Outcome of patients with traumatic head injury in infants: An institutional experience at level 1 trauma center.

BACKGROUND: Traumatic head injury is a common cause of mortality and acquired disability in infants and children. However, patterns and outcome of head injury in infants are different from other age groups. AIMS AND
OBJECTIVES: Aim of our study was to find out epidemiological factors, characteristics of injury, and outcome in infants with traumatic brain injury.
MATERIALS AND METHODS: This is a retrospective study from March 2009 through Feb 2012, at JPNATC, AIIMS, New Delhi. The clinical records of all patients, admitted with head injury were evaluated. Twenty-nine infants with traumatic brain injury were followed up and outcome was analyzed.
RESULTS: Twenty-nine infants with traumatic brain injury were included in the study. Of these 17 (59%) were boys and 12 (41%) were girls. Fall from height was recorded in 27 (93%) patients and road traffic accident was the mode of injury in 2 (7%). Mild head injury (GCS 14-15) was found in 18 (62%) patients, moderate in 4 (14%) patients (GCS 9-13), severe (GCS 3-8) in 7 (24%) patients. SDH was the most common injury in 8 (27%) patients. Out of these 4 (14%) were immediately operated, 25 (86%) were managed conservatively. Overall mortality was 11% (3 patients). Glasgow Outcome Scale was 5 in 20 (69%) patients and 3 (10.3%) patients each had GOS 3 or 4.
CONCLUSION: Infants suffered significant brain injury due to fall. Traumatic brain injury in infants generally carries good outcome. Severe head injury was observed to be a predictor of poor outcome.

Introduction

Traumatic brain injury (TBI) is one of the leading causes of acquired disability and death, in infants and children.[1] Falls and motor vehicle collisions are common non-inflicted causes, whereas child abuse in infants and young children are unfortunate inflicted causes of traumatic brain injury.[2] A total of 10-35% mortality in pediatric age group has been reported in various groups.[34] Management focuses on limiting the progression of the primary brain injury and minimizing secondary brain injury. In this study, we attempted to analyze epidemiological factors, management, and outcome of TBI in infants.

Materials and Methods

In this retrospective study over 3 years (March 2009 to Feb 2012), carried out at JPNATC, AIIMS, clinical records of all patients admitted with head injury were evaluated. Infants with traumatic brain injury were included in this study. These patient data including epidemiological factors, mode of injury, clinical findings, radiological findings, and interventions were analyzed and outcome assessed using GOS at the time of discharge from hospital and at follow up in outpatient department. Patients with absent brainstem reflexes and spontaneous respiration at the time of admission were excluded from the study.

Results

During the period of 1st March 2009 to 29th February 2012, there were a total of 29 infants admitted in neurosurgery ICU with traumatic brain injury in Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi. Age group ranges from 1 month to 12 months with mean age 8.7 months. Male patients were 17 (59%) and females 12 (41%). Fall from height was the mode of injury in 27 (93%) infants and RTA (Road Traffic Accident) in 2 (7%) infants.

Presenting symptoms were loss of consciousness in 9 (31%) patients, vomiting in 5 (17%) patients, seizure in 4 (14%), ENT bleed in 3 (10%). A total of 4 (14%) patients were asymptomatic and rest presented with combination of more than 1 symptoms. Anterior fontanelle were tense in three patients. Pupils were dilated and nonreactive in 3 (10%) patients. Out of these patients 18 (62%) had minor head injury (GCS 14-15), 4 (14%) had moderate head injury (GCS 9-13) and 7 (24%) had severe head injury (GCS 3-8) [Table 1].

Table 1

Distribution according to GCS

SDH (subdural hematoma) was observed in 8 (27%), skull bone fracture in 5 (17%), EDH (epidural hematoma) in 3 (10%), sub arachnoid hemorrhage (SAH), IVH, ICH in 5 (17%), diffuse brain edema in 3 (10%), contusion in 4 (14%) [Table 2]. Four patients from this group had multiple brain injuries including EDH, contusions, SAH, SDH, and skull bone fracture. Out of these, one patient had associated long bone fracture.

Table 2

According to nature of pathology

ICP monitoring was carried out only in 2 (7%) patients. Out of 29 patients, 4 (14%) were immediately operated, 25 (86%) were managed conservatively, and 2 patients underwent decompressive craniectomy. In one patient EDH evacuation was done [Figure 1a and b]. Posterior fossa decompression was performed in one patient. A total of 3 (10%) patients were tracheotomised later due to prolonged ventilation. Out of these 4 operated patients, 3 (75%) patients were improved after surgery. A patient who had undergone decompressive craniectomy presented after 1 month from discharge with post-traumatic hydrocephalus, and CSF diversion was carried out using low pressure ventriculo-peritoneal shunt [Figure 2a and b]. Patients were regularly followed up at outpatient department for a period of 6 months to 2 years (mean-10 months). Using GOS, outcomes was classified as good recovery -5, moderate disability -4, severe disability -3, persistent vegetative state -2, and death-1.[5] Final Glasgow Outcome Scale was GOS 5 in 20 (69%), GOS 4, and 3 in 3 (10.3%) patients each [Table 3].

Figure 1

(a) 8 month old infant with right fronto- parietal EDH. (b) After evacuation of EDH

Figure 2

(a) 1 month infant developed post traumatic hydrocephalus after decompressive craniectomy. (b) Right sided low pressure VP shunt insertion done

Table 3

Glasgow outcome scale in patients with head injury

Hospital stay ranged from 1-27 days, with a mean stay of 5.7 days. Overall in hospital mortality was 10.4% in these patients. Three patients expired, and their intracranial pathology was SDH, ICH and diffuse brain edema in one patient each. Out of those who died, two patients were managed conservatively and one patient was operated - decompressive craniectomy done. A total of 2 (36%) patients out of 7 with severe head injury and 1 (25%) out of 4 patients with moderate head injury expired.

Discussion

Traumatic brain injury (TBI) is one of the leading causes of acquired disability and death in infants and children.[1] Poor outcomes after pediatric head trauma have been linked to increased depth and duration of impaired consciousness, diffuse cerebral edema, cerebral hypoperfusion, brain infarction, and increased degree of parenchymal injury.[678]

In present study, incidence of traumatic brain injury in boys was higher than girls. The higher incidence of traumatic lesions in boys might, therefore, suggest that boys are at higher risk, perhaps because of their larger head circumference, more muscular and physical activities.[910] Most a common mode of injury was fall from a height, as described in a study by Wickham and Abrahamson[10] and Duhaime et al.,[11] followed by road traffic accidents, in some studies accidents were a common mode of injury.[291213] It has also been shown that the head injuries in infants are frequently the result of failure to protect the child from his/her environment or of failure of a protective device.[5] Infants can also get injury by pulling household articles like chair, TV, and washing machine etc., Inflicted injuries were also a relative common mode of injury in few studies ranging from 19-33%.[141516] However, in our study there was not even a single case of inflicted injury.

Loss of consciousness was most common presenting symptom which was followed by vomiting and seizures. Impaired consciousness and seizures are common presenting symptoms in traumatic brain injury, as described in the literature.[9161718]

Subdural hematoma was most common intracranial pathology, observed in this study in 27%, followed by skull fracture in 17%, which were comparable with study of Vinchon et al.[9] Higher incidence of SDH is related to underdeveloped brain as compared to adults. The most common mechanisms of head injury in very young children involve falls from a short height, which impart a predominantly translational (linear) force to the head. Such forces may result in local skull deformations, sufficient enough to cause simple skull fractures, and epidural hematomas. Subdural hematomas result from displacement of the brain relative to the dura, sufficient enough to cause rupture of the bridging veins, which course from the brain's surface to the overlying venous sinuses.[1920] Thus, unlike epidural hematomas, which occurs from the focal impact injuries, subdural hematoma almost always results from angular deceleration of the head, in which the brain continues to rotate relative to the more stationary skull and dura, associated with some form of diffuse parenchymal damage. This type of brain damage often results in severe and permanent neurologic sequelae.[2122]

Vinchon et al.[9] reported a study including 150 children with age less than 24 months. Their study reported GOS 5 in 85%, GOS 4, 3, 2 in 3.33% patients each. Mortality was reported only in 5% patients. In another study by Hymel et al.[23] in 54 infants showed, 4% mortality with a good outcome in 86% patients. In a report by Miyake et al.,[24] the outcomes in infants with both accidental and non-accidental trauma were compared. Most of the children underwent craniotomy for evacuation of SDH. In the non-inflicted group, 67% patients became normal, 11% had mild neurological deficit. A total of 11% had severe neurological deficit, and 1 patient died. Study from Chiaretti et al.,[12] in 40 children with severe head injury showed, GOS 4,5 in 52.3%, GOS 3 in 27.5%, and GOS 2 in 2.5% with a mortality of 17.5%. Present study shows good outcome (GOS 4, 5) in 80% of patients, severe disability, and mortality in 10% each. Post-traumatic hydrocephalus in infants is a common entity, more frequent in those patients who had a decompressive craniectomy.[25] It was noticed in 1 of 2 patients who underwent decompressive craniectomy in our study.

Our study confirmed the findings, reported by Duhaime et al.,[11] in accidental blunt head injuries, in children younger than 2 years of age, except for those caused by motor vehicle accidents and falls from a greater height.

Conclusion

Infants suffer significant brain injury due to fall and accidents. Traumatic brain injury in infants generally carries a good outcome. Severe head injury was noted to be a predictor of poor outcome. Most of these injuries are preventable by ensuring proper vigilance and extra care by the parents and the caretaker. Timely investigation to establish intracranial pathology and early surgical intervention can lead to a good outcome.