Patel Smruti K, Gozal Yair M, Krueger Bryan M, Bayley James C, Moody Suzanne, Andaluz Norberto, Falcone Richard A, Bierbrauer Karin S
Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH.
Division of General and Thoracic Surgery, Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Comprehensive Children's Injury Center, Cincinnati, OH.
J Pediatr Surg. 2018 Oct;53(10):2048-2054. doi: 10.1016/j.jpedsurg.2018.04.027. Epub 2018 Apr 27.
Mild traumatic brain injury (mTBI) comprises the majority of pediatric traumatic brain injury. Children with mTBI even with traumatic intracranial hemorrhage (tICH) rarely experience a clinically significant neurologic decline (CSND). The utility of routine surveillance imaging in the pediatric population also remains controversial, especially owing to concerns about the risks of radiation exposure at a young age. This study aims to identify demographic or injury-related characteristics that may facilitate recognition of children at risk of progression with mTBI.
We performed a retrospective review of patients <16 years old with mTBI (GCS 13-15) and tICH admitted to a Level I pediatric trauma center between 2009 and 2014. Management of these patients was directed by the Cincinnati Children's Hospital Medical Center Minor Head Injury Algorithm. We reviewed each chart with emphasis on patient demographics, injury specific data, and radiographic or clinical progression.
154 patients met inclusion criteria with mean age of 4 [0-16]; 116 sustained an tICH and 38 patients had isolated skull fractures. Repeat neuroimaging was obtained in 68 patients (59%). Only 9 patients (13%) with tICH had radiographic progression, none of which resulted in CSND. In addition, 9 patients experienced CSND, leading to neurosurgical intervention in 6 patients. Notably, none of these patients had repeat imaging prior to their neurologic changes. Both CSND and need for intervention were significantly higher in patients with epidural hematomas than other types of tICH (19.2% vs. 1.1%, p = 0.002). Of 154 patients, 19 did not have documented follow-up, 135 were seen as outpatients and 65 (48%) had follow up neuroimaging. All patients who had surveillance imaging in the outpatient setting had stable or resolved tICH.
Few children with mTBI and tICH experience clinical decline. Importantly, all patients that required neurosurgical intervention were identified by clinical changes rather than via repeat imaging. Our study suggests that in the vast majority of cases, clinical monitoring alone is safe and sufficient in patients in order to avoid exposure to repeat radiographic imaging.
Level III, prognostic and epidemiological.
轻度创伤性脑损伤（mTBI）占儿童创伤性脑损伤的大多数。患有mTBI甚至伴有创伤性颅内出血（tICH）的儿童很少经历具有临床意义的神经功能衰退（CSND）。儿科人群中常规监测成像的效用也仍存在争议，尤其是考虑到年幼时辐射暴露的风险。本研究旨在确定可能有助于识别有mTBI病情进展风险儿童的人口统计学或损伤相关特征。
我们对2009年至2014年间入住一级儿科创伤中心的年龄小于16岁的mTBI（格拉斯哥昏迷评分13 - 15分）和tICH患者进行了回顾性研究。这些患者的治疗遵循辛辛那提儿童医院医疗中心轻度头部损伤算法。我们查阅了每份病历，重点关注患者人口统计学、损伤特定数据以及影像学或临床进展情况。
154例患者符合纳入标准，平均年龄为4岁[0 - 16岁]；116例发生tICH，38例有孤立性颅骨骨折。68例患者（59%）进行了重复神经影像学检查。tICH患者中只有9例（13%）有影像学进展，均未导致CSND。此外，9例患者出现CSND，其中6例导致神经外科干预。值得注意的是，这些患者在神经功能改变之前均未进行重复成像检查。硬膜外血肿患者的CSND和干预需求均显著高于其他类型的tICH（19.2%对1.1%，p = 0.002）。154例患者中，19例没有记录的随访情况，135例为门诊患者，65例（48%）进行了随访神经影像学检查。所有在门诊进行监测成像的患者tICH均稳定或已消退。
很少有mTBI和tICH儿童出现临床衰退。重要的是，所有需要神经外科干预的患者都是通过临床变化而非重复成像检查识别出来的。我们的研究表明，在绝大多数情况下，仅进行临床监测对患者来说是安全且足够的，可避免接受重复影像学检查。
三级，预后和流行病学研究。
