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

View More View Less
  • 1 Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
USD  $45.00
USD  $515.00
USD  $612.00
Print or Print + Online Sign in

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.

ABBREVIATIONS

DAI = diffuse axonal injury; GCS = Glasgow Coma Scale; KOSCHI = King’s Outcome Scale for Childhood Head Injury; SWI = susceptibility-weighted imaging; TBI = traumatic brain injury.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
USD  $515.00
USD  $612.00
  • 1

    Ballestero MFM, Furlanetti LL, Augusto LP, Chaves PHC, Santos MV, de Oliveira RS. Decompressive craniectomy for severe traumatic brain injury in children: analysis of long-term neuropsychological impairment and review of the literature. Childs Nerv Syst. 2019;35(9):15071515.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Faul LM, Wald CV. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002–2006. Centers for Disease Control and Prevention,. National Center for Injury Prevention and Control;2010.

    • Search Google Scholar
    • Export Citation
  • 3

    Ferrazzano PA, Rosario BL, Wisniewski SR, et al. Use of magnetic resonance imaging in severe pediatric traumatic brain injury: assessment of current practice. J Neurosurg Pediatr. 2019;23(4):471479.

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

    Liesemer K, Riva-Cambrin J, Bennett KS, et al. Use of Rotterdam CT scores for mortality risk stratification in children with traumatic brain injury. Pediatr Crit Care Med. 2014;15(6):554562.

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

    Marquez de la Plata C, Ardelean A, Koovakkattu D, et al. Magnetic resonance imaging of diffuse axonal injury: quantitative assessment of white matter lesion volume. J Neurotrauma. 2007;24(4):591598.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Chastain CA, Oyoyo UE, Zipperman M, et al. Predicting outcomes of traumatic brain injury by imaging modality and injury distribution. J Neurotrauma. 2009;26(8):11831196.

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

    Paterakis K, Karantanas AH, Komnos A, Volikas Z. Outcome of patients with diffuse axonal injury: the significance and prognostic value of MRI in the acute phase. J Trauma. 2000;49(6):10711075.

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

    Smitherman E, Hernandez A, Stavinoha PL, et al. Predicting outcome after pediatric traumatic brain injury by early magnetic resonance imaging lesion location and volume. J Neurotrauma. 2016;33(1):3548.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Crouchman M, Rossiter L, Colaco T, Forsyth R. A practical outcome scale for paediatric head injury. Arch Dis Child. 2001;84(2):120124.

  • 10

    Calvert S, Miller HE, Curran A, et al. The King’s Outcome Scale for Childhood Head Injury and injury severity and outcome measures in children with traumatic brain injury. Dev Med Child Neurol. 2008;50(6):426431.

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

    Kan P, Amini A, Hansen K, et al. Outcomes after decompressive craniectomy for severe traumatic brain injury in children. J Neurosurg. 2006;105(5)(suppl):337342.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Jang SH. Diagnostic problems in diffuse axonal injury. Diagnostics (Basel). 2020;10(2):117.

  • 13

    Frati A, Cerretani D, Fiaschi AI, et al. Diffuse axonal injury and oxidative stress: a comprehensive review. Int J Mol Sci. 2017;18(12):2600.

  • 14

    Babikian T, Freier MC, Tong KA, et al. Susceptibility weighted imaging: neuropsychologic outcome and pediatric head injury. Pediatr Neurol. 2005;33(3):184194.

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

    Moen KG, Brezova V, Skandsen T, Håberg AK, Folvik M, Vik A. Traumatic axonal injury: the prognostic value of lesion load in corpus callosum, brain stem, and thalamus in different magnetic resonance imaging sequences. J Neurotrauma. 2014;31(17):14861496.

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

    Spitz G, Maller JJ, Ng A, O’Sullivan R, Ferris NJ, Ponsford JL. Detecting lesions after traumatic brain injury using susceptibility weighted imaging: a comparison with fluid-attenuated inversion recovery and correlation with clinical outcome. J Neurotrauma. 2013;30(24):20382050.

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

    Schweitzer AD, Niogi SN, Whitlow CT, Tsiouris AJ. Traumatic brain injury: imaging patterns and complications. Radiographics. 2019;39(6):15711595.

  • 18

    Figueira Rodrigues Vieira G, Guedes Correa JF. Early computed tomography for acute post-traumatic diffuse axonal injury: a systematic review. Neuroradiology. 2020;62(6):653660.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19

    Cremonini C, Lewis M, Wong MD, Benjamin ER, Inaba K, Demetriades D. Traumatic epidural hematomas in the pediatric population: clinical characteristics and diagnostic pitfalls. J Pediatr Surg. 2020;55(9):17731778.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Binder H, Tiefenboeck TM, Majdan M, et al. Management and outcome of traumatic subdural hematoma in 47 infants and children from a single center. Wien Klin Wochenschr. 2020;132(17-18):499505.

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

    Spazzapan P, Krašovec K, Velnar T. Risk factors for bad outcome in pediatric epidural hematomas: a systemic review. Chin Neurosurg J. 2019;5:19.

Metrics

All Time Past Year Past 30 Days
Abstract Views 781 781 85
Full Text Views 86 86 7
PDF Downloads 135 135 6
EPUB Downloads 0 0 0