Mild traumatic brain injury in children with ventricular shunts: a PREDICT study

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  • 1 Emergency Department, Royal Children’s Hospital, Melbourne;
  • | 2 Murdoch Children’s Research Institute, Melbourne, Victoria, Australia;
  • | 3 Emergency Department, Bristol Royal Hospital for Children, Bristol;
  • | 4 Faculty of Health and Life Sciences, University of the West of England, Bristol, United Kingdom;
  • | 5 Emergency Department, Perth Children’s Hospital;
  • | 6 School of Medicine, Divisions of Emergency Medicine and Paediatrics, University of Western Australia, Perth;
  • | 7 Emergency Department, Queensland Children’s Hospital, and Child Health Research Centre, Faculty of Medicine, The University of Queensland, South Brisbane;
  • | 8 Emergency Department, Women’s and Children’s Hospital, Adelaide;
  • | 9 Emergency Department, The Children’s Hospital at Westmead, Sydney;
  • | 10 Emergency Department, Monash Medical Centre, Melbourne;
  • | 11 Emergency Department, The Townsville Hospital, Townsville;
  • | 12 Emergency Department, University Hospital Geelong;
  • | 13 School of Medicine, Faculty of Health, Deakin University, Geelong, Victoria, Australia;
  • | 14 Emergency Department, KidzFirst Middlemore Hospital, Auckland, New Zealand;
  • | 15 Department of Women’s and Children’s Health, University of Padova, Italy;
  • | 16 Emergency Department, Starship Children’s Health, Auckland;
  • | 17 Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, New Zealand; and
  • | 18 Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
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OBJECTIVE

Current clinical decision rules (CDRs) guiding the use of CT scanning in pediatric traumatic brain injury (TBI) assessment generally exclude children with ventricular shunts (VSs). There is limited evidence as to the risk of abnormalities found on CT scans or clinically important TBI (ciTBI) in this population. The authors sought to determine the frequency of these outcomes and the presence of CDR predictor variables in children with VSs.

METHODS

The authors undertook a planned secondary analysis on children with VSs included in a prospective external validation of 3 CDRs for TBI in children presenting to 10 emergency departments in Australia and New Zealand. They analyzed differences in presenting features, management and acute outcomes (TBI on CT and ciTBI) between groups with and without VSs, and assessed the presence of CDR predictors in children with a VS.

RESULTS

A total of 35 of 20,137 children (0.2%) with TBI had a VS; only 2 had a Glasgow Coma Scale score < 15. Overall, 49% of patients with a VS underwent CT scanning compared with 10% of those without a VS. One patient had a finding of TBI on CT scanning, with positive predictor variables on CDRs. This patient had a ciTBI. No patient required neurosurgery. For children with and without a VS, the frequency of ciTBI was 2.9% (95% CI 0.1%–14.9%) compared with 1.4% (95% CI 1.2%–1.6%) (difference 1.5% [95% CI −4.0% to 7.0%]), and TBI on CT 2.9% (95% CI 0.1%–14.9%) compared with 2.0% (95% CI 1.8%–2.2%) (difference 0.9%, 95% CI −4.6% to 6.4%).

CONCLUSIONS

The authors’ data provide further support that the risk of TBI is similar for children with and without a VS.

ABBREVIATIONS

CATCH = Canadian Assessment of Tomography for Childhood Head Injury; CDR = clinical decision rule; CHALICE = Children’s Head Injury Algorithm for the Prediction of Important Clinical Events; ciTBI = clinically important TBI; ED = emergency department; GCS = Glasgow Coma Scale; PECARN = Pediatric Emergency Care Applied Research Network; PREDICT = Paediatric Research in Emergency Departments International Collaborative; TBI = traumatic brain injury; VS = ventricular shunt.

OBJECTIVE

Current clinical decision rules (CDRs) guiding the use of CT scanning in pediatric traumatic brain injury (TBI) assessment generally exclude children with ventricular shunts (VSs). There is limited evidence as to the risk of abnormalities found on CT scans or clinically important TBI (ciTBI) in this population. The authors sought to determine the frequency of these outcomes and the presence of CDR predictor variables in children with VSs.

METHODS

The authors undertook a planned secondary analysis on children with VSs included in a prospective external validation of 3 CDRs for TBI in children presenting to 10 emergency departments in Australia and New Zealand. They analyzed differences in presenting features, management and acute outcomes (TBI on CT and ciTBI) between groups with and without VSs, and assessed the presence of CDR predictors in children with a VS.

RESULTS

A total of 35 of 20,137 children (0.2%) with TBI had a VS; only 2 had a Glasgow Coma Scale score < 15. Overall, 49% of patients with a VS underwent CT scanning compared with 10% of those without a VS. One patient had a finding of TBI on CT scanning, with positive predictor variables on CDRs. This patient had a ciTBI. No patient required neurosurgery. For children with and without a VS, the frequency of ciTBI was 2.9% (95% CI 0.1%–14.9%) compared with 1.4% (95% CI 1.2%–1.6%) (difference 1.5% [95% CI −4.0% to 7.0%]), and TBI on CT 2.9% (95% CI 0.1%–14.9%) compared with 2.0% (95% CI 1.8%–2.2%) (difference 0.9%, 95% CI −4.6% to 6.4%).

CONCLUSIONS

The authors’ data provide further support that the risk of TBI is similar for children with and without a VS.

ABBREVIATIONS

CATCH = Canadian Assessment of Tomography for Childhood Head Injury; CDR = clinical decision rule; CHALICE = Children’s Head Injury Algorithm for the Prediction of Important Clinical Events; ciTBI = clinically important TBI; ED = emergency department; GCS = Glasgow Coma Scale; PECARN = Pediatric Emergency Care Applied Research Network; PREDICT = Paediatric Research in Emergency Departments International Collaborative; TBI = traumatic brain injury; VS = ventricular shunt.

In Brief

There is limited evidence as to the risk of abnormalities on CT or clinically important traumatic brain injury (ciTBI) in children with ventricular shunts (VSs) who sustain mild TBI. The authors sought to determine the frequency of these outcomes in children with VSs in a prospective multicenter study. Of 20,137 children with TBI, 35 (0.2%) had a VS. One patient had a CT abnormality, but none required neurosurgery. The rate of ciTBI in children with and without VSs was similar. Congruent with existing evidence, this study provides reasonable grounds to support a more restrictive approach to imaging than current practice.

While a number of clinical decision rules (CDRs) exist and are widely used by frontline clinicians to guide decisions on CT scanning for children who present to emergency departments (EDs) with possible traumatic brain injury (TBI), they tend to do so in specific populations.1–4 The eligibility criteria often exclude children because either management is clear and there is no need for a CDR (for example, very severe or trivial TBI) or the risk of TBI is potentially influenced by a preexisting comorbidity. In children with conditions who are believed to be at higher risk of TBI, such as those with a ventricular shunt (VS), application of CDRs is often challenging. Among the highest-quality CDRs, the Pediatric Emergency Care Applied Research Network (PECARN) CDR, for example, excluded patients with a VS but analyzed them separately. The Canadian Assessment of Tomography for Childhood Head Injury (CATCH) and the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) did not exclude these patients in their derivation process.1–4

VS insertion is one of the most commonly performed neurosurgical procedures in childhood, most often to treat hydrocephalus due to structural abnormalities, infection, intraventricular hemorrhage, or trauma.5 Congenital hydrocephalus has a global incidence of 1 per 1000 children, equivalent to 400,000 new cases every year.6 It has been postulated that children with a VS are at greater risk of significant intracranial injury than their peers due to the fragility of stretched dural bridging vessels or shunt fractures; moreover, it has also been suggested that a shunt may transiently mask signs and symptoms due to initial compensatory overdrainage of CSF. Some therefore have suggested that all children with a VS should undergo CT scanning after any TBI, regardless of their clinical presentation.7,8

In the largest series to date from the PECARN group, the prevalence of clinically important TBI (ciTBI) and injuries seen on CT scanning were no higher than that in the population without a VS.9 Despite this, CT usage rates were higher in children with VS than in the general population. Safe reduction in the use of CT is required, as repeated radiological evaluations for potential VS failure result in a higher cumulative lifetime radiation dose, increasing the risk of radiation-associated neoplasms in these children.10,11 The role of CDRs in achieving this remains unclear, as the one patient in the series who required neurosurgery was not identified by the CDR under evaluation.

We therefore undertook a planned secondary analysis of children with a VS enrolled in a prospectively collected sample of more than 20,000 children who presented to EDs with a TBI.12 We aimed to describe demographic and injury mechanism characteristics, clinician management, including CT scanning and observation practice, and the prevalence of clinically important TBI and positive CT findings, in order to better inform management of this understudied cohort.

Methods

Study Design and Setting

This a priori planned secondary analysis was conducted on the cohort of children with a VS enrolled in a prospective study validating existing CDRs for TBI12,13 across 10 EDs in the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network of Australia and New Zealand.14 Families attending one of these EDs between April 2011 and November 2014 were invited to participate, and clinical data pertaining to the PECARN, CATCH, and CHALICE CDRs were collected.1–4 CT scans were obtained at the discretion of treating clinicians, who followed their normal practice; there was no standardized head injury guideline in place across PREDICT sites at the time of the study. CT findings were collected from senior radiologist reports; for patients who did not undergo CT scanning, a structured telephone interview was performed with the family between 2 weeks and 3 months later to ensure that there were no missed significant intracranial injuries. The design and further details of the main study have been described previously.12,13 All participating sites obtained ethics approval from their local institutions prior to commencement.

Patient Selection

Children younger than 18 years with TBI of any severity were enrolled in the main validation study except those who 1) had trivial facial injuries, 2) did not wait to be seen by a clinician, 3) were referred to another provider prior to ED clinician assessment, or 4) had imaging performed elsewhere prior to arrival in a participating ED. Children with a VS were identified by clinicians at the time of assessment through the use of a standard question on the study case report form. We did not exclude children based on TBI severity or the presence of other underlying disease, including brain tumors.

Outcome Measures

The primary outcome measures were 1) the prevalence of ciTBI defined as the presence of one or more factors (death, neurosurgical intervention, intubation for greater than 24 hours, or 2 or more nights in the hospital for the management of the TBI in association with a positive CT scan result); 2) neurosurgery (any neurosurgical procedure including intracranial pressure monitoring); and 3) TBI on CT (intracranial hemorrhage/contusion, traumatic infarction, sigmoid sinus thrombosis, diffuse axonal injury, pneumocephalus, midline shift or signs of brain herniation, diastasis of the skull, or skull fracture depressed more than the table width of the skull). Secondary outcomes included rates of CT scanning performance and admission or observation.

Statistical Analysis

Data were entered into Epidata (The Epidata Association), and later REDCap,15 and analyzed using Stata version 13 (StataCorp). Results are presented using descriptive statistics, including counts and percentage, with 95% CIs for categorical data. Continuous data are presented using medians and IQRs where appropriate. We compared patients with and without VS using odds ratios with 95% CIs.

Results

During the study period, 24,230 patients were assessed for eligibility (5203 were missed). Of those eligible for inclusion, 20,137 patients had complete data, from which we identified 35 patients with a VS at the time of injury (Fig. 1). Of the 35 children with a VS, the sex ratio was evenly split, and the majority (33/35, 94%) had a Glasgow Coma Scale (GCS) score of 15; none had a GCS score below 13. Children presenting with a TBI who had a VS were similar to those presenting with a TBI without a VS in terms of age, sex, GCS score, and mechanism of injury (Table 1).

FIG. 1.
FIG. 1.

Study flowchart. *Trivial facial injuries were defined as a ground-level fall or walking or running into an object with no signs or symptoms of injury other than facial abrasions or lacerations below the eyebrows.

TABLE 1.

Characteristics of children with a VS compared with those with no shunt

Group w/ VSGroup w/o VS
Value95% CIValue95% CI
No. of patients3520,102
Median age, yrs (IQR)3.6 (2.4–8.4)4.2 (1.9–9.0)
Age category, yrs
 <25 (14.3)4.8–30.3%5369 (26.7)26.1–27.3%
 2–517 (48.6)31.4–66.0%7130 (35.5)34.8–36.1%
 6–116 (17.1)6.6–33.6%4587 (22.8)22.8–23.4%
 12–187 (20.0)8.4–36.9%3016 (15.0)15.0–15.5%
Sex
 Male19 (54.3)36.6–71.2%12,804 (63.7)63.0–64.4%
 Female16 (45.7)28.8–63.4%7293 (36.3)35.6–37.0%
GCS score
 1533 (94.3)80.8–99.3%19,174 (95.4)95.1–95.7%
 141 (2.9)0.1–14.9%577 (2.9)2.6–3.1%
 131 (2.9)0.1–14.9%134 (0.7)0.6–0.8%
 9–120 (0.0)0.0–10.0%96 (0.5)0.4–0.6%
 3–80 (0.0)0.0–10.0%121 (0.6)0.5–0.7%
Mechanism of injury
 MVA related1 (2.9)0.1–14.9%848 (4.3)4.0–4.6%
 Fall related26 (74.3)56.7–87.5%14,093 (70.1)69.5–70.7%
 Bicycle fall (no helmet)0 (0.0)0.0–10.0%383 (1.9)1.7–2.1%
 High-impact object/projectile1 (2.9)0.1–14.9%1310 (6.5)6.2–6.9%
 Suspected NAI0 (0.0)0.0–10.0%112 (0.6)0.5–0.7%

MVA = motor vehicle accident; NAI = nonaccidental injury.

Values represent the number of patients (%) unless stated otherwise.

Of the 35 patients with a VS, 17 (49%) underwent CT scanning, compared with a scan rate of 10% in those without shunts (OR 8.14 [95% CI 4.23–16.65]) (Table 2). One patient had a TBI on CT and ciTBI, and no patients had evidence of missed intracranial injury at follow-up or needed neurosurgery. For children with a VS compared with those without, the frequency of ciTBI was 2.9% (95% CI 0.1%–14.9%) compared with 1.4% (95% CI 1.2%–1.6%) (difference 1.5% [95% CI −4.0% to 7.0%]), and the frequency of TBI on CT was 2.9% (95% CI 0.1%–14.9%) compared with 2.0% (95% CI 1.8%–2.2%) (difference 0.9% [95% CI −4.6% to 6.4%]). Patients with a VS (43%) were more frequently observed than those without shunts (26%, OR 2.12 [95% CI 1.10–4.11]).

TABLE 2.

Prevalence of primary and secondary outcomes and presence of predictor variables of childhood head injury CDRs in children with VSs

Group w/ VSGroup w/o VS
No. of Patients (%)95% CINo. of Patients (%)95% CI% Difference (95% CI)
Total3520,102
Primary outcome
 ciTBI present*1 (2.9)0.1 to 14.9%280 (1.4)1.2 to 1.6%1.5 (−4.0 to 7.0)
 TBI on CT1 (2.9)0.1 to 14.9%394 (2.0)1.8 to 2.2%0.9 (−4.6 to 6.4)
 Neurosurgery0 (0.0)0.0 to 10.0%83 (0.4)0.3 to 0.5%0.4 (0.3 to 0.5)
Secondary outcome
 CT scan done17 (48.6)31.4 to 66.0%2089 (10.4)10.0 to 10.8%38.2 (21.6 to 54.7)
 Observed15 (42.9)26.3 to 60.6%5224 (26.0)25.5 to 26.7%16.8 (0.4 to 33.2)
 Admitted to ward6 (17.1)6.6 to 33.6%1327 (6.6)6.3 to 7.0%16.7 (−10.4 to 43.8)
Presence of predictor variables from CDRs
 Any PECARN predictors9 (25.7)12.5 to 43.3%5853 (29.1)28.5 to 29.7%3.4 (−11.1 to 17.9)
 No PECARN predictors26 (74.3)56.7 to 87.5%14,249 (70.9)70.2 to 71.5%
 Any CATCH predictors10 (28.6)14.6 to 46.3%6268 (31.2)30.5 to 31.8%2.6 (−12.4 to 17.6)
 No CATCH predictors25 (71.4)53.7 to 85.4%13,834 (68.8)68.2 to 69.5%
 Any CHALICE predictors8 (22.9)10.4 to 40.1%4716 (23.5)22.9 to 24.1%0.6 (−13.3 to 14.5)
 No CHALICE predictors27 (77.1)59.9 to 89.6%15,386 (76.5)75.9 to 77.1%

Defined as one or more TBIs resulting in death, neurosurgical intervention, intubation for greater than 24 hours, or 2 or more nights in the hospital for the management of the TBI in association with a positive CT scan result.

Defined as intracranial hemorrhage/contusion, traumatic infarction, sigmoid sinus thrombosis, diffuse axonal injury, pneumocephalus, midline shift or signs of brain herniation, diastasis of the skull, or skull fracture depressed more than the table width of the skull.

Nine of 35 patients (26%) with a VS presented with predictor variables from the PECARN CDR, 10 (29%) presented with CATCH predictor variables, and 8 (23%) presented with CHALICE predictor variables (Table 2). Of those with predictor variables for PECARN, CATCH, and CHALICE, 7 of 9 (77%), 6 of 10 (60%), and 6 of 8 (75%) patients underwent CT scanning, respectively. Itemized predictor variables by CDR are presented in Supplemental Table 1; there were no significant differences between those with a VS and those without, either when taking each CDR as a whole or at the level of individual predictor variables.

The one patient with abnormal findings on CT scanning (intracranial contusion, nondepressed skull fracture) was a 4-year-old girl with a low-level fall. She presented with a 4-cm boggy occipital hematoma without vomiting or loss of consciousness. Although she did not undergo neurosurgery, she was admitted to the hospital for 2 nights and therefore fulfilled criteria for having sustained a ciTBI. She had positive PECARN, CATCH, and CHALICE criteria.

Discussion

In this large prospective cohort of children with TBI presenting to EDs, we detected no statistically significant difference between the cohort with a VS and the overall population in the frequency of ciTBI or TBI findings on CT scanning, and, furthermore, no children in this cohort required neurosurgical intervention. There were, however, significant differences in clinical management of these children, with higher rates of CT scanning and observation.

Our findings are closely aligned with those of the largest case series published to date, a planned secondary analysis from the PECARN CDR derivation study, where children with a VS were enrolled but not included in the derivation data set and analyzed separately.3 The proportion of children with a VS was 0.2% in both the PECARN and our studies, with the prevalence of ciTBI and TBI findings on CT scanning in the PECARN series of 1% and 2%, respectively.9 The age distribution in our study and PECARN was broadly similar (< 2 years of age: 14% and 19%, respectively), as were the presenting GCS scores and the frequency with which predictor variables from the PECARN CDR were present.

While the CT scanning rates in the group with a VS were similar between this study and the PECARN series (49% and 46%, respectively) this represents a greater deviation in management in our setting, with a baseline CT scan rate overall of 10%12 compared with 35% in the PECARN study.3 The reasons for such a marked difference are unclear, as we did not detect significant differences in presenting features. This, therefore, most likely represents clinician uncertainty in managing a head injury in a child with a VS. Practice at the time of performing the study may have been influenced by scant evidence available. This consists mostly of case reports and small series, which postulated an increased risk of intracranial injury due to stretching of bridging vessels,16 or potential delayed detection due to transient overcompensatory CSF drainage or VS fracture.7,17

Patients with a VS have an increased radiation burden compared with the general population due to more frequent use of CT scans to investigate potential shunt malfunction, with consequent increased risk of developing radiation-associated malignancies.10,11 Strategies to reduce this burden have been proposed in the form of limited-sequence CT scanning,18 or fast MRI protocols, although these may not be practical in the context of TBI due to view limitations and the potential incompatibility of shunts with MRI.19 The low prevalence of ciTBI and CT abnormalities in both the PECARN and our series provides reasonable grounds to suggest a more restrictive approach to imaging than current practice, which may further reduce radiation burden if coupled with optimized pediatric CT protocols. Indeed, some recently published national guidelines have suggested a prolonged (6-hour) observation period in asymptomatic patients with a shunt rather than performing scanning in all patients.20,21 However, while such an approach appears safe, ongoing prospective evaluation using national TBI data sets and VS registries will be essential, as even when combining these two large case series the total population of patients with a VS was only 133 patients, with 2 outcomes of ciTBI and 2 of CT abnormalities. It is doubtful that a prospective validation of a CDR can be conducted for patients with a VS considering the numbers required.

The small size of the VS population limits the ability to infer a definite role for any of the existing CDRs. Of note, no patients in our series deteriorated after discharge from the hospital, there were no missed injuries, and no shunt fractures, disconnections, or malfunctions were identified. This pattern was replicated in the PECARN series. Thus, it would appear that in the combined 71 cases from both studies, clinicians made the appropriate decision not to perform CT scanning. Obviously, it remains essential to inform parents of the potential risk and warning signs of delayed-onset increases in intracranial pressure when providing discharge advice.

In summary, the findings of this study are congruent with existing evidence in suggesting that the prevalence of ciTBI and CT abnormalities in children with a VS is low after head trauma. Existing CDRs may provide a framework on which to base CT scanning decisions in these children, although additional caution should be exercised in cases of preexisting anatomical abnormalities, or direct impact force to shunts.

Limitations

Our study had some limitations. Despite the main prospective study population being very large, the number of children with a VS was small, which may have affected the precision of our risk estimates. This, in turn, may have affected our ability to determine a difference in rates of ciTBI and TBI on CT scanning between children with and those without shunts. CT scanning decisions rested with clinicians in this study, as it would not have been ethical to perform CT scanning in all children with a head injury. However, the parents or guardians of all patients not undergoing CT scanning completed a structured telephone follow-up, making it very unlikely that any significant intracranial injuries were missed. This study was mainly performed in tertiary children’s hospitals across Australia and New Zealand, where clinicians may have substantial experience in managing children with a VS. We did not collect information on the underlying reason for shunt placement in our study or the type of shunt placed, although it is unlikely that any difference in risk would be detectable given the size of the cohort. We did not collect detailed functional information on children with a VS, and so it is possible that the activities undertaken by these children may result in different mechanisms and intensities of injury. Despite the PREDICT study including children with all severities of head injury, the cohort with a VS only presented with mild TBI (GCS scores 13–15), and the generalizability of these results to the moderate and severe TBI populations remains to be determined. Finally, the definition of what represents a “clinically important” TBI was consensus based.3

Conclusions

The prevalence of ciTBI and abnormalities on CT are low in children with a VS who sustain mild TBIs, although clinicians are significantly more likely to obtain images and observe these patients. It would appear that the risk of ciTBI in children with a VS who sustain mild TBIs is similar to that in children without a VS who sustain a mild TBI.

Acknowledgments

We thank the participating families, ED staff, and research staff at all participating sites.

The study was funded by grants from the National Health and Medical Research Council (NHMRC; project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560), Canberra, Australia; the Murdoch Children’s Research Institute, Melbourne, Australia; the Emergency Medicine Foundation (EMPJ-11162), Brisbane, Australia; Perpetual Philanthropic Services (2012/1140), Australia; Auckland Medical Research Foundation (No. 3112011) and the A + Trust (Auckland District Health Board), Auckland, New Zealand; WA Health Targeted Research Funds 2013, Perth, Australia; and the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund, Townsville, Australia. The study was supported by the Victorian Government’s Infrastructure Support Program, Melbourne, Australia. F.E.B.’s time was funded in part by a grant from the Royal Children’s Hospital Foundation, Melbourne, Australia, and an NHMRC Practitioner Fellowship. S.R.D.’s time was funded by the Health Research Council of New Zealand (HRC13/556) and Cure Kids New Zealand. The funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Babl.

Supplemental Information

Online-Only Content

Supplemental material is available with the online version of the article.

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Supplementary Materials

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    Study flowchart. *Trivial facial injuries were defined as a ground-level fall or walking or running into an object with no signs or symptoms of injury other than facial abrasions or lacerations below the eyebrows.

  • 1

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  • 2

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  • 3

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  • 9

    Nigrovic LE, Lillis K, Atabaki SM, et al. The prevalence of traumatic brain injuries after minor blunt head trauma in children with ventricular shunts. Ann Emerg Med. 2013; 61(4): 389393.

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  • 11

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  • 12

    Babl FE, Borland ML, Phillips N, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017; 389(10087): 23932402.

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  • 13

    Babl FE, Lyttle MD, Bressan S, et al. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr. 2014; 14: 148.

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  • 14

    Babl F, Borland M, Ngo P, et al. Paediatric Research in Emergency Departments International Collaborative (PREDICT): first steps towards the development of an Australian and New Zealand research network. Emerg Med Australas. 2006; 18(2): 143147.

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  • 15

    Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009; 42(2): 377381.

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  • 16

    Aoki N, Mizutani H. Acute subdural hematoma due to minor head trauma in patients with a lumboperitoneal shunt. Surg Neurol. 1988; 29(1): 2226.

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  • 17

    Okazaki T, Oki S, Migita K, Kurisu K. A rare case of shunt malfunction attributable to a broken Codman-Hakim programmable shunt valve after a blow to the head. Pediatr Neurosurg. 2005; 41(5): 241243.

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  • 18

    Park DB, Hill JG, Thacker PG, et al. The role of limited head computed tomography in the evaluation of pediatric ventriculoperitoneal shunt malfunction. Pediatr Emerg Care. 2016; 32(9): 585589.

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  • 19

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  • 20

    Da Dalt L, Parri N, Amigoni A, et al. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr. 2018; 44(1): 7.

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  • 21

    Astrand R, Rosenlund C, Undén J. Scandinavian guidelines for initial management of minor and moderate head trauma in children. BMC Med. 2016; 14: 33.

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