation to a comparable general population. Clinical relevance of reported symptoms is indicated by a score of 8, which is one standard deviation above the mean of the general population sample.

Conclusion

The German version of the PCSI-SR8 is suitable for assessment of PCS after pTBI. The reference values allow for a more comprehensive evaluation of PCS following pTBI. Future research should focus on validation of the PCSI-SR8 in more acute phases of TBI, psychometric examination of the pre-post version, and child-proxy comparisons.

A Multidimensional Approach to Assessing Factors Impacting Health-Related Quality of Life after Pediatric Traumatic Brain Injury

In the field of pediatric traumatic brain injury (TBI), relationships between pre-injury and injury-related characteristics and post-TBI outcomes (functional recovery, post-concussion depression, anxiety) and their impact on disease-specific health-related quality of life (HRQoL) are under-investigated. Here, a multidimensional conceptual model was tested using a structural equation model (SEM). The final SEM evaluates the associations between these four latent variables. We retrospectively investigated 152 children (8-12 years) and 148 adolescents (13-17 years) after TBI at the recruiting clinics or online. The final SEM displayed a fair goodness-of-fit (SRMR = 0.09, RMSEA = 0.08 with 90% CI [0.068, 0.085], GFI = 0.87, CFI = 0.83), explaining 39% of the variance across the four latent variables and 45% of the variance in HRQoL in particular. The relationships between pre-injury and post-injury outcomes and between post-injury outcomes and TBI-specific HRQoL were moderately strong. Especially, pre-injury characteristics (children's age, sensory, cognitive, or physical impairments, neurological and chronic diseases, and parental education) may aggravate post-injury outcomes, which in turn may influence TBI-specific HRQoL negatively. Thus, the SEM comprises potential risk factors for developing negative post-injury outcomes, impacting TBI-specific HRQoL. Our findings may assist healthcare providers and parents in the management, therapy, rehabilitation, and care of pediatric individuals after TBI.

Consensus-Based Evaluation of Outcome Measures in Pediatric Stroke Care: A Toolkit

Following a pediatric stroke, outcome measures selected for monitoring functional recovery and development vary widely. We sought to develop a toolkit of outcome measures that are currently available to clinicians, possess strong psychometric properties, and are feasible for use within clinical settings. A multidisciplinary group of clinicians and scientists from the International Pediatric Stroke Organization comprehensively reviewed the quality of measures in multiple domains described in pediatric stroke populations including global performance, motor and cognitive function, language, quality of life, and behavior and adaptive functioning. The quality of each measure was evaluated using guidelines focused on responsiveness and sensitivity, reliability, validity, feasibility, and predictive utility. A total of 48 outcome measures were included and were rated by experts based on the available evidence within the literature supporting the strengths of their psychometric properties and practical use. Only three measures were found to be validated for use in pediatric stroke: the Pediatric Stroke Outcome Measure, the Pediatric Stroke Recurrence and Recovery Questionnaire, and the Pediatric Stroke Quality of Life Measure. However, multiple additional measures were deemed to have good psychometric properties and acceptable utility for assessing pediatric stroke outcomes. Strengths and weaknesses of commonly used measures including feasibility are highlighted to guide evidence-based and practicable outcome measure selection. Improving the coherence of outcome assessment will facilitate comparison of studies and enhance research and clinical care in children with stroke. Further work is urgently needed to close the gap and validate measures across all clinically significant domains in the pediatric stroke population.

Pediatric Traumatic Brain Injury in a Geographically Dispersed Population: A Relationship Between Distance to Definitive Neurosurgical Treatment and Outcome

BACKGROUND

There are limited data on the association between transport distance and outcomes in pediatric patients with severe traumatic brain injuries (sTBIs), despite children having to travel further to pediatric trauma centers (PTCs).

OBJECTIVE

To assess whether distance from a PTC is associated with outcomes in children who undergo cranial surgery after sTBI.

METHODS

Children with sTBI who underwent craniectomy/craniotomy at our PTC between 2010 and 2019 were identified retrospectively. Of these 92 patients, 83 sustained blunt injury and underwent surgery within 24 hours. The distance from injury location to PTC was based on injury zip code and calculated as Euclidean distance. Variables associated with transport, including distance, time, and rural-urban disparity, were analyzed for correlation with poor outcome.

RESULTS

Of the 83 patients identified, 81 had injury location information. Forty patients were injured within 30 miles and 41 were injured ≥30 miles from the PTC. Injury severity and pediatric trauma scores were not significantly different between groups. Sixty-eight children (82%) had a satisfactory outcome and 10 children (12%) died. There was a nonsignificant association between distance traveled and poor outcome, even when the cohort was stratified into those with subdural hematomas and those with nonabusive injuries.

CONCLUSIONS

Regardless of the distance from the PTC at which their injury occurred, most children in this cohort made a moderate to good recovery. Children injured at greater distances from the PTC did not have worse outcomes; however, studies with larger cohorts are needed to more definitively assess prehospital pediatric transport systems in this population.

Development and internal validation of a nomogram for predicting outcomes in children with traumatic subdural hematoma

Background

A subdural hematoma (SDH) following a traumatic brain injury (TBI) in children can lead to unexpected death or disability. The nomogram is a clinical prediction tool used by physicians to provide prognosis advice to parents for making decisions regarding treatment. In the present study, a nomogram for predicting outcomes was developed and validated. In addition, the predictors associated with outcomes in children with traumatic SDH were determined.

Methods

In this retrospective study, 103 children with SDH after TBI were evaluated. According to the King’s Outcome Scale for Childhood Head Injury classification, the functional outcomes were assessed at hospital discharge and categorized into favorable and unfavorable. The predictors associated with the unfavorable outcomes were analyzed using binary logistic regression. Subsequently, a two-dimensional nomogram was developed for presentation of the predictive model.

Results

The predictive model with the lowest level of Akaike information criterion consisted of hypotension (odds ratio [OR], 9.4; 95% confidence interval [CI], 2.0–42.9), Glasgow coma scale scores of 3–8 (OR, 8.2; 95% CI, 1.7–38.9), fixed pupil in one eye (OR, 4.8; 95% CI, 2.6–8.8), and fixed pupils in both eyes (OR, 3.5; 95% CI, 1.6–7.1). A midline shift ≥5 mm (OR, 1.1; 95% CI, 0.62–10.73) and co-existing intraventricular hemorrhage (OR, 6.5; 95% CI, 0.003–26.1) were also included.

Conclusions

SDH in pediatric TBI can lead to mortality and disability. The predictability level of the nomogram in the present study was excellent, and external validation should be conducted to confirm the performance of the clinical prediction tool.

Postoperative magnetic resonance imaging may predict poor outcome in children with severe traumatic brain injuries who undergo cranial surgery

OBJECTIVE

Multiple studies have evaluated the use of MRI for prognostication in pediatric patients with severe traumatic brain injury (TBI) and have found a correlation between diffuse axonal injury (DAI)-type lesions and outcome. However, there remains a limited understanding about the use of MRI for prognostication after severe TBI in children who have undergone cranial surgery.

METHODS

Children with severe TBI who underwent craniectomy or craniotomy at Primary Children's Hospital in Salt Lake City, Utah, between 2010 and 2019 were identified retrospectively. Of these 92 patients, 43 underwent postoperative brain MRI within 4 months of surgery. Susceptibility-weighted imaging (SWI) and FLAIR sequences were used to designate areas of hemorrhagic and nonhemorrhagic cerebral lesions related to DAI. Patients were then stratified based on the location of the DAI as read by a neuroradiologist as superficial, deep, or brainstem. The location of the DAI and other variables associated with poor outcome, including Glasgow Coma Scale (GCS) score, pediatric trauma score, mechanism of injury, and time to surgery, were analyzed for correlation with poor outcome. Outcomes were reported using the King's Outcome Scale for Childhood Head Injury (KOSCHI).

RESULTS

In the 43 children with severe TBI who underwent postoperative brain MRI, the median GCS score on arrival was 4. The most common cause of injury was falls (14 patients, 33%). The most common primary intracranial pathology was subdural hematoma in 26 patients (60%), followed by epidural hematoma in 9 (21%). Fifteen patients (35%) had cerebral herniation and 31 (72%) had evidence of contusion. Variables associated with poor outcome included cerebral herniation (r = 0.338, p = 0.027) and location of DAI (r = 0.319, p = 0.037). In a separate analysis, brainstem DAI was shown to predict poor outcome, whereas location (no, superficial, or deep DAI) did not. Logistic regression showed that brainstem DAI (OR 22.3, p = 0.020) had a higher odds ratio than cerebral herniation (OR 10.5, p = 0.044) for poor outcome. Thirty-six children (84%) had a satisfactory outcome at last follow-up; 3 (7%) children died.

CONCLUSIONS

The majority of children in this series who presented with a severe TBI and underwent craniectomy or craniotomy made a satisfactory recovery. In patients in whom there is a concern for poor outcome, the location of DAI-type lesions with SWI and FLAIR may assist in prognostication. The authors' results revealed that DAI-type lesions in the brainstem and evidence of cerebral herniation may indicate a poorer prognosis; however, more studies with larger cohorts are needed to make definitive conclusions.

Acute surgical management of children with ruptured brain arteriovenous malformation

OBJECTIVE

Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM.

METHODS

This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury.

RESULTS

A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently.

CONCLUSIONS

HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.

Hemorrhage Expansion After Pediatric Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

Significant hemorrhage expansion (sHE) is a known predictor of poor outcome after an intracerebral hemorrhage (ICH) in adults but remains poorly reported in children. In a large inception cohort, we aimed to explore the prevalence of sHE, its associations with clinical outcomes, and its clinical-imaging predictors in children.

METHODS

Children admitted between January 2000 and March 2020 at a quaternary care pediatric hospital were screened for inclusion. Sample was restricted to children with 2 computed tomography scans within 72 hours of ICH onset, and a minimal clinical follow-up of months. sHE was defined as an increase from baseline ICH volume by 6 cc or 33% on follow-up computed tomography. Clinical outcome was assessed at 12 months with the King's Outcome Scale for Childhood Head Injury score and defined as favorable for scores ≥5.

RESULTS

Fifty-two children met inclusion criteria, among which 8 (15%) demonstrated sHE, and 18 (34.6%) any degree of expansion. Children with sHE had more frequent coagulation disorders (25.0% versus 2.3%; P=0.022). After multivariable adjustment, only the presence of coagulation disorders at baseline remained independently associated with sHE (adjusted odds ratio, 14.4 [95% CI, 1.04-217]; P=0.048). sHE was independently associated with poor outcome (King's Outcome Scale for Childhood Head Injury <5A, odds ratio, 5.77 [95% CI, 1.01-38.95]; P=0.043).

CONCLUSIONS

sHE is a frequent phenomenon after admission for a pediatric ICH and more so in children with coagulation defects. As sHE was strongly associated with poorer clinical outcomes, these data mandate a baseline coagulation work up and questions the need for protocolized repeat head computed tomography in children admitted for pediatric ICH.

Opiate analgesics and testing of post traumatic amnesia in school-aged children

OBJECTIVE

To assess the validity of the Westmead PTA scale in school-aged children treated with opiate analgesics.

METHOD

Twenty-eight hospitalized children without brain injury, aged between 8 and 16 years treated with opiate analgesics for pain relief following surgery were tested on the Westmead PTA scale. Pain and stress levels were also self-reported each day.

RESULTS

Only 29% (n = 7) of children assessed over four days obtained a maximum score of 12/12 on three consecutive days, thus 71% would have been deemed to have been in PTA when they were not. The percentage of children who obtained a maximum score significantly decreased over consecutive days of assessment, due to an increase in error rate on picture memory items. Self-reported pain and stress ratings were not correlated with PTA scores.

CONCLUSIONS

Opiate analgesia can disrupt performance on the Westmead PTA scale in school-aged children resulting in a high false-positive error rate. It is therefore important to record pain medication schedules and interpret results cautiously when opiate analgesia is used following a TBI. Alteration of the method of administration of the memory items should be researched as this may increase the validity of the scale for children with TBI treated with opiate analgesics.

Hydrocephalus in children with ruptured cerebral arteriovenous malformation

OBJECTIVE

Hydrocephalus is a strong determinant of poor neurological outcome after intracerebral hemorrhage (ICH). In children, ruptured brain arteriovenous malformations (bAVMs) are the dominant cause of ICH. In a large prospective cohort of pediatric patients with ruptured bAVMs, the authors analyzed the rates and predictive factors of hydrocephalus requiring acute external ventricular drainage (EVD) or ventriculoperitoneal shunt (VPS).

METHODS

The authors performed a single-center retrospective analysis of the data from a prospectively maintained database of children admitted for a ruptured bAVM since 2002. Admission clinical and imaging predictors of EVD and VPS placement were analyzed using univariate and multivariate statistical models.

RESULTS

Among 114 patients (mean age 9.8 years) with 125 distinct ICHs due to ruptured bAVM, EVD and VPS were placed for 55/125 (44%) hemorrhagic events and 5/114 patients (4.4%), respectively. A multivariate nominal logistic regression model identified low initial Glasgow Coma Scale (iGCS) score, hydrocephalus on initial CT scan, the presence of intraventicular hemorrhage (IVH), and higher modified Graeb Scale (mGS) score as strongly associated with subsequent need for EVD (all p < 0.001). All children who needed a VPS had initial hydrocephalus requiring EVD and tended to have higher mGS scores.

CONCLUSIONS

In a large cohort of pediatric patients with ruptured bAVM, almost half of the patients required EVD and 4.4% required permanent VPS. Use of a low iGCS score and a semiquantitative mGS score as indicators of the IVH burden may be helpful for decision making in the emergency setting and thus improve treatment.

Intracranial pressure-based barbiturate coma treatment in children with refractory intracranial hypertension due to traumatic brain injury

OBJECTIVE

Refractory intracranial pressure (ICP) hypertension following traumatic brain injury (TBI) is a severe condition that requires potentially harmful treatment strategies such as barbiturate coma. However, the use of barbiturates may be restricted due to concerns about inducing multiorgan system complications related to the therapy. The purpose of this study was to evaluate the outcome and occurrence of treatment-related complications to barbiturate coma treatment in children with refractory intracranial hypertension (RICH) due to TBI in a modern multimodality neurointensive care unit (NICU).

METHODS

The authors conducted a retrospective cohort study of 21 children ≤ 16 years old who were treated in their NICU between 2005 and 2015 with barbiturate coma for RICH following TBI. Demographic and clinical data were acquired from patient records and physiological data from digital monitoring system files.

RESULTS

The median age of these 21 children was 14 years (range 2-16 years) and at admission the median Glasgow Coma Scale score was 7 (range 4-8). Barbiturate coma treatment was added due to RICH at a median of 46 hours from trauma and had a median duration of 107 hours. The onset of barbiturate coma resulted in lower ICP values, lower pulse amplitudes on the ICP curve, and decreased amount of A-waves. No major disturbances in blood gases, liver and kidney function, or secondary insults were observed during this period. Outcome 1 year later revealed a median Glasgow Outcome Scale score of 5 (good recovery), however on the King's Outcome Scale for Childhood Head Injury, the median was 4a (moderate disability).

CONCLUSIONS

The results of this study indicate that barbiturate coma, when used in a modern NICU, is an effective means of lowering ICP without causing concomitant severe side effects in children with RICH and was compatible with good long-term outcome.

Standards for Studies of Neurological Prognostication in Comatose Survivors of Cardiac Arrest: A Scientific Statement From the American Heart Association

Significant improvements have been achieved in cardiac arrest resuscitation and postarrest resuscitation care, but mortality remains high. Most of the poor outcomes and deaths of cardiac arrest survivors have been attributed to widespread brain injury. This brain injury, commonly manifested as a comatose state, is a marker of poor outcome and a major basis for unfavorable neurological prognostication. Accurate prognostication is important to avoid pursuing futile treatments when poor outcome is inevitable but also to avoid an inappropriate withdrawal of life-sustaining treatment in patients who may otherwise have a chance of achieving meaningful neurological recovery. Inaccurate neurological prognostication leading to withdrawal of life-sustaining treatment and deaths may significantly bias clinical studies, leading to failure in detecting the true study outcomes. The American Heart Association Emergency Cardiovascular Care Science Subcommittee organized a writing group composed of adult and pediatric experts from neurology, cardiology, emergency medicine, intensive care medicine, and nursing to review existing neurological prognostication studies, the practice of neurological prognostication, and withdrawal of life-sustaining treatment. The writing group determined that the overall quality of existing neurological prognostication studies is low. As a consequence, the degree of confidence in the predictors and the subsequent outcomes is also low. Therefore, the writing group suggests that neurological prognostication parameters need to be approached as index tests based on relevant neurological functions that are directly related to the functional outcome and contribute to the quality of life of cardiac arrest survivors. Suggestions to improve the quality of adult and pediatric neurological prognostication studies are provided.

Depression and Depressive Symptoms in Pediatric Traumatic Brain Injury: A Scoping Review

OBJECTIVE

This scoping review aimed to summarize the existing knowledge base regarding depression and depressive symptoms in pediatric traumatic brain injury (TBI) and to identify gaps in the literature in an effort to guide future research.

METHODS

MEDLINE Ovid and PsycINFO Ovid databases were each searched by the authors using search terms intended to identify any original research study that examined depressive symptoms in children (ie, aged 0-18 years) with TBI.

RESULTS

A total of 14 published studies were included in the review. The studies included examined the prevalence of depression, risk factors associated with depression, and depression as a predictor of other TBI-related outcomes.

CONCLUSION

Existing research suggests that depressive symptoms are more common in a TBI population than in a healthy or orthopedically injured population. Injury-related factors such as lesions in the brain and the presence of pain, as well as noninjury factors such as older age at injury and low socioeconomic status, may be predictive of depressive symptoms. Depression is likely a secondary outcome of pediatric TBI rather than a direct result of the injury itself. Overall, a relative dearth of research exists on this topic; thus, the review concludes by proposing future research directions.

Preliminary validation study of the Sydney Post-Traumatic Amnesia Scale (SYPTAS) in children with traumatic brain injury aged 4 to 7 years

The aim of this study was to assess the validity (developmental, concurrent, and predictive) of the Sydney Post-Traumatic Amnesia Scale (SYPTAS) for assessment of post-traumatic amnesia (PTA) in 4 to 7 year old children with traumatic brain injury (TBI). The design of this study is a retrospective cohort study. The SYPTAS was administered to 35 children (26 boys) aged 4.0 to 7.8 years who were consecutively admitted to a children's hospital with mild (n = 26), moderate (n = 3), or severe (n = 7) TBI. Concurrent validity of the SYPTAS was assessed against the Glasgow Coma Scale Scores (GCS). Predictive validity of the SYPTAS for functional outcomes was evaluated against the King's Outcome Scale for Childhood Head Injury (KOSCHI) at discharge and outpatient follow-ups. The length of PTA, measured by the SYPTAS, was invariant of children's chronological age, confirming the scale's developmental validity. Longer PTA was associated with lower GCS, endorsing concurrent validity of PTA duration measured by the SYPTAS, as a clinical indicator of TBI severity. PTA duration measured by the SYPTAS was a significant predictor of functional outcomes on the KOSCHI at discharge and follow-ups. This study provides evidence that the SYPTAS has good developmental, concurrent and predictive validity for assessment of PTA in children aged 4 to 7 years. PTA duration assessed by the SYPTAS is a clinical indicator of TBI severity and can aid rehabilitation planning post TBI.

The use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in maxillofacial trauma

In recent years, recombinant human bone morphogenetic protein-2 (rhBMP-2) has been introduced as a therapeutic option in the treatment of several congenital and acquired craniofacial defects. Although there have been promising clinical results, the international literature still lacks complete guidelines, including limits and indications for the use of rhBMP-2. The possible indications for rhBMP-2 in patients undergoing facial trauma are discussed in this article.

Hydrocephalus associated with childhood nonaccidental head trauma

OBJECTIVE

The incidence of posttraumatic ventriculomegaly (PTV) and shunt-dependent hydrocephalus after nonaccidental head trauma (NAHT) is unknown. In the present study, the authors assessed the timing of PTV development, the relationship between PTV and decompressive craniectomy (DC), and whether PTV necessitated placement of a permanent shunt. Also, NAHT/PTV cases were categorized into a temporal profile of delay in admission and evaluated for association with outcomes at discharge.

METHODS

The authors retrospectively reviewed the cases of patients diagnosed with NAHT throughout a 10-year period. Cases in which sequential CT scans had been obtained (n = 28) were evaluated for Evans' index to determine the earliest time ventricular dilation was observed. Discharge outcomes were assessed using the King's Outcome Scale for Childhood Head Injury score.

RESULTS

Thirty-nine percent (11 of 28) of the patients developed PTV. A low admission Glasgow Coma Scale (GCS) score predicted early PTV presentation (within < 3 days) versus a high GCS score (> 1 week). A majority of PTV/NAHT patients presented with a subdural hematoma (both convexity and interhemispheric) and ischemic stroke, but subarachnoid hemorrhage was significantly associated with PTV/NAHT (p = 0.011). Of 6 patients undergoing a DC for intractable intracranial pressure, 4 (67%) developed PTV (p = 0.0366). These patients tended to present with lower GCS scores and develop ventriculomegaly early. Only 2 patients developed hydrocephalus requiring shunt placement.

CONCLUSIONS

PTV presents early after NAHT, particularly after a DC has been performed. However, the authors found that only a few PTV/NAHT patients developed shunt-dependent hydrocephalus.

A Review of the Development and Application of Generic Multi-Attribute Utility Instruments for Paediatric Populations

Multi-attribute utility instruments (MAUIs) are increasingly being used as a means of quantifying utility for the calculation of quality-adjusted life-years within the context of cost utility analysis. Traditionally, MAUIs have been developed and applied in adult populations. However, increasingly, researchers in health economics and other disciplines are recognising the importance of the measurement and valuation of health in both children and adolescents. Presently, there are nine generic MAUIs available internationally that have been used in paediatric populations: the Quality of Well-Being Scale (QWB), the Health Utility Index Mark 2 (HUI2), the HUI3, the Sixteen-dimensional measure of health-related quality of life (HRQoL) (16D), the Seventeen-dimensional measure of HRQoL (17D), the Assessment of Quality of Life 6-Dimension (AQoL-6D) Adolescent, the Child Health Utility 9D (CHU9D), the EQ-5D Youth version (EQ-5D-Y) and the Adolescent Health Utility Measure (AHUM). This paper critically reviews the development and application of the above nine MAUIs and discusses the specific challenges of health utility measurement in children and adolescents. Areas for further research relating to the development and application of generic MAUIs in paediatric populations are highlighted.

Duration of post-traumatic amnesia as a predictor of functional outcome in school-age children: a systematic review

AIM

In adults, duration of post-traumatic amnesia (PTA) is a powerful early predictor of functional outcomes in traumatic brain injury. The aim of this work was to assess the predictive validity of PTA duration for outcomes in children (6-18y).

METHOD

PsycINFO, MEDLINE, Web of Science, and Embase were searched for papers published to January 2014. Ten studies met inclusion criteria: they used standardized instruments to assess PTA and functional outcomes, and examined relationships between the two. Outcomes were classified according to (1) the International Classification of Functioning, Disability and Health (ICF) core sets for neurological conditions for post-acute care and (2) global functioning and quality of life. Methodological quality was rated for each study.

RESULTS

The search identified 10 studies of moderate mean quality (M=11.8 out of 18). Longer PTA duration related to worse functional outcomes: global functioning and in the two ICF categories ('body function', 'activities and participation'). Relationships between PTA duration and quality of life and the ICF category of 'body structure' were not examined. PTA duration was, in 46 out of 60 (76.67%) instances, a stronger predictor of outcomes than other indices of injury severity.

CONCLUSION

Longer PTA duration is a valid predictor of worse outcomes in school-age children. Thus, PTA should be routinely assessed in children after traumatic brain injury.

Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes

BACKGROUND

Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation.

OBJECTIVE

Extent of delay in seeking medical attention may be related to patient outcome.

METHODS

A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6-12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case.

RESULTS

All children were 3 years of age or younger (2.1-34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay.

CONCLUSION

Patients presenting to medical care 6-12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.

Natural sequence of recovery from child post-traumatic amnesia: A retrospective cohort study

The aim of this study was to determine the sequence of skills recovery during post-traumatic amnesia (PTA) in children with moderate to severe traumatic brain injuries (TBIs).

SETTING

Fifty children aged 8 to 15 years consecutively admitted to a children's hospital with TBI and PTA>24 were tested in a retrospective cohort study where the main measure was the Westmead PTA Scale (WPTAS). The group analyses show that orientation to time took longer to recover than orientation to person and place, but not memory, while the individual analyses revealed that when orientation to time was grouped with memory, 94% of children recovered orientation to person and place before orientation to time and memory (examiner and pictures). Correlation coefficients between age and the number of days taken to recover skills were not found to be significant. It was established that, in terms of the natural sequence of skills recovery in children aged 8 to 15 years following moderate to severe TBI, recovery of orientation to time is more closely aligned to memory than to orientation to person and place. It was also established that WPTAS items are developmentally appropriate for children aged 8 to 15 years who have sustained TBI. These findings are clinically important because monitoring recovery from PTA both impacts the rehabilitation offered to individuals during acute care and aids discharge planning.

Head and maxillofacial injuries in child and adolescent victims of automotive accidents

Background. Victims of motor vehicle accidents may suffer multiple lesions, including maxillofacial injuries. The aim of this study was to evaluate the prevalence and factors associated with head, facial, and maxillofacial injuries in child and adolescent victims of automobile accidents. A cross-sectional study was carried out with analysis of forensic medical reports from the Legal Medical Institute of Campina Grande, Brazil, between January 2008 and December 2011. Descriptive and inferential statistical analysis was conducted using the chi-square test (α = 0.05). From 1613 medical reports analyzed, the sample is composed 232 (14.4%) reports referring to child and adolescent victims of automobile accidents aged 0–19 years of both sexes. Victims were mostly adolescents aged from 15 to 19 years (64.2%), males (73.7%), and motorcyclists (51.3%). More than half of the victims had single lesions (54.3%) located in the head (20.7%) and face (21.6%). Head injuries occurred more frequently in children aged 0–4 years (53.8%, PR = 5.065, 95% CI = 1.617–5.870) and pedestrians (30.4%, PR = 2.039, 95% CI = 1.024–4.061), while facial and maxillofacial injuries occurred in higher proportion among females (31.1%, PR = 0.489, 95% CI = 0.251–0.954). Our findings suggest that accidents involving motorcyclists are the most prevalent, affecting male adolescents aged from 15 to 19 years, resulting in a high frequency of injuries in the head and face regions.

Children's self-reported quality of life after intensive care treatment

OBJECTIVES

A number of studies have reported on parental/clinician reports of children's quality of life after intensive care treatment. The aim of this study was to establish children's own views of their outcome. [corrected].

DESIGN

Prospective cohort study. [corrected].

SETTING

Twenty-one bed PICU in a tertiary Children's Hospital.

PATIENTS

Ninety-seven children aged over 7 yr, with no preexisting learning difficulties, consecutively admitted to PICU over an 18 month period

INTERVENTIONS

Patients completed the Pediatric Quality of Life Inventory and a post-traumatic stress screener, at 3 months and again at 1 year (n = 72) after discharge from PICU.

MEASUREMENTS AND MAIN RESULTS

At 3 months post-discharge, the mean total Pediatric Quality of Life Inventory score reported by the PICU group was lower than that reported in the literature for a non-clinical community sample (PICU mean = 79.1 vs community mean = 83.9, p = 0.003), but by 1 year, they were comparable (82.2, p = 0.388). The mean physical functioning subscale score remained lower (PICU mean=81.6 vs. community mean=88.5, p = 0.01), but improved significantly from 73.4 at 3 months (p = 0.001).Sub-group analyses revealed that the elective group reported higher emotional functioning than the community sample (91.0, p=0.005 at 3 months and 88.2, p = 0.038 at 1 year vs community mean=78.5), and made significant gains in social functioning between timepoints (79.1 to 91.4, p = 0.015).Finally, although total PedsQL scores at 1 year were not associated with measures of severity of illness during admission, they were significantly negatively associated with concurrent post-traumatic stress symptom scores (r = -0.40, p = 0.001).

CONCLUSIONS

The self-report version of the Pediatric Quality of Life Inventory proved to be a feasible and sensitive tool for assessing health related quality of life in this group of PICU survivors.

Use of the King's Outcome Scale for Childhood Head Injury in the evaluation of outcome in childhood traumatic brain injury

OBJECTIVE

To examine the inter-rater reliability of The King's Outcome Scale for Childhood Head Injury (KOSCHI) with clinicians of varying experience in paediatric traumatic brain injury (TBI); and to examine change in outcome during long-term follow-up of children following traumatic brain injury (TBI) using KOSCHI.

METHOD

Retrospective assessment of detailed clinic reports of 97 children followed-up by a tertiary specialist paediatric brain injury service. Investigators were blinded to each other's scores.

RESULTS

Inter-rater reliability was substantial (weighted kappa 0.71) and similar for investigators of varying experience. KOSCHI outcome was strongly associated with markers of injury severity (p = 0.028). In longitudinal follow-up, KOSCHI score worsened in 7 (23%) children who were injured under 8 years but in no older children (p = 0.02).

CONCLUSION

KOSCHI has high inter-rater reliability for investigators of different experience. Long-term KOSCHI outcome is associated with injury severity. Some young children may develop worse disability over time.

Paediatric head injury admissions over a 10-year period in a regional neurosurgical unit

Traumatic brain injury is a leading cause of death and disability in childhood. A retrospective study of all paediatric head injuries admitted to the neurosurgical unit for the West of Scotland over a 10-year period was performed to assess the impact of the National Institute for Health and Clinical Excellence head injury guidelines on the admission rate and to determine the associated risk factors, causes, severity and outcomes of these injuries. There were 564 admissions between 1998 and 2007. The median age at presentation was nine years and two months. There was no change in the admission rate, injury mechanism or severity of head injury admitted over the period studied. A relationship was observed between the Scottish Index of Multiple Deprivation Score and the incidence of head injury ( P = 0.05). Alcohol was reported as a causative factor in only a small number of cases, and moderate to severe head injuries were more commonly identified as a result of road traffic accidents.

Charges associated with pediatric head injuries: a five year retrospective review of 41 pediatric hospitals in the US

Background:

Brain injuries are a significant public health problem, particularly among the pediatric population. Brain injuries account for a significant portion of pediatric injury deaths, and are the highest contributor to morbidity and mortality in the pediatric and young adult populations. Several studies focus on particular mechanisms of brain injury and the cost of treating brain injuries, but few studies exist in the literature examining the highest contributing mechanisms to pediatric brain injury and the billed charges associated with them.

Methods:

Data were extracted from the Pediatric Health Information System (PHIS) from member hospitals on all patients admitted with diagnosed head injuries and comparisons were made between ICU and non-ICU admissions. Collected data included demographic information, injury information, total billed charges, and patient outcome.

Results:

Motor vehicle collisions, falls, and assaults/abuse are the three highest contributors to brain injury in terms of total numbers and total billed charges. These three mechanisms of injury account for almost $1 billion in total charges across the five-year period, and account for almost half of the total charges in this dataset over that time period.

Conclusions:

Research focusing on brain injury should be tailored to the areas of the most pressing need and the highest contributing factors. While this study is focused on a select number of pediatric hospitals located throughout the country, it identifies significant contributors to head injuries, and the costs associated with treating them.

Early clinical indicators of developmental outcome in abusive head trauma

PURPOSE

The purpose of the study was to determine the developmental prognostic significance of early clinical indicators in abusive head trauma.

METHODS

Seventy-one children were diagnosed with abusive head trauma and followed in a post-injury growth and development clinic. A retrospective chart review was completed to gather clinical features at the time of injury, including presence or absence of early post-traumatic seizures, presence or absence of intubation, and presence or absence of pediatric intensive care unit admission. Children then underwent developmental testing with use of the Capute Scales of the Cognitive Adaptive Test (CAT) and the Clinical Linguistic and Auditory Milestone Scale (CLAMS) during follow-up clinic visits. Clinical features at initial injury were compared to developmental outcome.

RESULTS

Thirty-four of 71 patients with seizures during their admission hospitalization scored significantly lower on follow-up developmental testing than patients who did not have seizures. Twenty-one of 71 patients who required intubation scored lower on developmental testing than patients who did not require intubation. Thirty-five of 71 patients who required pediatric intensive care unit admission scored lower on developmental testing than patients who did not require pediatric intensive care unit admission.

CONCLUSIONS

This study demonstrates that clinical factors at the time of injury, such as early post-traumatic seizures and intubation requirement, are associated with poorer developmental outcome. This study also suggests that close developmental follow-up should be obtained for all children with abusive head trauma, regardless of whether or not the child was admitted to the PICU.

A comparison of doctors', parents' and children's reports of health states and health-related quality of life in children with chronic conditions

BACKGROUND

Health-related quality of life is an important outcome. Self-report is the gold standard, but in the paediatric setting we often rely on proxy reporting. Our understanding of the differences between self- and proxy reports and the factors that influence them is limited. These differences can impact on treatment choices and the patient-doctor relationship.

OBJECTIVE

To evaluate differences between children's, parents' and doctors' perceptions of health states and health-related quality of life in children with chronic illness and explore factors which explain these differences.

METHODS

Consecutive families attending eligible clinics at a tertiary paediatric centre were invited to complete the Health Utilities Index (HUI) 23 questionnaire. Percentage agreement and kappas were calculated as a measure of the agreement between pairs. Chi-squared tests or Fisher's exact test, if appropriate, were performed to determine if there was an association between level of agreement and participant variables.

RESULTS

Data were collected for 130 parent-doctor pairs, 59 child-parent pairs and 59 child-doctor pairs. Overall health-related quality of life scores did not differ between responders, but there was poorer agreement for subjective domains. Doctor-child agreement was lower than parent-child agreement. Children with a diagnosis of cerebral palsy or chronic neurological condition were more likely to have lower inter-rater agreement for both subjective and objective domains. On the HUI2, agreement was lower for parent-child pairs when the father was the respondent. For child-doctor pairs, an increased frequency of patient-doctor visits and doctors' seniority were predictors of poorer agreement on the HUI3 and HUI2 respectively.

CONCLUSIONS

We identified factors associated with level of agreement for self- and proxy reporting on the HUI23. Parent-child agreement was higher than doctor-child agreement. Patients with significant pain or emotional distress and patients with a diagnosis of severe cerebral palsy or chronic neurological conditions were more susceptible to under-reporting of subjective aspects of well-being by doctors and parents and may benefit from formal assessment of health-related quality of life in the clinical setting.

Recommendations for the use of common outcome measures in pediatric traumatic brain injury research

This article addresses the need for age-relevant outcome measures for traumatic brain injury (TBI) research and summarizes the recommendations by the inter-agency Pediatric TBI Outcomes Workgroup. The Pediatric Workgroup's recommendations address primary clinical research objectives including characterizing course of recovery from TBI, prediction of later outcome, measurement of treatment effects, and comparison of outcomes across studies. Consistent with other Common Data Elements (CDE) Workgroups, the Pediatric TBI Outcomes Workgroup adopted the standard three-tier system in its selection of measures. In the first tier, core measures included valid, robust, and widely applicable outcome measures with proven utility in pediatric TBI from each identified domain including academics, adaptive and daily living skills, family and environment, global outcome, health-related quality of life, infant and toddler measures, language and communication, neuropsychological impairment, physical functioning, psychiatric and psychological functioning, recovery of consciousness, social role participation and social competence, social cognition, and TBI-related symptoms. In the second tier, supplemental measures were recommended for consideration in TBI research focusing on specific topics or populations. In the third tier, emerging measures included important instruments currently under development, in the process of validation, or nearing the point of published findings that have significant potential to be superior to measures in the core and supplemental lists and may eventually replace them as evidence for their utility emerges.

Caring for traumatic brain injury in children can be a challenge!

Traumatic brain injury is the most common cause of morbidity and mortality in children. However, it is still challengeable to early predict the outcome of individual patients with severe head injuries. Glasgow outcome scale is the most widely used scoring system in evaluating neurological outcome for head injury patients. Moreover, it is likely to underestimate morbidity and is not always readily applicable in children. It is an important issue to develop a practical, reliable and valid neurological outcome instrument in children in forwarding research.

Predictors of outcome in childhood intracerebral hemorrhage: a prospective consecutive cohort study

BACKGROUND AND PURPOSE

The purposes of this study were to describe features of children with intracerebral hemorrhage (ICH) and to determine predictors of short-term outcome in a single-center prospective cohort study.

METHODS

A single-center prospective consecutive cohort study was conducted of spontaneous ICH in children aged 1 to 18 years from January 2006 to June 2008. Exclusion criteria were inciting trauma; intracranial tumor; isolated epidural, subdural, intraventricular, or subarachnoid hemorrhage; hemorrhagic transformation of ischemic stroke; and cerebral sinovenous thrombosis. Hospitalization records were abstracted. Follow-up assessments included outcome scores using the Pediatric Stroke Outcome Measure and King's Outcome Scale for Childhood Head Injury. ICH volumes and total brain volumes were measured by manual tracing.

RESULTS

Twenty-two patients, median age 10.3 years (range, 4.2 to 16.6 years), had presenting symptoms of headache in 77%, focal deficits 50%, altered mental status 50%, and seizures 41%. Vascular malformations caused hemorrhage in 91%. Surgical treatment (hematoma evacuation, lesion embolization or excision) was performed during acute hospitalization in 50%. One patient died acutely. At a median follow-up of 3.5 months (range, 0.3 to 7.5 months), 71% of survivors had neurological deficits; 55% had clinically significant disability. Outcome based on Pediatric Stroke Outcome Measure and King's Outcome Scale for Childhood Head Injury scores was worse in patients with ICH volume >2% of total brain volume (P=0.023) and altered mental status at presentation (P=0.005).

CONCLUSIONS

Spontaneous childhood ICH was due mostly to vascular malformations. Acute surgical intervention was commonly performed. Although death was rare, 71% of survivors had persisting neurological deficits. Larger ICH volume and altered mental status predicted clinically significant disability.

Decompressive craniectomy and postoperative complication management in infants and toddlers with severe traumatic brain injuries

OBJECT

Infants with severe traumatic brain injury represent a therapeutic challenge. The internal absence of open space within the infant cranial vault makes volume increases poorly tolerated. This report presents 7 cases of decompressive craniectomy in infants with cerebral edema.

METHODS

The authors reviewed the medical charts of infants with brain injuries who presented to Albany Medical Center Hospital between January 2004 and July 2007. Variables that were examined included patient age, physical examination results at admission, positive imaging findings, surgery performed, complications, requirement of permanent CSF diversion, and physical examination results at discharge and outpatient follow-up using the King's Outcome Scale for Childhood Head Injury. Seven infants met the inclusion criteria for the study. Six infants experienced nonaccidental trauma, and 1 had a large infarction of the middle cerebral artery territory secondary to a carotid dissection. At admission, all patients were minimally responsive, 4 had equal and minimally reactive pupils, 3 had anisocoria with the enlarged pupil on the same side as the brain lesion, and all had right-sided hemiparesis. Six patients received a left hemicraniectomy, whereas 1 received a left frontal craniectomy. In all cases, bone was cultured and stored at the bone bank.

RESULTS

Postoperatively, 3 patients who developed draining CSF fistulas needed insertions of external ventricular drains, with incisions oversewn using nylon sutures and a liquid bonding agent. After prolonged CSF drainage and wound care, these patients all developed epidural and subdural empyemas necessitating surgical drainage and debridement. Methicillin-resistant Staphylococcus aureus was found in 2 patients and Enterococcus in the third. All patients developed hydrocephalus necessitating the insertion of a ventriculoperitoneal shunt, and all had bone replaced within 1-6 months from the time of the original operation. Two patients required reoperation due to bone resorption. At outpatient follow-up visits, all had scores of 3 or 4 on the King's Outcome Scale for Childhood Head Injury. Each patient was awake, interactive, and could sit, as well as either crawl or walk with assistance. All had persistent, improving right-sided hemiparesis and spasticity.

CONCLUSIONS

Despite poor initial examination results, infants with severe traumatic brain injury can safely undergo decompressive craniectomy with reasonable neurological recovery. Postoperative complications must be anticipated and treated appropriately. Due to the high rate of CSF fistulas encountered in this study, it appears reasonable to recommend both the suturing in of a dural augmentation graft and the placement of either a subdural drain or a ventriculostomy catheter to relieve pressure on the healing surgical incision. Also, one might want to consider using a T-shaped incision as opposed to the traditional reverse question mark-shaped incision because wound healing may be compromised due to the potential interruption of the circulation to the posterior and inferior limb with this latter incision.