Validation of the Surgical Intervention for Traumatic Injury scale in the pediatric population

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  • 1 Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio;
  • | 2 Department of Neurological Surgery, University of Tennessee Health Science Center and Semmes Murphey Clinic, Memphis, Tennessee;
  • | 3 Division of Pediatric Neurological Surgery, Nationwide Children’s Hospital, Columbus, Ohio; and
  • | 4 Department of Neurological Surgery, University of California, San Francisco, California
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OBJECTIVE

While the Glasgow Coma Scale (GCS) has been effective in describing severity in traumatic brain injury (TBI), there is no current method for communicating the possible need for surgical intervention. This study utilizes a recently developed scoring system, the Surgical Intervention for Traumatic Injury (SITI) scale, which was developed to efficiently communicate the potential need for surgical decompression in adult patients with TBI. The objective of this study was to apply the SITI scale to a pediatric population to provide a tool to increase communication of possible surgical urgency.

METHODS

The SITI scale uses both radiographic and clinical findings, including the GCS score on presentation, pupillary examination, and CT findings. To examine the scale in pediatric TBI, a neurotrauma database at a level 1 pediatric trauma center was retrospectively evaluated, and the SITI score for all patients with an admission diagnosis of TBI between 2010 and 2015 was calculated. The primary endpoint was operative intervention, defined as a craniotomy or craniectomy for decompression, performed within the first 24 hours of admission.

RESULTS

A total of 1524 patients met inclusion criteria for the study during the 5-year span: 1469 (96.4%) were managed nonoperatively and 55 (3.6%) patients underwent emergent operative intervention. The mean SITI score was 4.98 ± 0.31 for patients undergoing surgical intervention and 0.41 ± 0.02 for patients treated nonoperatively (p < 0.0001). The area under the receiver operating characteristic (AUROC) curve was used to examine the diagnostic accuracy of the SITI scale in this pediatric population and was found to be 0.98. Further evaluation of patients presenting with moderate to severe TBI revealed a mean SITI score of 5.51 ± 0.31 in 40 (15.3%) operative patients and 1.55 ± 0.02 in 221 (84.7%) nonoperative patients, with an AUROC curve of 0.95.

CONCLUSIONS

The SITI scale was designed to be a simple, objective communication tool regarding the potential need for surgical decompression after TBI. Application of this scale to a pediatric population reveals that the score correlated with the perceived need for emergent surgical intervention, further suggesting its potential utility in clinical practice.

ABBREVIATIONS

AUROC = area under the ROC; CI = confidence interval; ED = emergency department; GCS = Glasgow Coma Scale; IQR = interquartile range; MVC = motor vehicle crash; OR = odds ratio; ROC = receiver operating characteristic; SITI = Surgical Intervention for Traumatic Injury; TBI = traumatic brain injury.

OBJECTIVE

While the Glasgow Coma Scale (GCS) has been effective in describing severity in traumatic brain injury (TBI), there is no current method for communicating the possible need for surgical intervention. This study utilizes a recently developed scoring system, the Surgical Intervention for Traumatic Injury (SITI) scale, which was developed to efficiently communicate the potential need for surgical decompression in adult patients with TBI. The objective of this study was to apply the SITI scale to a pediatric population to provide a tool to increase communication of possible surgical urgency.

METHODS

The SITI scale uses both radiographic and clinical findings, including the GCS score on presentation, pupillary examination, and CT findings. To examine the scale in pediatric TBI, a neurotrauma database at a level 1 pediatric trauma center was retrospectively evaluated, and the SITI score for all patients with an admission diagnosis of TBI between 2010 and 2015 was calculated. The primary endpoint was operative intervention, defined as a craniotomy or craniectomy for decompression, performed within the first 24 hours of admission.

RESULTS

A total of 1524 patients met inclusion criteria for the study during the 5-year span: 1469 (96.4%) were managed nonoperatively and 55 (3.6%) patients underwent emergent operative intervention. The mean SITI score was 4.98 ± 0.31 for patients undergoing surgical intervention and 0.41 ± 0.02 for patients treated nonoperatively (p < 0.0001). The area under the receiver operating characteristic (AUROC) curve was used to examine the diagnostic accuracy of the SITI scale in this pediatric population and was found to be 0.98. Further evaluation of patients presenting with moderate to severe TBI revealed a mean SITI score of 5.51 ± 0.31 in 40 (15.3%) operative patients and 1.55 ± 0.02 in 221 (84.7%) nonoperative patients, with an AUROC curve of 0.95.

CONCLUSIONS

The SITI scale was designed to be a simple, objective communication tool regarding the potential need for surgical decompression after TBI. Application of this scale to a pediatric population reveals that the score correlated with the perceived need for emergent surgical intervention, further suggesting its potential utility in clinical practice.

ABBREVIATIONS

AUROC = area under the ROC; CI = confidence interval; ED = emergency department; GCS = Glasgow Coma Scale; IQR = interquartile range; MVC = motor vehicle crash; OR = odds ratio; ROC = receiver operating characteristic; SITI = Surgical Intervention for Traumatic Injury; TBI = traumatic brain injury.

In Brief

Prompt diagnosis and treatment of pediatric TBI is of utmost importance and highly reliant on efficient communication between providers. The authors assessed the SITI scale, previously validated in adults, in the pediatric population to determine its utility. Insights from this study found this scoring system to strongly correlate with operative intervention in pediatric patients, underscoring its potential utility as a communicative tool in the setting of closed head injury TBI.

Traumatic brain injury (TBI) in the pediatric population represents a significant socioeconomic and public health issue, with high rates of severe TBI, hospitalizations, and mortality.1 With an annual incidence of 1.7 million events, TBI is responsible for more than 250,000 hospitalizations per year in the US, with more than 60,000 hospitalizations and 7400 deaths coming from the pediatric population.1,2 While neuroprotective pharmacotherapies have shown limited utility following TBI,2 timely management may reduce secondary injury and has been shown to improve outcomes.3,4 Particularly in patients with moderate and severe TBI, minimal time to neurosurgical intervention, when necessary, is beneficial.4 While the Glasgow Coma Scale (GCS) has been effective in describing TBI severity, it does not adequately address the potential need for surgical intervention.5

Numerous predictive scales have been developed that evaluate prognostic factors that correlate with long-term outcomes in TBI. Lower initial GCS score and the presence of fixed and dilated pupils have been shown to correlate with poorer prognosis and increased mortality in previous predictive models.6,7 Furthermore, evaluation of the Corticosteroid Randomization After Significant Head Injury (CRASH) and the International Mission on Prognosis and Analysis of Randomized Controlled Trials in TBI (IMPACT) models revealed that GCS score, pupillary examination, presence of an epidural hematoma, subarachnoid hemorrhage, and systemic shock all correlate with early mortality following TBI.8 While these studies were largely designed based on adult populations, they have been shown to be accurate predictors in pediatric TBI as well.9 Nonetheless, while these tools provide prognostic information, they provide little assistance in terms of acute TBI management.

In order to provide a communication tool to relay information regarding possible surgical decision-making in patients presenting with TBI, the Surgical Intervention for Traumatic Injury (SITI) scoring system was initially developed in an adult population (Table 1).10 Utilizing objective clinical and radiographic findings, this scale was designed to function as a tool to easily communicate the potential need for surgical intervention. Prior retrospective studies of this scale demonstrated that a score of 3 or greater correlated with an increased rate of emergent decompressive hemicraniectomy in adults.11 Given that pediatric patients can achieve good functional outcomes in 72.2% of cases following severe TBI,7 early treatment is essential in this patient population. The SITI score was designed by identifying key objective measures that might correlate with a potential increased need for emergent surgical intervention.10,12 The intention was to create a communication tool that would facilitate and expedite treatment.

TABLE 1.

SITI scoring system

ComponentPoints
GCS score
 12–150
 9–121
 3–82
Unilateral pupil
 No0
 Yes2
Head CT
 Midline shift, mm
  <50
  5–102
  >104
 Temporal lobe pathology
  No0
  Yes1
 Epidural hematoma (≥10 mm)
  No0
  Yes2

Points awarded for key clinical and radiographic components of the SITI score.

Methods

Patient Population

Data for this study were obtained retrospectively from a state-mandated trauma database (Central Trauma Registry) that is maintained by dedicated data entry personnel under the supervision of nurse practitioners and physicians. Patients were treated at a level 1 pediatric trauma center between January 2010 and December 2015. This study was approved by the IRB at Nationwide Children’s Hospital in Columbus, Ohio. Informed consent was not required for admission into this study, given its retrospective nature.

Patients were identified by description of injury in the trauma registry. Inclusion criteria included patients who were admitted with a diagnosis of TBI, regardless of etiology. As the SITI score was designed to predict surgical intervention following blunt TBI, patients were excluded from analysis if they presented with penetrating injuries, depressed skull fractures, or open skull fractures.

Patients were identified as having a surgical intervention if they received a craniectomy or craniotomy within 24 hours of admission. Patients undergoing minor procedures, such as ventriculostomy or placement of an intracranial pressure monitoring device, were included in the nonoperative cohort. There was no standardized protocol to guide TBI management, as these decisions were left to the clinical judgment of individual neurosurgical providers.

Data Acquisition

Baseline patient demographics, including age, sex, and mechanism of injury, were obtained from the trauma database, along with GCS score and Injury Severity Score on presentation. The presence of intubation or a unilateral fixed and dilated pupil was recorded, based on documentation by the initial emergency department (ED) provider. The degree of midline shift, presence of temporal lobe pathology, and size of visualized epidural hematoma on initial CT of the head were obtained from the official radiology report.

The SITI score and its calculation have been described previously, originally influenced by published surgical guidelines.10 Briefly, the scale is composed of 5 key factors: GCS score on initial presentation, pupillary findings, and three head CT findings (midline shift, presence of blood in the region of the temporal lobe, and the presence of an epidural hematoma). We obtained the GCS score from the patient’s initial evaluation in the ED. The point values ascribed to each of these findings are shown in Table 1, with a maximum possible score of 11. Based on these components, a SITI score was calculated for each patient. The primary outcome measure was emergent decompressive craniectomy or craniotomy within 24 hours of admission.

Statistical Analysis

Statistical analyses were performed by independent statisticians using the SPSS statistical program (version 23, IBM Corp.). Analyses comparing patients in the nonoperative and operative cohorts were performed utilizing the chi-square test, Fisher exact test, and unpaired Student t-test as appropriate for categorical and continuous variables. Descriptive analysis of ordinal variables is presented as medians with an associated interquartile range (IQR), utilizing the nonparametric Wilcoxon-Mann-Whitney test. Statistical significance was defined as p < 0.05. Potential correlation between SITI score and decompressive hemicraniectomy was first analyzed by binomial logistic regression analysis and is presented as odds ratios (ORs) with the corresponding 95% confidence intervals (CIs). To identify an optimal cutoff value for the SITI score and its correlation with emergent surgery, receiver operating characteristic (ROC) curve analysis was performed.

Results

Patient Characteristics

Between 2010 and 2015, 1524 patients met inclusion criteria for the study. The majority of patients were managed nonoperatively (1469 patients, 96.4%), and 55 (3.6%) patients underwent emergent operative intervention. Patient characteristics and baseline demographics were examined by univariate analysis (Table 2). Comparing the operative and nonoperative cohorts, there was no significant difference in any of the baseline demographic variables assessed. Fall was the most frequent mechanism of injury (33.3%), followed by motor vehicle crashes (MVCs; 28.7%), assault (11.7%), vehicle versus pedestrian (8.2%), and bicycle accidents (7.9%). There was no significant impact of mechanism of injury on operative intervention. Patients who underwent operative intervention more frequently presented to the ED after being intubated in the field or at another hospital (74.6% vs 12.3%, p < 0.0001).

TABLE 2.

Baseline patient demographics and mechanism of injury

VariableNonoperative, n = 1469Operative, n = 55p Value
Median age (IQR), yrs7 (2–13)4 (2–12)0.5331
Sex, n (%)0.2841
 Male938 (63.9)39 (70.9)
 Female531 (36.2)16 (29.1)
Mechanism of injury, n (%)0.2743
 MVC423 (28.8)15 (27.3)
 Fall496 (33.8)12 (21.8)
 Assault167 (11.4)11 (20.0)
 Bicycle115 (7.8)5 (9.1)
 Other268 (18.2)12 (21.8)
Intubation, n (%)*180 (12.3)41 (74.6)<0.0001

Present on admission.

SITI Score

A wide dichotomy was present between the individual components of the SITI score in the operative and nonoperative groups (Table 3). Comparing the operative and nonoperative patients, operative patients were more likely to present with GCS scores < 9 (67.3% vs 10.8%, p < 0.0001), whereas nonoperative patients were more likely to present with GCS scores > 12 (85.0% vs 27.3%, p < 0.0001). Similarly, operative patients had a higher rate of a unilateral enlarged pupil on initial examination (32.7% vs 0.7%, p < 0.0001).

TABLE 3.

Components of SITI score observed in nonoperative and operative cohorts

ComponentNonoperative, n = 1469Operative, n = 55p Value
GCS score<0.0001
 3–8159 (10.8)37 (67.3)
 9–1262 (4.2)3 (5.5)
 12–151248 (85.0)15 (27.3)
Unilateral pupil10 (0.7)18 (32.7)<0.0001
Midline shift, mm<0.0001
 <51463 (99.6)24 (43.6)
 5–106 (0.4)22 (40.0)
 >100 (0.0)9 (16.4)
Temporal pathology137 (9.3)33 (60.0)<0.0001
Epidural hematoma >10 mm20 (1.4)21 (38.2)<0.0001

Values are presented as number of patients (%).

Regarding imaging findings, nearly all nonoperative patients had midline shift of < 5 mm on head CT (99.6%). Operative patients were more likely to present with midline shift of > 5 mm (56.4% vs 0.4%, p < 0.0001), temporal pathology (60.0% vs 9.3%, p < 0.0001), and presence of an epidural hematoma (38.2% vs 1.4%, p < 0.0001).

SITI Score and Surgical Intervention

In the entire cohort of included TBI patients, the mean SITI score was 4.98 ± 0.31 for operative patients and 0.41 ± 0.02 for nonoperative patients (p < 0.0001); 86.9% of the nonoperative patients had SITI scores of 0 or 1, whereas 3.6% of the operative cohort had similar scores. Utilizing a SITI score of 2 or higher as the threshold for a positive test yields a sensitivity of 96.4% and a specificity of 86.9%, with a positive predictive value of 21.5% and a negative predictive value of 99.8%. The area under the ROC (AUROC) curve was assessed and was found to be 0.979 (Fig. 1).

FIG. 1.
FIG. 1.

AUROC for SITI score in a pediatric TBI population. The AUROC for the SITI score in the pediatric population was 0.979, demonstrating the correlation between a higher score and the perceived need for surgical intervention. Figure is available in color online only.

Assessing patients with moderate to severe TBI (GCS scores 3–12), the mean SITI score of the operative cohort was 5.51 ± 0.31, while that of the nonoperative cohort was 1.55 ± 0.02; 86.6% of nonoperative patients and 10.0% of the operative patients had SITI scores of 0–2. In patients with GCS scores < 12, utilizing a threshold SITI score of 3 or higher as a positive test yields a sensitivity of 90.0%, a specificity of 87.3%, a positive predictive value of 56.3%, and a negative predictive value of 98.0%. The AUROC curve in this model was 0.947.

Discussion

The SITI scale has been previously studied in adult patients and was found to correlate with a neurosurgeon’s perceived need for surgical intervention in the treatment of TBI.10–12 It has not yet been applied to pediatric patients. This retrospective analysis of a large cohort of pediatric neurotrauma patients revealed a similarly strong correlation between the SITI score and potential need for a craniotomy or craniectomy for TBI treatment. This statistical difference suggests that the SITI score may be a mechanism to quickly analyze and communicate potential need for emergent decompressive surgery. In addition to revealing a strong dichotomy in the perceived need for operative intervention, we utilized AUROC analysis to further assess the potential utility of the SITI scale as a diagnostic test in the pediatric population.

The AUROC in this model was found to be 0.979, indicating a robust association between higher SITI scores and potential need for operative intervention, as determined by the treating neurosurgeon in the pediatric population. By comparison, analysis of this model in an adult population to predict a perceived need for craniotomy or craniectomy found the AUROC to be 0.89.12 While no single scale can determine management or clinical decision-making, the SITI score may be a useful adjunct to the clinical impression of the surgeon and ED provider to guide TBI management in the acute setting.

A component of the debate surrounding the benefits of decompressive craniectomy in the management of TBI centers around the indications for surgery used to select optimal patients.4 Previous investigators have used differing inclusion criteria, and findings have not been consistent among studies.4,13 Rather than dictating surgical decision-making, this scale was designed to create an objective measure to assist in facilitating communication between clinicians, streamlining the relay of information from the ED to the neurosurgeon and for hospital-to-hospital transfers.10,12

The data needed to calculate the SITI score are information already obtained when patients with TBI present to the ED, and are easily assessed. Cranial imaging, GCS score, and presence of an enlarged unilateral pupil are generally obtained in all TBI patients. From the head CT image, midline shift, temporal lobe pathology, and presence of an epidural hematoma greater than 10 mm can all be identified quickly. Each component of the SITI scale in our study was statistically different between the operative and nonoperative groups, but combining them in a unified scale results in a stronger analytical tool.

Importantly, it should be noted that the threshold for surgical intervention in the pediatric population appears to be lower than that observed in the adult population.10 While direct comparisons cannot be made between these two populations, there exists a much wider dichotomy in GCS score (GCS score < 12, 72.7% vs 15.0%) and temporal pathology (60.0% vs 9.3%) in pediatric patients who eventually receive operative intervention, when compared to similar studies evaluating the impact of GCS score (mean GCS score = 9 vs 10.7) and temporal pathology (67.0% vs 62.5%) on the perceived need for operative intervention in the adult population.10 This would indicate that these individual components of the SITI score may have a greater impact on the perceived need for operative intervention in the pediatric population.

No scale currently exists that gauges the perceived need for surgical intervention in pediatric patients with TBI. Other scales exist for predicting and analyzing outcomes.14–16 Most notably, the GCS score has been validated to predict outcomes for neurotrauma in both adults and children, while the Pediatric Cerebral Performance Category scale and Glasgow Outcome Scale–Extended for Pediatrics are frequently used to analyze outcomes in pediatric patients.14–16 The SITI scale would potentially fill a void where no clinical tool is currently used to enhance clear communication between clinicians to expedite the transition of patients to the operating room when needed. Although this scale was not developed to determine surgical candidacy, streamlined communication would be expected to reduce transition time from presentation to surgical decompression in pediatric patients who are surgical candidates, which may improve TBI outcomes.3,7,17

Although the SITI scale was developed and validated in adult patients, it is important to assess its validity in pediatric patients as well, as factors affecting TBI outcomes differ between the populations and findings from adult studies may not translate to the pediatric population.18 Previous studies in adults have shown that a mean SITI score of 5.1 is highly correlative with a perceived need for surgical management, and that a threshold of 3 or higher is indicative of a positive test.10–12 This provided a sensitivity of 93% with a specificity of 66%, with the mean SITI score in the nonoperative cohort being 2.5.12 Notably, the present study demonstrates that the benchmark is lower in pediatrics. This study found that a SITI score of 2 or higher correlates with the treating neurosurgeon’s perceived need to perform a craniotomy or craniectomy in the treatment of TBI. This threshold maintains a strong sensitivity of 96.4% with a stronger specificity (86.9%) than is seen in the adult population. This is likely due to the divergence noted in the mean operative (4.98) and nonoperative (0.41) SITI scores in the pediatric population. After investigating pediatric patients with moderate to severe TBI alone (GCS scores 3–12), a threshold of 3 or higher on the SITI scale maintained a similar correlation to that seen in adult neurotrauma patients.

While this scale provides both strong sensitivity and specificity, it is important to note the low positive predictive value (21.5%) indicates that there are many patients with SITI scores of 2 or higher who do not require operative intervention. The negative predictive value of this threshold remains high (99.8%), as patients with a SITI score of 0 or 1 are unlikely to require surgical treatment. While rare, even patients with a low score may at times require surgical intervention. Further, the majority of patients scoring above the described threshold will not require surgical intervention, underscoring the need for a pediatric neurosurgeon to assess all components of the patient’s care. It should be stressed that this scoring system is simply a communicative tool to convey vital surgical information and potential surgical need, but certainly should not be used as the sole means of selecting surgical patients.

The difference in optimal thresholds in the adult and pediatric populations may be due to a variety of factors, including more aggressive treatment with children given lower reserve to tolerate cerebral edema. These results are consistent with the published literature that pediatric patients achieve better functional outcomes and lower mortality rates when compared to adults with similar presentations. As a result, pediatric patients may obtain greater benefit from more aggressive treatment.7 Delineating a scale optimized for use in the pediatric population will help triage patients, ensuring that patients get appropriate treatment as quickly as possible to maximize good outcomes.

This study has several limitations. The retrospective nature of the study introduces potential bias and is unable to represent TBI management decisions made with the aid of the SITI scale. While the original SITI score was not published until the final year of this study period, it is conceivable that this may have influenced surgical decision-making. Nonetheless, the SITI scale was not routinely used in clinical care for TBI management during the study period. This scale only assesses closed head injury as other forms of TBI, such as open/depressed skull fractures, penetrating injuries, and posterior fossa pathology, have additional factors and differing indications influencing surgical decision-making. Furthermore, all data were collected at a single medical center, where decompressive surgeries were performed on a limited patient population solely by surgeons employed at that center. To further refine and validate the SITI scale, both multicenter and prospective studies of TBI patients are needed and further clinical trials will evaluate the clinical utilization of the SITI scale in pediatric patients to determine its clinical efficacy.

Conclusions

The SITI scale was created to be an efficient mechanism to quickly and easily convey the potential need for emergent decompressive surgery in TBI patients, facilitating communication between clinicians. This study applied the SITI scale to pediatric patients, investigating its possible utility as a robust clinical tool to triage pediatric TBI patients, correlating with the treating neurosurgeon’s perceived need for operative intervention. Given the results of this study, further research utilizing the SITI scale in pediatric patients in a prospective manner is warranted.

Disclosures

Dr. Dhall reports being a consultant to DePuy and Globus.

Author Contributions

Conception and design: Dornbos, Huntoon, Leonard, Dhall, Sribnick. Acquisition of data: Dornbos, Monson, Look. Analysis and interpretation of data: Dornbos, Monson, Look, Sribnick. Drafting the article: Dornbos, Smith. Critically revising the article: Dornbos, Huntoon, Smith, Sribnick. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Dornbos. Study supervision: Leonard, Dhall, Sribnick.

Supplemental Information

Previous Presentations

A portion of the content was previously presented orally at the AANS/CNS Pediatric Section Meeting in Orlando, Florida, on December 7, 2016.

References

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    Emami P, Czorlich P, Fritzsche FS, et al. 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. 2017;126(3):760767.

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    Sribnick EA, Hanfelt JJ, Dhall SS. A clinical scale to communicate surgical urgency for traumatic brain injury: a preliminary study. Surg Neurol Int. 2015;6:1.

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    Sribnick EA, Shi J, Lunney MP, et al. 379 Communicating a traumatic brain injury patient’s potential need for operative intervention: the Surgical Intervention for Traumatic Injury scale. Neurosurgery. 2016;63(suppl 1):213.

    • Search Google Scholar
    • Export Citation
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    Sribnick EA, Lunney M, Wright DW, et al. The Surgical Intervention for Traumatic Injury scale: a clinical tool for traumatic brain injury. West J Emerg Med. 2019;20(4):578584.

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    Fiser DH. Assessing the outcome of pediatric intensive care. J Pediatr. 1992;121(1):6874.

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Contributor Notes

Correspondence David Dornbos III: The Ohio State University Wexner Medical Center, Columbus, OH. david.dornbos.3@gmail.com.

INCLUDE WHEN CITING Published online April 10, 2020; DOI: 10.3171/2020.2.PEDS19474.

Disclosures Dr. Dhall reports being a consultant to DePuy and Globus.

  • View in gallery

    AUROC for SITI score in a pediatric TBI population. The AUROC for the SITI score in the pediatric population was 0.979, demonstrating the correlation between a higher score and the perceived need for surgical intervention. Figure is available in color online only.

  • 1

    Report to Congress on Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. Centers for Disease Control and Prevention; 2015. Accessed February 24, 2020. https://www.cdc.gov/traumaticbraininjury/pubs/congress_epi_rehab.html

    • Search Google Scholar
    • Export Citation
  • 2

    Stein DG, Geddes RI, Sribnick EA. Recent developments in clinical trials for the treatment of traumatic brain injury. Handb Clin Neurol. 2015;127:433451.

    • Search Google Scholar
    • Export Citation
  • 3

    Joosse P, Saltzherr TP, van Lieshout WA, et al. Impact of secondary transfer on patients with severe traumatic brain injury. J Trauma Acute Care Surg. 2012;72(2):487490.

    • Search Google Scholar
    • Export Citation
  • 4

    Kolias AG, Guilfoyle MR, Helmy A, et al. Traumatic brain injury in adults. Pract Neurol. 2013;13(4):228235.

  • 5

    McNett M. A review of the predictive ability of Glasgow Coma Scale scores in head-injured patients. J Neurosci Nurs. 2007;39(2):6875.

    • Search Google Scholar
    • Export Citation
  • 6

    Perel P, Arango M, Clayton T, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008;336(7641):425429.

    • Search Google Scholar
    • Export Citation
  • 7

    Emami P, Czorlich P, Fritzsche FS, et al. 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. 2017;126(3):760767.

    • Search Google Scholar
    • Export Citation
  • 8

    Gómez PA, de-la-Cruz J, Lora D, et al. Validation of a prognostic score for early mortality in severe head injury cases. J Neurosurg. 2014;121(6):13141322.

    • Search Google Scholar
    • Export Citation
  • 9

    Young AM, Guilfoyle MR, Fernandes H, et al. The application of adult traumatic brain injury models in a pediatric cohort. J Neurosurg Pediatr. 2016;18(5):558564.

    • Search Google Scholar
    • Export Citation
  • 10

    Sribnick EA, Hanfelt JJ, Dhall SS. A clinical scale to communicate surgical urgency for traumatic brain injury: a preliminary study. Surg Neurol Int. 2015;6:1.

    • Search Google Scholar
    • Export Citation
  • 11

    Sribnick EA, Shi J, Lunney MP, et al. 379 Communicating a traumatic brain injury patient’s potential need for operative intervention: the Surgical Intervention for Traumatic Injury scale. Neurosurgery. 2016;63(suppl 1):213.

    • Search Google Scholar
    • Export Citation
  • 12

    Sribnick EA, Lunney M, Wright DW, et al. The Surgical Intervention for Traumatic Injury scale: a clinical tool for traumatic brain injury. West J Emerg Med. 2019;20(4):578584.

    • Search Google Scholar
    • Export Citation
  • 13

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