Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA, USA.
Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Neurocrit Care. 2022 Apr;36(2):492-503. doi: 10.1007/s12028-021-01336-8. Epub 2021 Aug 30.
Traumatic brain injury (TBI) is the leading cause of death and disability in children, but effective tools for predicting outcome remain elusive. Although many pediatric patients receive early magnetic resonance imaging (MRI), data on its utility in prognostication are lacking. Diffuse axonal injury (DAI) is a hallmark of TBI detected on early MRI and was shown previously to improve prognostication in adult patients with TBI. In this exploratory study, we investigated whether DAI grade correlates with functional outcome and improves prognostic accuracy when combined with core clinical variables and computed tomography (CT) biomarkers in pediatric patients with moderate-severe TBI (msTBI).
Pediatric patients (≤ 19 years) who were admitted to two regional level one trauma centers with a diagnosis of msTBI (Glasgow Coma Scale [GCS] score < 13) between 2011 and 2019 were identified through retrospective chart review. Patients who underwent brain MRI within 30 days of injury and had documented clinical follow-up after discharge were included. Age, pupil reactivity, and initial motor GCS score were collected as part of the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. Imaging was reviewed to calculate the Rotterdam score (CT) and DAI grade (MRI) and to evaluate for presence of hypoxic-ischemic injury (MRI). The primary outcome measure was the Pediatric Cerebral Performance Category Scale (PCPCS) score at 6 months after TBI, with favorable outcome defined as PCPCS scores 1-3 and unfavorable outcome defined as PCPCS scores 4-6. The secondary outcome measure was discharge disposition to home versus to an inpatient rehabilitation facility.
Of 55 patients included in the study, 45 (82%) had severe TBI. The most common mechanism of injury was motor vehicle collision (71%). Initial head CT scans showed acute hemorrhage in 84% of patients. MRI was acquired a median of 5 days after injury, and hemorrhagic DAI lesions were detected in 87% of patients. Each 1-point increase in DAI grade increased the odds of unfavorable functional outcome by 2.4-fold. When controlling for core IMPACT clinical variables, neither the DAI grade nor the Rotterdam score was independently correlated with outcome and neither significantly improved outcome prediction over the IMPACT model alone.
A higher DAI grade on early MRI is associated with worse 6-month functional outcome and with discharge to inpatient rehabilitation in children with acute msTBI in a univariate analysis but does not independently correlate with outcome when controlling for the GCS score. Addition of the DAI grade to the core IMPACT model does not significantly improve prediction of poor neurological outcome. Further study is needed to elucidate the utility of early MRI in children with msTBI.
颅脑创伤（TBI）是儿童死亡和残疾的主要原因，但仍缺乏有效的预测结果的工具。尽管许多儿科患者接受了早期磁共振成像（MRI）检查，但缺乏关于其在预测中的效用的数据。弥散性轴索损伤（DAI）是 TBI 的早期 MRI 检测的特征，先前的研究表明，它可以改善成人 TBI 患者的预后。在这项探索性研究中，我们研究了 DAI 分级是否与功能结局相关，并在结合核心临床变量和 CT 生物标志物后，是否能提高儿科中度至重度 TBI（msTBI）患者的预后准确性。
通过回顾性病历审查，确定了 2011 年至 2019 年期间在两家地区一级创伤中心因 msTBI（格拉斯哥昏迷量表[GCS]评分<13）就诊的≤19 岁儿科患者。纳入了在损伤后 30 天内接受脑 MRI 检查且出院后有记录的临床随访的患者。年龄、瞳孔反应和初始运动 GCS 评分作为国际 TBI 预后和分析临床试验（IMPACT）模型的一部分进行采集。影像学检查用于计算 Rotterdam 评分（CT）和 DAI 分级（MRI），并评估是否存在缺氧缺血性损伤（MRI）。主要结局测量是 TBI 后 6 个月的小儿脑功能表现量表（PCPCS）评分，良好结局定义为 PCPCS 评分 1-3，不良结局定义为 PCPCS 评分 4-6。次要结局测量是出院时是否在家或住院康复设施。
在纳入的 55 例患者中，45 例（82%）为重度 TBI。最常见的损伤机制是机动车碰撞（71%）。初始头部 CT 扫描显示 84%的患者有急性出血。MRI 在损伤后中位数 5 天进行，87%的患者发现出血性 DAI 病变。DAI 分级每增加 1 分，不良功能结局的可能性增加 2.4 倍。在控制核心 IMPACT 临床变量后，DAI 分级和 Rotterdam 评分均与结局无独立相关性，且均不能单独改善 IMPACT 模型的预后预测。
在单变量分析中，急性 msTBI 患儿早期 MRI 上的 DAI 分级较高与 6 个月时的功能结局较差和住院康复有关，但在控制 GCS 评分后，与结局无独立相关性。将 DAI 分级添加到核心 IMPACT 模型中，并不会显著提高不良神经结局的预测能力。需要进一步研究来阐明早期 MRI 在 msTBI 患儿中的应用价值。
