Selection of children with ultra-severe traumatic brain injury for neurosurgical intervention

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OBJECTIVE

A recent retrospective study of severe traumatic brain injury (TBI) in pediatric patients showed similar outcomes in those with a Glasgow Coma Scale (GCS) score of 3 and those with a score of 4 and reported a favorable long-term outcome in 11.9% of patients. Using decision tree analysis, authors of that study provided criteria to identify patients with a potentially favorable outcome. The authors of the present study sought to validate the previously described decision tree and further inform understanding of the outcomes of children with a GCS score 3 or 4 by using data from multiple institutions and machine learning methods to identify important predictors of outcome.

METHODS

Clinical, radiographic, and outcome data on pediatric TBI patients (age < 18 years) were prospectively collected as part of an institutional TBI registry. Patients with a GCS score of 3 or 4 were selected, and the previously published prediction model was evaluated using this data set. Next, a combined data set that included data from two institutions was used to create a new, more statistically robust model using binomial recursive partitioning to create a decision tree.

RESULTS

Forty-five patients from the institutional TBI registry were included in the present study, as were 67 patients from the previously published data set, for a total of 112 patients in the combined analysis. The previously published prediction model for survival was externally validated and performed only modestly (AUC 0.68, 95% CI 0.47, 0.89). In the combined data set, pupillary response and age were the only predictors retained in the decision tree. Ninety-six percent of patients with bilaterally nonreactive pupils had a poor outcome. If the pupillary response was normal in at least one eye, the outcome subsequently depended on age: 72% of children between 5 months and 6 years old had a favorable outcome, whereas 100% of children younger than 5 months old and 77% of those older than 6 years had poor outcomes. The overall accuracy of the combined prediction model was 90.2% with a sensitivity of 68.4% and specificity of 93.6%.

CONCLUSIONS

A previously published survival model for severe TBI in children with a low GCS score was externally validated. With a larger data set, however, a simplified and more robust model was developed, and the variables most predictive of outcome were age and pupillary response.

ABBREVIATIONS AUC = area under the curve; ER = Emergency Room; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; GOS-E = Extended GOS; ICP = intracranial pressure; MVA = motor vehicle accident; NAT = nonaccidental trauma; RH = Riley Hospital; TBI = traumatic brain injury; tSAH = traumatic subarachnoid hemorrhage; UCD = UC Davis.

Article Information

Correspondence Marike Zwienenberg: University of California, Davis, Sacramento, CA. mzwien@ucdavis.edu.

INCLUDE WHEN CITING Published online April 5, 2019; DOI: 10.3171/2019.1.PEDS18293.

Disclosures This work was supported by a financial grant from the UC Davis Department of Neurological Surgery and the UC Davis Clinical and Translational Science Center supported by the National Institutes of Health through grant no. UL1 TR001860.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Comparison of mechanisms of injury between UCD cohort and Fulkerson et al. study. Asterisks indicate statistical significance at p < 0.008. Peds = pedestrian.

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    Decision tree for favorable outcomes in the combined data set. BR = bilateral reactive; n = number of patients; UNR = unilateral nonreactive.

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    Decision tree for survival in the combined data set. BNR = bilateral nonreactive.

References

  • 1

    Anderson VGodfrey CRosenfeld JVCatroppa C: Predictors of cognitive function and recovery 10 years after traumatic brain injury in young children. Pediatrics 129:e254e2612012

    • Search Google Scholar
    • Export Citation
  • 2

    Arnett ABPeterson RLKirkwood MWTaylor HGStancin TBrown TM: Behavioral and cognitive predictors of educational outcomes in pediatric traumatic brain injury. J Int Neuropsychol Soc 19:8818892013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Beers SRWisniewski SRGarcia-Filion PTian YHahner TBerger RP: Validity of a pediatric version of the Glasgow Outcome Scale–Extended. J Neurotrauma 29:112611392012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Brennan PMMurray GDTeasdale GM: Simplifying the use of prognostic information in traumatic brain injury. Part 1: The GCS-Pupils score: an extended index of clinical severity. J Neurosurg 128:161216202018

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Centers for Disease Control and Prevention: Ten leading causes of death by age group, United States, 2016. CDC.gov (https://www.cdc.gov/injury/wisqars/LeadingCauses.html) [Accessed February 15 2019]

    • Export Citation
  • 6

    Chiaretti APiastra MPulitanò SPietrini DDe Rosa GBarbaro R: Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst 18:1291362002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Crowe LMCatroppa CBabl FERosenfeld JVAnderson V: Timing of traumatic brain injury in childhood and intellectual outcome. J Pediatr Psychol 37:7457542012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Di Battista ASoo CCatroppa CAnderson V: Quality of life in children and adolescents post-TBI: a systematic review and meta-analysis. J Neurotrauma 29:171717272012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Ducrocq SCMeyer PGOrliaguet GABlanot SLaurent-Vannier ARenier D: Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med 7:4614672006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Emami PCzorlich PFritzsche FSWestphal MRueger JMLefering R: Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study. J Neurosurg 126:7607672017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Fulkerson DHWhite IKRees JMBaumanis MMSmith JLAckerman LL: Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr 16:4104192015

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Gómez PAde-la-Cruz JLora DJiménez-Roldán LRodríguez-Boto GSarabia R: Validation of a prognostic score for early mortality in severe head injury cases. J Neurosurg 121:131413222014

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Haider AHCrompton JGOyetunji TRisucci DDiRusso SBasdag H: Mechanism of injury predicts case fatality and functional outcomes in pediatric trauma patients: the case for its use in trauma outcomes studies. J Pediatr Surg 46:155715632011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Han JXSee AAQGandhi MKing NKK: Models of mortality and morbidity in severe traumatic brain injury: an analysis of a Singapore neurotrauma database. World Neurosurg 108:885893893.e1 2017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Hoffmann MLefering RRueger JMKolb JPIzbicki JRRuecker AH: Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg 99 (Suppl 1):1221302012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Hukkelhoven CWSteyerberg EWRampen AJFarace EHabbema JDMarshall LF: Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients. J Neurosurg 99:6666732003

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Jagannathan JOkonkwo DOYeoh HKDumont ASSaulle DHaizlip J: Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure. J Neurosurg Pediatr 2:2402492008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Kesmarky KDelhumeau CZenobi MWalder B: Comparison of two predictive models for short-term mortality in patients after severe traumatic brain injury. J Neurotrauma 34:223522422017

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kirkham FJNewton CRWhitehouse W: Paediatric coma scales. Dev Med Child Neurol 50:2672742008

  • 20

    Michaud LJRivara FPGrady MSReay DT: Predictors of survival and severity of disability after severe brain injury in children. Neurosurgery 31:2542641992

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Perel PArango MClayton TEdwards PKomolafe EPoccock S: Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336:4254292008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Pillai SPraharaj SSMohanty AKolluri VR: Prognostic factors in children with severe diffuse brain injuries: a study of 74 patients. Pediatr Neurosurg 34:981032001

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Rizoli SPetersen ABulger ECoimbra RKerby JDMinei J: Early prediction of outcome after severe traumatic brain injury: a simple and practical model. BMC Emerg Med 16:322016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Simpson DReilly P: Pediatric coma scale. Lancet 2:4501982

  • 25

    Steyerberg EWMushkudiani NPerel PButcher ILu JMcHugh GS: Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5:e1652008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Tatman AWarren AWilliams APowell JEWhitehouse W: Development of a modified paediatric coma scale in intensive care clinical practice. Arch Dis Child 77:5195211997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Thurman DJAlverson CDunn KAGuerrero JSniezek JE: Traumatic brain injury in the United States: a public health perspective. J Head Trauma Rehabil 14:6026151999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Tien HCCunha JRWu SNChughtai TTremblay LNBrenneman FD: Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival? J Trauma 60:2742782006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Tude Melo JRDi Rocco FBlanot SOliveira-Filho JRoujeau TSainte-Rose C: Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery 67:154215472010

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 30

    Young AMGuilfoyle MRFernandes HGarnett MRAgrawal SHutchinson PJ: The application of adult traumatic brain injury models in a pediatric cohort. J Neurosurg Pediatr 18:5585642016

    • Crossref
    • Search Google Scholar
    • Export Citation

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