Outcome from head injury related to patient' age

A longitudinal prospective study of adult and pediatric head injury

Full access

✓ A series of 8814 head-injured patients admitted to 41 hospitals in three separate metropolitan areas were prospectively studied. Of these, 1906 patients (21.6%) were 14 years of age or less. This “pediatric population” was compared to the remaining “adult population” for mechanism of injury, admission Glasgow Coma Scale score, motor score, blood pressure, pupillary reactivity, the presence of associated injuries, and the presence of subdural or epidural hematoma. The relationship of each of these factors was then correlated with posttraumatic mortality. Except for patients found to have subdural hematoma and those who were profoundly hypotensive, the pediatric patients exhibited a significantly lower mortality rate compared to the adults, thus confirming this generally held view. This study indicates that age itself, even within the pediatric age range, is a major independent factor affecting the mortality rate in head-injured patients.

Many clinical factors have been shown to predict the outcome in patients with head injury. Numerous studies have indicated that these important factors are: patient' age, admission Glasgow Coma Scale (GCS) score, motor responses, pupillary responses, and the presence of associated injuries, hypotension, hypoxia, and certain intracranial hemorrhages.1,5,6,11,23,27,37 Although it is generally, but not universally, accepted that children suffer a lower risk of mortality from head injury than adults,2 it has not been clear whether this relationship is independent of the injury mechanism or due to a lower rate of occurrence of mass lesions in children.2,8,9,17,24,25,40 There has also been disagreement about the effect of age on outcome within the pediatric age group itself. Some authors have reported that outcome tends to be better for patients aged under 10 years,2,11,14,35,50 while others have suggested that infants have a higher mortality rate than older children.20,24,26,31,41

Most studies of outcome from head injury suffer from a failure to address the age question within the population reported,46 or they report only limited numbers of young patients.23 This requires comparisons with studies performed at major pediatric centers, which have no concurrent comparable adult population.2,8,9,25,39 The present study compares the outcome of adult and pediatric patients within a large population and analyzes the differences in outcome for each major clinical determinant of mortality due to head injury.

Clinical Material and Methods

Information was obtained prospectively, beginning with admission to the hospital, for all patients with head injuries who were admitted during the years 1980 to 1981 to six hospitals in Bronx County, New York, three hospitals in Harris County, Texas, and 32 hospitals in San Diego County, California. Within each region, all hospitals with designated adult or pediatric trauma centers were specifically included in the study.

A head injury was defined as any injury resulting in unconsciousness, amnesia, seizure, or skull fracture. Patients whose head injury was the direct result of a gunshot wound or was limited to scalp lacerations or bruises without causing unconsciousness were excluded. Variables recorded at the time of admission included age, sex, mechanism of injury, vital signs on admission, GCS score after nonsurgical resuscitation, pupillary size and reactivity, major symptoms, the presence of associated injuries, the results of diagnostic studies including computerized tomography (CT) scans and skull x-ray films, and the presence or absence of brain injury as determined by a CT scan or surgical procedure. The presence of significant multiple injury was determined by Abbreviated Injury Scale coding (AIS),13 and included the presence or absence of injury to the spinal column or spinal cord, chest (defined as the need for tube thoracostomy or open thoracotomy), or abdomen (such as a hypotensive patient who was found to have intra-abdominal organ injury or a positive peritoneal lavage), and fractures of the extremities or pelvis. Mortality information was confined to deaths occurring prior to hospital discharge.

Statistical testing was performed using nonparametric methods. Two-by-two tables were analyzed by Pearson' chi-square test with Yates' correction. Ordered contingency tables were analyzed by the Mantel-Haenszel procedure.32 In order to determine whether age significantly improved prediction of survival when other factors were taken into account, logistic regression was used.15

Results

Originally, 9272 patients were prospectively entered into this study; however, information concerning the age of the patient was available for only 8814. The overall mortality rate for this population was 8.8%. A graph demonstrating mortality by age, in 5-year epochs, for 8671 patients is shown in Fig. 1 (143 patients, all of whom were adults, did not have their exact ages recorded). This graph reveals a progressive decline in mortality rate throughout the first 15 years of life, followed by a variable but progressive increase throughout adulthood.

Fig. 1.
Fig. 1.

Percent mortality for 8671 patients by 5-year age groups with denominators shown in parentheses. Exact ages were not known for 143 of the 8814 patients, all of whom were over 15 years of age, and these were excluded from this analysis.

The “pediatric group” included 1906 patients aged 14 years or less (21.6%), and the “adult group” included 6908 patients who were aged 15 years or older (78.4%). The mortality rate for these two groups was 2.5% and 10.4%, respectively. For pediatric patients, the highest mortality rate occurred in very young children: for children up to 1 year of age it was 3.3%, rising to 6.2% for the patients aged 1 and 2 years, and then steadily decreasing throughout childhood. The lowest mortality rate (0.9%) for the entire patient population of both children and adults occurred at the age of 12 years. The steepest increase in mortality rates in patients over 15 years of age occurred between the ages of 15 and 24 years. The average mortality rate for this group was 9.1%, 3.6 times greater than for the pediatric patients. This 10-year epoch also contained 55% of all the patients in the population.

The distribution of head injury severity was different for adults and children. In 1705 children and 5614 adults for whom the admission GCS score was available, 95 children (5.6%) presented with a GCS score of 8 or less, compared to 681 adults (12.1%). However, there was little difference in the occurrence of moderate head injury (GCS score 9 to 12) between the two groups, with 138 children (8.1%) and 522 adults (9.2%) admitted with this score. Mild head injuries (GCS score 13 to 15) were more common in children (1472 patients, 86.3%) than in adults (4411 patients, 78.6%).

The major mechanisms of injury are shown in Fig. 2 left. In very young children and in adults over the age of 60 years, the most frequent cause of head injury, regardless of outcome, was falls. In the pediatric age group the major cause of head injury was falls, followed by motor-vehicle accidents, bicycle accidents, assaults, and sporting injuries. In the adult population the leading cause of head injury was motor-vehicle accidents, followed by assault and falls. Sixty percent of the head injuries in the 15- to 24-year age group were caused by automobile and motorcycle accidents.

Fig. 2.
Fig. 2.

Major mechanisms of head injury shown by 5-year age groups. Data are shown for the entire group (left) and for head injury resulting in death (right).

Figure 2 right shows the mechanism of injury for patients who subsequently died of their head injury. The most common mechanism of injury resulting in death for patients between 0 and 55 years of age was motor-vehicle accidents. Over the age of 55 years, falls accounted for about the same percentage of deaths as motor-vehicle accidents. In the pediatric age group other fatal mechanisms of injury were falls and bicycle accidents. Falls were more likely to result in death in very young children and bicycle accidents were more likely to result in death in older children. The incidence of lethal assault fell steadily throughout the childhood age groups, and then rose again after the age of 25 years. Motorcycle accidents represented an important cause of death from head injury in the 15- to-39-year age population.

Table 1 and Fig. 3 show the mortality rates correlated with admission GCS scores for the adult and pediatric populations. There were 1705 pediatric patients and 5614 adult patients for whom GCS score, age, and mortality information were available. No pediatric patient with a GCS score of 11 or more died in this series. Figure 3 shows that, with the exception of a GCS score of 5 or 9, the mortality for pediatric patients was reproducibly lower than for adult patients with the same GCS score (Mantel-Haenszel summary chi-square: p < 0.001). Table 1 demonstrates that these differences in mortality are more important for severe (GCS score 3 to 8) and mild (GCS score 13 to 15) head injuries than for moderate injuries (GCS score 9 to 12). When the actual pediatric deaths for each group of injury severity are compared to those that would be expected if adult mortality prevailed, it was found that there were 39 fewer deaths than expected, but that only 7.5 of these were found in the moderate injury group.

TABLE 1

Mortality rate correlated with patients' age and GCS score*

GCS ScoreAge (yrs)Difference: Adult vs. Pediatric Deaths 
0–14≥ 15p Value   
3–8 28.4%47.7%< 0.00145.3 − 27= 18.3 
(severe) (95)(681) 
9–12 1.4%6.8%0.0259.5 − 2 = 7.5 
(moderate) (138)(522) 
13–15 0.0%0.9%< 0.00113.2 − 0 = 13.2 
(mild) (1472)(4411) 

GCS = Glasgow Coma Scale. Denominators are shown in parentheses.

Calculated pediatric deaths were computed as: expected deaths (based on adult data) − observed deaths = difference.

Fig. 3.
Fig. 3.

Mortality rate for each Glasgow Coma Scale score obtained on admission after neurosurgical resuscitation for children and adults.

Previous work has indicated that the motor score element of the GCS score correlates best with outcome.4,6,26,37 Furthermore, the motor examination is most likely to be comparable between all ages of patients. Therefore, the mortality rate in relation to the admission motor score was calculated for pediatric and adult patients (Fig. 4). There were 1807 pediatric patients and 6317 adult patients with the information available for this analysis. For each motor score, the mortality due to head injury was lower for pediatric patients than for adult patients, an effect that was progressively magnified for greater motor scores. As indicated by the results of the GCS score analysis, no child in this series with a motor score of 6 died.

Fig. 4.
Fig. 4.

Mortality rate correlated with the motor score element of the Glasgow Coma Scale obtained on admission after nonsurgical resuscitation for children and adults.

In order to further demonstrate the relationship of age to mortality for various levels of injury severity, patients were divided by GCS score into three groups: severe (GCS score ≤ 8), moderate (GCS score 9 to 12), and mild (GCS score 13 to 15). The mortality rate by age for each group is shown in Fig. 5. For all degrees of injury severity there was a clear general increase in the mortality rate with increasing age. However, for severely head-injured children there was a decline in the mortality rate up to the age of 14 years. For moderately injured patients there appeared to be essentially no change with age throughout childhood and then a steady increase with age throughout adulthood, although not as steep as with the severely injured patients. No child with a mild head injury died. However, there was a slight but perceptible increase in the incidence of mortality with increasing age for mild head injury in adult patients.

Fig. 5.
Fig. 5.

Mortality rate correlated with age and stratified by Glasgow Coma Scale (GCS) score on admission after nonsurgical resuscitation. The mortality rate due to severe head injury declines with increasing age in childhood; the rate for mild and moderate head injury generally increases with age in adults only.

In 1688 children and 5856 adults there were enough data to study the effect on mortality of the presence or absence of pupillary activity. Twenty-five (53.2%) of 47 children with bilaterally fixed pupils died compared to 290 (66.5%) of 436 adults (p = 0.07). Among patients with a unilaterally fixed pupil and a contralateral reactive pupil, 15 (20.5%) of 73 children died compared to 153 (38.5%) of 402 adults (p < 0.006). For patients with bilaterally reactive pupils, 14 (0.9%) of 1582 children died compared to 178 (3.5%) of 5018 adults (p < 0.001).

The relationship between blood pressure on admission and mortality was examined in 1531 children and 6434 adults. For this analysis, blood pressures on admission were compared to the expected normal blood pressure corrected for age and sex,3thus allowing a more accurate assessment of which patients were truly hypotensive or hypertensive. Patients were then grouped by the difference in their admission systolic blood pressure from the expected normal. As shown in Table 2, for head-injured children who were profoundly hypotensive (that is, more than 30 mm Hg below the expected median for their age), the mortality rate was 33.3% compared with a mortality rate of 11.8% for patients who were older than 15 years of age (p < 0.005). However, for any other range of blood pressure the mortality rate for the pediatric age group was 65% to 80% less than that for the corresponding adults. These data also show that both hypotension and hypertension are associated with a higher mortality rate in adults; only hypotension was associated with a higher incidence of mortality in children.

TABLE 2

Percent mortality correlated with patient' age and degree of hypotension*

Age (yrs)Systolic Blood Pressure on Admission (mm Hg)
−30−29 to −10−9 to +9+10 to +29 +30 
0–14 33.34.72.2 2.8 
(1531 cases) (24)(172)(498) (463) 
≥ 15 yrs 11.813.46.6 7.9 
(6434 cases) (702)(621)(968) (1724) 

Numbers of patients available for analysis are shown in parentheses.

Difference in systolic blood pressure on admission from normal values corrected for age and sex.

The effect of associated injuries on death from head injury34,38,48 could be examined in 1906 children and 6908 adults. The presence of injuries other than spinal trauma caused a significant increase in mortality of patients with a head injury in both the adult and pediatric age groups. This effect was most profound for chest and abdominal injury, and least profound for injuries to an extremity or the pelvis. However, as shown in Table 3, the mortality rate for head-injured children with multiple injuries and with fractures was significantly lower than for similarly injured adults.

TABLE 3

Percent mortality correlated with patient' age and associated injury*

Associated InjuryAge Group (yrs)pValue
0–14≥ 15   
multiple trauma6.4 (390) 13.8 (2860) < 0.001
arm, leg, or pelvic fractures6.0 (182) 15.0 (1191) < 0.002
spine injury8.3 (12) 10.3 (311) 0.79
chest injury17.5 (57) 21.6 (719) 0.60
abdominal injury16.7 (60) 26.6 (455) 0.13
chest & abdominal injury15.0 (20) 35.4 (189) 0.11
total cases(1906) (6908) 

Numbers of patients available for analysis are shown in parentheses.

Sample size plays a key role. For multiple injuries or long-bone or pelvic fractures, children showed less than half the risk of adults. The death rates for spine or chest injury and head injury are clearly not significantly different. The differences for abdominal injury and chest and abdominal injury are great, but the samples are small and therefore not statistically significant.

Figure 6 demonstrates the occurrence of subdural hematoma (SDH) and epidural hematoma (EDH) by age, computed in 5-year intervals. The occurrence of SDH generally decreased as age increased throughout childhood and then increased with age, beginning with the teen-age years. In contrast, the occurrence of EDH rose progressively throughout childhood and early adulthood, reaching a peak at about 27 years of age and then steadily fell throughout the major adult age groups. There was then a secondary rise in the occurrence of EDH in very elderly patients. Thirty-seven children were found to have SDH and 15 (40.5%) of these children died; 435 adults had SDH and 191 (43.9%) died. Information on the admission motor examination for the children with SDH was available for 36 of the 37 children and 365 of the 435 adults. Fifty percent of the children and 43% of the adults initially presented with abnormal flexion or worse.

Fig. 6.
Fig. 6.

The distribution of subdural and epidural hematomas grouped by age in 5-year intervals. The occurrence of subdural hematoma falls with increasing age throughout childhood and increases with increasing age throughout adulthood. Epidural hematomas were most commonly seen between the ages of 15 and 35 years.

Twenty-three children were found to have EDH, but only one (4.3%) of these children died. In contrast, 195 adults had EDH but, unlike the children, 42 (21.5%) of these patients died. However, this large difference was not statistically significant (p = 0.09). Information on the admission examination for patients with EDH was available for 22 of the 23 children and 165 of the 195 adults. Almost 60% of the children with EDH were obeying commands on admission, in contrast to about one-third of adults.

The data were also analyzed in order to determine the effect of eliminating patients with SDH or EDH on the age-mortality curve shown in Fig. 1. Figure 7 shows mortality curves by age, excluding EDH and SDH. The exclusion of the diagnosis of epidural hematoma had a trivial effect of the shape of the mortality curve. However, the exclusion of SDH resulted in a reduction of the slope of the curve, but only for adult patients.

Fig. 7.
Fig. 7.

The effect of removing patients from analysis who were found to have subdural (SDH) or epidural (EDH) hematomas on the mortality rate-by-age curve. Removing patients with EDH has essentially no effect on the shape of the curve. Removing patients with SDH diminishes mortality for both adults and children, but more so in adults, and this effect is magnified by increasing age.

Logistic regression analysis indicated that age (that is, 14 years of age or younger vs. 15 years or older) significantly added to the accuracy of a predictive model that included the GCS score, pupillary reactivity, mechanism of injury, systolic blood pressure, multiple injuries, SDH, and EDH. When this extensive list of clinical factors was taken into account, pediatric patients were estimated to have a relative risk of death which was 84% of that for equivalently injured adults (p = 0.001). This is a summary value, because the data indicate that risk varies continuously with age. Finally, although the logistic model suggested that a large proportion of the difference between adult and pediatric mortality rates could be accounted for by factors other than age, since unadjusted risk of death for children was only 25% of that for adults, it did indicate that the risk attributable solely to age was still highly statistically significant.

Discussion

This study correlates the mortality rate from head injury based on the patients' age. Of major factors directly related to injury severity, age has been shown in most studies, although not all, to have some effect on outcome,1,4,6,9,11,14,16,18,23,26,31,37,47 such that older patients have poorer outcomes. The current study confirms this trend for adult patients only. In contrast, we found that in the pediatric age group the overall mortality from head injury declined with increasing age. This is an important difference between adults and children that has not been previously reported.

The data from this large series of patients indicate that a natural division based on outcome occurred in early adolescence. Clearly, the mortality rate changed at about 15 years of age, although the lowest mortality occurred at age 12 years. Furthermore, the major mechanism of injury changed at 15 years of age, with motorvehicle accidents surpassing both falls and bicycle accidents as the major cause of head injury. There was also a marked increase in the mortality rate in patients between the ages of 15 and 35 years, where most of the head injuries in this population occurred. These are the “trauma-prone” ages, which we consider to be a subset of the adult age group. Thus, it seems reasonable to suggest that, for the purposes of comparing outcomes from head injury, “pediatric head injuries” be defined as those occurring in patients under 15 years of age.

This study demonstrates several other differences based generally on age. For instance, even though severe head injury occurred much less often in children than in adults, the mortality rate for severe head injury in the adult age group was almost twice that of the pediatric patients. This has been noted by others, and may be due partially to differences in the mechanism of injury,26–28 the effects of alcohol and drugs, the increased frequency of mass lesions in the adult age group, and the possibility that systemic injury is more severe in adult patients. The mortality rates reported in this series of severely head-injured adults are comparable to the findings of other major published series,6,26,36 although some centers have reported lower mortality rates.1,5,43 The mortality rate for severe head injury in the pediatric age group found in this study (28.4%) is also comparable to rates found in other reported series,2,7,23,24,29,31,40 although rates as low as 6% have been reported.9 However, comparisons with mortality data in other series of head-injured children are confounded by a variation in the definitions of the pediatric age group and by the average age of the patients in the series. In contrast, the present study carries the advantages of large numbers and a fully balanced age distribution.

The difference in mortality rates between adults and children continues throughout the less severe ranges of head injury. The mortality rate for children admitted with a GCS score of 9 to 12 was only 1.4% compared to almost 7% for adults with a similar neurological examination. We could not find a published mortality rate for moderate head injury in children, but the data for adults with moderate head injury are similar to those reported by Rimel, et al.42 We also found that 0.9% of adult patients with mild head injury died, whereas no child in this study who was admitted with a GCS score of 13 or above or a motor score of 6 died. Snoek, et al.,45 reported a mortality rate of 0.3% in 967 mildly head-injured children, indicating that children are occasionally at risk for delayed deterioration. The importance of concern for “low risk” patients has been emphasized,33 but it appears that children at risk do not die or that neurological deterioration is recognized earlier and major complications are avoided in such cases. It is possible that children with mild or moderate head injuries are more likely to undergo neuroradiographic studies than are adult patients because of perceived difficulties in performing complete neurological examinations or because a slight alteration in consciousness in a child is less likely to be ascribed to other factors, such as the use of alcohol. In any event, there clearly remains an independent effect of age on outcome that pertains to all degrees of injury.

Another way at looking at this phenomenon is by comparing outcomes for each level of motor score examination. This analysis shows that about 65% of children who were flaccid on admission died, compared to about 80% of adults, a general finding that compares well to the 76% mortality rate reported by Butterworth, et al.,10 for patients of all ages who were flaccid on admission. Higher motor scores carried lower mortality for both groups (Fig. 4), but the differences in mortality rates between children and adults became progressively greater as motor scores became higher. As motor scores improved (Fig. 4), the mortality rate decreased for both groups, more so for pediatric patients than for adults.

This study also shows a dramatically lower mortality rate for children compared to adults for similar pupillary reactivities, the associated presence of multiple injuries, and most levels of blood pressure on admission, except for patients with profound hypotension. In this regard, head-injured children who showed a systolic blood pressure of 30 mm Hg less than their expected normal systolic blood pressure (corrected for their age and sex) had a mortality rate of 33% compared to only 11.8% for adults with this degree of hypotension. Furthermore, children with severe hypertension had the lowest mortality rate, a finding which is in contrast to recent reports indicating that severe hypertension for brain-injured pediatric patients is an ominous prognostic sign.28 It is possible, however, that this finding is artificial and related to the fact that children who are feeling pain and who might otherwise be unable to communicate could show significant elevations in their pulse and blood pressure.

The analysis of the effect of certain mass lesions provided some interesting comparisons between children and adults. It has been known that SDH is a common accompaniment of severe head injury in infants and very young children.22,49 This study documents that SDH occurs as frequently in infants as in young adults, and that the mortality rate for children with SDH is essentially the same as that for adults with this finding. This may be due less to the hematoma itself and more to the possibility that the presence of SDH serves as a marker of significant diffuse brain injury in both adults and children. In this series, children with SDH tended to show neurological findings that were only slightly worse than those in adults: 50% of children and 42% of adults exhibited abnormal flexion or worse on admission.

In contrast, EDH was relatively infrequent in very young children and became progressively more frequent until 20 to 40 years old; the incidence then progressively declined over the next two decades. In contrast to those children presenting with SDH, initial neurological examinations showed that 90% of children with EDH showed withdrawal in response to pain or to a less noxious stimulus. In fact, almost 60% of children were following commands even though they harbored (or would develop) EDH. This should be compared to the finding that almost one-third of adult patients with EDH presented with reflex flexion or worse on their initial examination, and only 30% were following commands on admission. With these considerations, the mortality rate for EDH was different between adult and pediatric patients. Only one (4.3%) of 22 children with EDH died in this series compared to 42 (21.5%) of the 195 adult patients who were found to have this diagnosis. A low mortality rate for EDH in childhood has been reported previously by Gutierrez, et al.,21 but others have reported higher mortality rates similar to that of the adult population.12,30,39 Again, some of the differences found in the the present study are associated with the finding that adult patients with EDH were more likely to be comatose at presentation, which has been shown to be associated with a significantly higher mortality rate.44 This study again confirms the findings of Gennarelli, et al.,19 and Miller, et al.,36 regarding the negative effect on outcome that certain intracranial lesions can have. However, the overall poor outcome from SDH seems not to be affected by the patient' age. The outcome from EDH appears to be at least partially age-related.

In order to analyze the effect of the presence of SDH on the overall age-mortality curve, the data were recalculated to exclude all patients known to harbor SDH. This resulted in a definite reduction in mortality rates for older patients but only a very slight improvement in the mortality rates for children. However, even when patients with SDH were excluded, there was still a clearcut relationship of age to outcome, with a declining mortality rate with age in the pediatric population and a progressively increasing mortality with age in the adult population. Thus, although SDH is a significant contributor to overall mortality due to head injury, it is clearly not a sufficient explanation in and of itself for the age-related increase in mortality rate seen throughout the adult group.

Logistic regression analysis showed a highly significant difference between the mortality rate for adults and children with head injury. This analysis, which took into account other major predictors of mortality, indicates that some of the differences in crude mortality rates can be explained by other predictors. However, it is possible and even likely that some of these predictors of mortality are also significantly influenced by age.

Conclusions

This study strongly confirms the relationship of patients' age to mortality from head injury. This relationship is different for children than for adults, and applies through all levels of severity. With the exception of patients harboring SDH or patients who are profoundly hypotensive on admission, patients aged under 14 years had lower mortality rates than older patients for all other determinants of mortality studied. We were unable to investigate the effect of intracranial pressure, hypoxia, the degree of brain swelling or shift, or the size of mass lesions on outcome. These are important issues, and further studies of the effect of these parameters, especially in the pediatric age group, are needed.

Acknowledgments

We are grateful for the contributions of the following individuals and institutions: Michael D. Walker, M.D., National Institute of Neurological and Communicative Disorders and Stroke; Howard Eisenberg, M.D., University of Texas Medical Branch, Galveston, Texas; Robert G. Grossman, M.D., and Guy L. Clifton, M.D., Baylor College of Medicine, Houston, Texas; Michael Miner, M.D., Ph.D., and Philip L. Gildenberg, M.D., The University of Texas Medical School, Houston, Texas; Kamran Tabaddor, M.D., Bronx Municipal Hospital Center, Bronx, New York; and Robert J. Frye, Ph.D., and Judith C. Huang, University of California Medical Center, San Diego, California. Mr. Ward Flexer provided expert editorial assistance.

References

  • 1.

    Becker DPMiller JDWard JDet al: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:4915021977J Neurosurg 47:

  • 2.

    Berger MSPitts LHLovely Met al: Outcome from severe head injury in children and adolescents. J Neurosurg 62:1941991985J Neurosurg 62:

  • 3.

    Blumenthal SEpps RPHeavenvich Ret al: Report of the task force on blood pressure control in children. Pediatrics 59:(Suppl)7978201977Pediatrics 59 (Suppl):

  • 4.

    Born JDAlbert AHans Pet al: Relative prognostic value of best motor response and brain stem reflexes in patients with severe head injury. Neurosurgery 16:5956011985Neurosurgery 16:

  • 5.

    Bowers SAarshall LF: Outcome in 200 consecutive cases of severe head injury tested in San Diego County: a prospective analysis. Neurosurgery 6:2372421980Neurosurgery 6:

  • 6.

    Braakman RGelpke GJHabbema JDFet al: Systematic selection of prognostic features in patients with severe head injury. Neurosurgery 6:3623701980Neurosurgery 6:

  • 7.

    Bruce DAAlavi ABilaniuk LTet al: Diffuse cerebral swelling following head injuries in children: the syndrome of “malignant brain edema.” J Neurosurg 54:1701781981J Neurosurg 54:

  • 8.

    Bruce DARaphaely RCGoldberg AIet al: Pathophysiology, treatment and outcome following severe head injury in children. Childs Brain 5:1741791979Childs Brain 5:

  • 9.

    Bruce DASchut LBruno LAet al: Outcome following severe head injuries in children. J Neurosurg 48:6796881978J Neurosurg 48:

  • 10.

    Butterworth JF IVSelhorst JBGreenberg RPet al: Flaccidity after head injury: diagnosis, management, and outcome. Neurosurgery 9:2422481981 416Neurosurgery 9:

  • 11.

    Carlsson CAvon Essen CLöfgren J: Factors affecting the clinical course of patients with severe head injuries. Part 1: Influence of biological factors. Part 2: Significance of posttraumatic coma. J Neurosurg 29:2422511968J Neurosurg 29:

  • 12.

    Choux MGrisoli FPeragut JC: Extradural hematomas in children. 104 cases. Childs Brain 1:3373471975Childs Brain 1:

  • 13.

    Committee on Injury Scaling: The Abbreviated Injury Scale. Morton Grove, 111: American Association of Automotive Medicine1980Committee on Injury Scaling: The Abbreviated Injury Scale.

  • 14.

    Comninos SC: Early prognosis of severe head injuries in children. Acta Neurochir Suppl 28:1441471979Comninos SC: Early prognosis of severe head injuries in children. Acta Neurochir Suppl 28:

  • 15.

    Cox DR: The Analysis of Binary Data. London: Methuen1970Cox DR: The Analysis of Binary Data.

  • 16.

    Edna TH: Risk factors in traumatic injury. Acta Neurochir 69:1155211983Edna TH: Risk factors in traumatic injury. Acta Neurochir 69:

  • 17.

    Facco EZuccarello MPittoni Get al: Early outcome prediction in severe head injury: comparison between children and adults. Childs Nerv Syst 2:67711986Childs Nerv Syst 2:

  • 18.

    Gale JLDikman SWyler Aet al: Head injury in the Pacific Northwest. Neurosurgery 12:4874911983Neurosurgery 12:

  • 19.

    Gennarelli TASpielman GMLangfitt TWet al: Influence of the type of intracranial lesion on outcome from severe head injury. J Neurosurg 56:26321982J Neurosurg 56:

  • 20.

    Gross CRWolf CKunitz SCet al: Pilot Traumatic Coma Data Bank: a profile of head injuries in childrenDacey RG JrWinn HRRimel RWet al (eds): Trauma of the Central Nervous System. New York: Raven Press19851926Trauma of the Central Nervous System.

  • 21.

    Gutierrez FAMcLone DGRaimondi AJ: Epidural hematomas in infancy and childhoodAmerican Society for Pediatric Neurosurgery (eds): Concepts in Pediatric Neurosurgery I. Basel: Karger1981188201Concepts in Pediatric Neurosurgery I.

  • 22.

    Gutierrez FARaimondi AJ: Acute subdural hematoma in infancy and childhood. Childs Brain 1:2692901975Childs Brain 1:

  • 23.

    Heiden JSSmall RCaton Wet al: Severe head injury and outcome: prospective studyPopp AJBourke RSNelson LRet al (eds): Neural Trauma. New York: Raven Press1979181193Neural Trauma.

  • 24.

    Humphreys RP: Outcome of severe head injury in childrenRaimondi AJ (ed): Concepts in Pediatric Neurosurgery 3. Basel: Karger1983191201Concepts in Pediatric Neurosurgery 3.

  • 25.

    Ivan LPChoo SHVentureya ECG: Head injuries in childhood: a 2-year survey. Can Med Assoc J 128:2812841983Can Med Assoc J 128:

  • 26.

    Jennett BTeasdale GBraakman Ret al: Prognosis of patients with severe head injury. Neurosurgery 4:2832891979Neurosurgery 4:

  • 27.

    Jennett BTeasdale GGalbraith Set al: Severe head injuries in three countries. J Neurol Neurosurg Psychiatry 40:2912981977J Neurol Neurosurg Psychiatry 40:

  • 28.

    Kanter RKCarroll JBPost EM: Association of arterial hypertension with poor outcome in children with acute brain injury. Clin Pediatr 24:3203231985Clin Pediatr 24:

  • 29.

    Klöti J: Can modern therapy influence the prognosis of brain injuries in childhood? Z Kinderchir 40:1311351985Klöti J: Can modern therapy influence the prognosis of brain injuries in childhood?. Z Kinderchir 40:

  • 30.

    Lobato RDCordobes FRivas JJet al: Outcome from severe head injury related to the type of intracranial lesion. A computerized tomography study. J Neurosurg 59:7627741983J Neurosurg 59:

  • 31.

    Mahoney WJD'ouza BJHaller JAet al: Long-term outcome of children with severe head trauma and prolonged coma. Pediatrics 71:7567621983Pediatrics 71:

  • 32.

    Mantel N: Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 58:6907001963Mantel N: Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 58:

  • 33.

    Marshall LFToole BMBowers SA: The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:2852881983J Neurosurg 59:

  • 34.

    Mayer TWalker MLShasha Iet al: Effect of multiple trauma on outcome of pediatric patients with neurologic injuries. Childs Brain 8:1891971981Childs Brain 8:

  • 35.

    Mazza CPasqualin AFeriotti Get al: Traumatic extradural haematomas in children: experience with 62 cases. Acta Neurochir 65:67801982Acta Neurochir 65:

  • 36.

    Miller JDBecker DPRosner MJet al: Implications of intracranial mass lesions for outcome of severe head injuryPopp AJBourke RSNelson LRet al (eds): Neural Trauma. New York: Raven Press1979173180Neural Trauma.

  • 37.

    Miller JDButterworth JFGudeman SKet al: Further experience in the management of severe head injury. J Neurosurg 54:2892991981J Neurosurg 54:

  • 38.

    Miller JDSweet RCNarayan Ret al: Early insults to the injured brain. JAMA 240:4394421978JAMA 240:

  • 39.

    Pagni CASignoroni GCrotti Fet al: Severe traumatic coma in infancy and childhood: results after surgery and resuscitation. J Neurosurg Sci 19:1201281975J Neurosurg Sci 19:

  • 40.

    Pfenninger JKaiser GLütschg Jet al: Treatment and outcome of the severely head injured child. Intensive Care Med 9:13161983Intensive Care Med 9:

  • 41.

    Raimondi AJHirschauer J: Head injury in the infant and toddler. Coma scoring and outcome scale. Childs Brain 11:12351984Childs Brain 11:

  • 42.

    Rimel RWGiordani BBarth JTet al: Moderate head injury: completing the clinical spectrum of brain trauma. Neurosurgery 11:3443511982Neurosurgery 11:

  • 43.

    Saul TGDucker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:4985031982J Neurosurg 56:

  • 44.

    Seelig JMMarshall LFToutant JMet al: Traumatic acute epidural hematoma: unrecognized high lethality in comatose patients. Neurosurgery 15:6176201984Neurosurgery 15:

  • 45.

    Snoek JWMinderhoud JMWilmink JT: Delayed deterioration following minor head injury in children. Brain 107:15361984Brain 107:

  • 46.

    Tamas LBDacey RG JrWinn HR: Studies of severe head injury: an overviewDacey RG JrWinn HRRimel RWet al (eds): Trauma of the Central Nervous System. New York: Raven Press1985103122Trauma of the Central Nervous System.

  • 47.

    Teasdale GSkene AParker Let al: Age and outcome of severe head injury. Acta Neurochir Suppl 28:1401431979Acta Neurochir Suppl 28:

  • 48.

    Walker MLMayer TAStorrs BBet al: Pediatric head injury — factors which influence outcomeChapman PH (ed): Concepts in Pediatric Neurosurgery 6. Basel: Karger19858497Concepts in Pediatric Neurosurgery 6.

  • 49.

    Zimmerman RABilaniuk LTBruce Det al: Computed tomography of craniocerebral injury in the abused child. Radiology 130:6876901979Radiology 130:

  • 50.

    Zuccarello MFacco EZampieri Pet al: Severe head injury in children: early prognosis and outcome. Childs Nerv Syst 1:1581721985Childs Nerv Syst 1:

This study was supported by Contracts N01-NS-9-2312, 2313, and 2314B from the National Institute of Neurological and Communicative Disorders and Stroke.

This work was presented in part at the Annual Meeting of the Pediatric Section of the American Association of Neurological Surgeons, in Pittsburgh, Pennsylvania, on December 5, 1986.

Article Information

Address reprint requests to: Thomas G. Luerssen, M.D., Division of Neurosurgery H-893, UCSD Medical Center, 225 Dickinson Street, San Diego, California 92103.

© AANS, except where prohibited by US copyright law."

Headings

Figures

  • View in gallery

    Percent mortality for 8671 patients by 5-year age groups with denominators shown in parentheses. Exact ages were not known for 143 of the 8814 patients, all of whom were over 15 years of age, and these were excluded from this analysis.

  • View in gallery

    Major mechanisms of head injury shown by 5-year age groups. Data are shown for the entire group (left) and for head injury resulting in death (right).

  • View in gallery

    Mortality rate for each Glasgow Coma Scale score obtained on admission after neurosurgical resuscitation for children and adults.

  • View in gallery

    Mortality rate correlated with the motor score element of the Glasgow Coma Scale obtained on admission after nonsurgical resuscitation for children and adults.

  • View in gallery

    Mortality rate correlated with age and stratified by Glasgow Coma Scale (GCS) score on admission after nonsurgical resuscitation. The mortality rate due to severe head injury declines with increasing age in childhood; the rate for mild and moderate head injury generally increases with age in adults only.

  • View in gallery

    The distribution of subdural and epidural hematomas grouped by age in 5-year intervals. The occurrence of subdural hematoma falls with increasing age throughout childhood and increases with increasing age throughout adulthood. Epidural hematomas were most commonly seen between the ages of 15 and 35 years.

  • View in gallery

    The effect of removing patients from analysis who were found to have subdural (SDH) or epidural (EDH) hematomas on the mortality rate-by-age curve. Removing patients with EDH has essentially no effect on the shape of the curve. Removing patients with SDH diminishes mortality for both adults and children, but more so in adults, and this effect is magnified by increasing age.

References

1.

Becker DPMiller JDWard JDet al: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:4915021977J Neurosurg 47:

2.

Berger MSPitts LHLovely Met al: Outcome from severe head injury in children and adolescents. J Neurosurg 62:1941991985J Neurosurg 62:

3.

Blumenthal SEpps RPHeavenvich Ret al: Report of the task force on blood pressure control in children. Pediatrics 59:(Suppl)7978201977Pediatrics 59 (Suppl):

4.

Born JDAlbert AHans Pet al: Relative prognostic value of best motor response and brain stem reflexes in patients with severe head injury. Neurosurgery 16:5956011985Neurosurgery 16:

5.

Bowers SAarshall LF: Outcome in 200 consecutive cases of severe head injury tested in San Diego County: a prospective analysis. Neurosurgery 6:2372421980Neurosurgery 6:

6.

Braakman RGelpke GJHabbema JDFet al: Systematic selection of prognostic features in patients with severe head injury. Neurosurgery 6:3623701980Neurosurgery 6:

7.

Bruce DAAlavi ABilaniuk LTet al: Diffuse cerebral swelling following head injuries in children: the syndrome of “malignant brain edema.” J Neurosurg 54:1701781981J Neurosurg 54:

8.

Bruce DARaphaely RCGoldberg AIet al: Pathophysiology, treatment and outcome following severe head injury in children. Childs Brain 5:1741791979Childs Brain 5:

9.

Bruce DASchut LBruno LAet al: Outcome following severe head injuries in children. J Neurosurg 48:6796881978J Neurosurg 48:

10.

Butterworth JF IVSelhorst JBGreenberg RPet al: Flaccidity after head injury: diagnosis, management, and outcome. Neurosurgery 9:2422481981 416Neurosurgery 9:

11.

Carlsson CAvon Essen CLöfgren J: Factors affecting the clinical course of patients with severe head injuries. Part 1: Influence of biological factors. Part 2: Significance of posttraumatic coma. J Neurosurg 29:2422511968J Neurosurg 29:

12.

Choux MGrisoli FPeragut JC: Extradural hematomas in children. 104 cases. Childs Brain 1:3373471975Childs Brain 1:

13.

Committee on Injury Scaling: The Abbreviated Injury Scale. Morton Grove, 111: American Association of Automotive Medicine1980Committee on Injury Scaling: The Abbreviated Injury Scale.

14.

Comninos SC: Early prognosis of severe head injuries in children. Acta Neurochir Suppl 28:1441471979Comninos SC: Early prognosis of severe head injuries in children. Acta Neurochir Suppl 28:

15.

Cox DR: The Analysis of Binary Data. London: Methuen1970Cox DR: The Analysis of Binary Data.

16.

Edna TH: Risk factors in traumatic injury. Acta Neurochir 69:1155211983Edna TH: Risk factors in traumatic injury. Acta Neurochir 69:

17.

Facco EZuccarello MPittoni Get al: Early outcome prediction in severe head injury: comparison between children and adults. Childs Nerv Syst 2:67711986Childs Nerv Syst 2:

18.

Gale JLDikman SWyler Aet al: Head injury in the Pacific Northwest. Neurosurgery 12:4874911983Neurosurgery 12:

19.

Gennarelli TASpielman GMLangfitt TWet al: Influence of the type of intracranial lesion on outcome from severe head injury. J Neurosurg 56:26321982J Neurosurg 56:

20.

Gross CRWolf CKunitz SCet al: Pilot Traumatic Coma Data Bank: a profile of head injuries in childrenDacey RG JrWinn HRRimel RWet al (eds): Trauma of the Central Nervous System. New York: Raven Press19851926Trauma of the Central Nervous System.

21.

Gutierrez FAMcLone DGRaimondi AJ: Epidural hematomas in infancy and childhoodAmerican Society for Pediatric Neurosurgery (eds): Concepts in Pediatric Neurosurgery I. Basel: Karger1981188201Concepts in Pediatric Neurosurgery I.

22.

Gutierrez FARaimondi AJ: Acute subdural hematoma in infancy and childhood. Childs Brain 1:2692901975Childs Brain 1:

23.

Heiden JSSmall RCaton Wet al: Severe head injury and outcome: prospective studyPopp AJBourke RSNelson LRet al (eds): Neural Trauma. New York: Raven Press1979181193Neural Trauma.

24.

Humphreys RP: Outcome of severe head injury in childrenRaimondi AJ (ed): Concepts in Pediatric Neurosurgery 3. Basel: Karger1983191201Concepts in Pediatric Neurosurgery 3.

25.

Ivan LPChoo SHVentureya ECG: Head injuries in childhood: a 2-year survey. Can Med Assoc J 128:2812841983Can Med Assoc J 128:

26.

Jennett BTeasdale GBraakman Ret al: Prognosis of patients with severe head injury. Neurosurgery 4:2832891979Neurosurgery 4:

27.

Jennett BTeasdale GGalbraith Set al: Severe head injuries in three countries. J Neurol Neurosurg Psychiatry 40:2912981977J Neurol Neurosurg Psychiatry 40:

28.

Kanter RKCarroll JBPost EM: Association of arterial hypertension with poor outcome in children with acute brain injury. Clin Pediatr 24:3203231985Clin Pediatr 24:

29.

Klöti J: Can modern therapy influence the prognosis of brain injuries in childhood? Z Kinderchir 40:1311351985Klöti J: Can modern therapy influence the prognosis of brain injuries in childhood?. Z Kinderchir 40:

30.

Lobato RDCordobes FRivas JJet al: Outcome from severe head injury related to the type of intracranial lesion. A computerized tomography study. J Neurosurg 59:7627741983J Neurosurg 59:

31.

Mahoney WJD'ouza BJHaller JAet al: Long-term outcome of children with severe head trauma and prolonged coma. Pediatrics 71:7567621983Pediatrics 71:

32.

Mantel N: Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 58:6907001963Mantel N: Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 58:

33.

Marshall LFToole BMBowers SA: The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg 59:2852881983J Neurosurg 59:

34.

Mayer TWalker MLShasha Iet al: Effect of multiple trauma on outcome of pediatric patients with neurologic injuries. Childs Brain 8:1891971981Childs Brain 8:

35.

Mazza CPasqualin AFeriotti Get al: Traumatic extradural haematomas in children: experience with 62 cases. Acta Neurochir 65:67801982Acta Neurochir 65:

36.

Miller JDBecker DPRosner MJet al: Implications of intracranial mass lesions for outcome of severe head injuryPopp AJBourke RSNelson LRet al (eds): Neural Trauma. New York: Raven Press1979173180Neural Trauma.

37.

Miller JDButterworth JFGudeman SKet al: Further experience in the management of severe head injury. J Neurosurg 54:2892991981J Neurosurg 54:

38.

Miller JDSweet RCNarayan Ret al: Early insults to the injured brain. JAMA 240:4394421978JAMA 240:

39.

Pagni CASignoroni GCrotti Fet al: Severe traumatic coma in infancy and childhood: results after surgery and resuscitation. J Neurosurg Sci 19:1201281975J Neurosurg Sci 19:

40.

Pfenninger JKaiser GLütschg Jet al: Treatment and outcome of the severely head injured child. Intensive Care Med 9:13161983Intensive Care Med 9:

41.

Raimondi AJHirschauer J: Head injury in the infant and toddler. Coma scoring and outcome scale. Childs Brain 11:12351984Childs Brain 11:

42.

Rimel RWGiordani BBarth JTet al: Moderate head injury: completing the clinical spectrum of brain trauma. Neurosurgery 11:3443511982Neurosurgery 11:

43.

Saul TGDucker TB: Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury. J Neurosurg 56:4985031982J Neurosurg 56:

44.

Seelig JMMarshall LFToutant JMet al: Traumatic acute epidural hematoma: unrecognized high lethality in comatose patients. Neurosurgery 15:6176201984Neurosurgery 15:

45.

Snoek JWMinderhoud JMWilmink JT: Delayed deterioration following minor head injury in children. Brain 107:15361984Brain 107:

46.

Tamas LBDacey RG JrWinn HR: Studies of severe head injury: an overviewDacey RG JrWinn HRRimel RWet al (eds): Trauma of the Central Nervous System. New York: Raven Press1985103122Trauma of the Central Nervous System.

47.

Teasdale GSkene AParker Let al: Age and outcome of severe head injury. Acta Neurochir Suppl 28:1401431979Acta Neurochir Suppl 28:

48.

Walker MLMayer TAStorrs BBet al: Pediatric head injury — factors which influence outcomeChapman PH (ed): Concepts in Pediatric Neurosurgery 6. Basel: Karger19858497Concepts in Pediatric Neurosurgery 6.

49.

Zimmerman RABilaniuk LTBruce Det al: Computed tomography of craniocerebral injury in the abused child. Radiology 130:6876901979Radiology 130:

50.

Zuccarello MFacco EZampieri Pet al: Severe head injury in children: early prognosis and outcome. Childs Nerv Syst 1:1581721985Childs Nerv Syst 1:

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 57 57 57
PDF Downloads 23 23 23
EPUB Downloads 0 0 0

PubMed

Google Scholar