Clinical Parameters, Management, and Outcomes of Childhood Traumatic Brain Injury in Ilorin.

BACKGROUND: Traumatic brain injury (TBI) is common among children, accounting for 75% of children hospitalized for trauma. Childhood TBI is a leading cause of death from trauma in the pediatric age group and the incidence is on the rise globally.
OBJECTIVE: The objective of this study was to determine the etiology, management, and outcome of childhood TBI in our setting. SUBJECTS AND METHODS: This is a retrospective study of all cases of childhood TBI. Relevant data extracted from case records were analyzed using a 2011 Statistical Package for the Social Sciences (SPSS; IBM, Armonk, New York) software for Windows, version 20.
RESULTS: A total of 168 children with TBI were studied. Of which, 109 (65%) were males and 59 (35%) were females (male/female ratio of 13:7, mean age, 7 ± 4 years). Most of the injuries (138, 82%) occurred outdoor; road traffic crash and fall accounted for 101 (60.1%) and 47 (27.9%) cases, respectively. Pedestrian motor vehicular accident accounted for 41 (41.8%) cases, whereas 30 (30.6%) were due to motorcycle road traffic crash. Good recovery was recorded in 138 (81%) patients, 22 (13.1%) had moderate disability. Mortality rate was 6%.
CONCLUSION: Brain injury from trauma still constitutes a significant part of childhood morbidity and mortality in our setting; these deaths are avoidable in most cases. The outlook can be better if preventive efforts are geared toward domestic and road safety campaign. Copyright:

Introduction

Brain injury is the most common cause of morbidity and mortality in children worldwide.[12] Incident rate ranged from 75 to 1,373 per 100,000 among children aged below 15 years in the United States, Australia, and New Zealand.[34567] Severity of head injury as measured on the Glasgow Coma Scale (GCS) varies, and the overall burden it poses on public health is significant. However, the public health importance of these injuries remains underemphasized and neglected in developing countries like ours.[891011] We study the pattern and outcome of childhood traumatic brain injury (TBI) in our setting.

Subjects and Methods

This is a four-year retrospective study of clinical records of all patients below the age of 18 years, who were treated for brain injury at our hospital, between February 2011 and January 2017. Patients with TBI were initially resuscitated in the accident and emergency room and treated following established guidelines. However, the admission of patients with severe TBI to our 3-bedded multispecialty intensive care unit (ICU) was dependent on the availability of bed space. Information retrieved from the medical records included demographics, time, place and mechanism of injury, anatomical site of injury, GCS score, and associated injuries at presentation. Computed tomography (CT) scan findings, treatment modality, and outcome of definitive management were also documented. The patients were followed up for variable period but the outcome was determined at death or at six months after injury using the Glasgow Outcome Score. Neuropsychological assessment was not routinely carried out for children with TBI in the center during the period of study due to lack of expertise, and therefore has not been included in outcome measure. Only case records with complete documentation and relevant data were included for analysis in this study. Data were analyzed using a 2011 Statistical Package for the Social Sciences (SPSS; IBM, Armonk, New York) software for Windows, version 20. Results were presented in simple charts and tables using descriptive statistics of frequency and percentages and Microsoft Excel software for graphical presentation.

Results

A total of 168 children with brain injury were observed during the study period. Of which, 109 (65%) were males and 59 (35%) were females, male/female ratio was 1.8:1, and the mean age was 7 ± 4 years [Table 1]. Most of the injuries occurred outdoor (138, 82%), with 30 (18%) occurring indoor, and the children under five were the most vulnerable in both locations of injury (P = 0.04) [Table 2]. Road traffic crash and fall accounted for 101 (60.1%) and 47 (27.9%) cases, respectively [Table 1]. Pedestrian motor vehicular crash (41, 41.8%) was the most common type of auto crash followed by pedestrian motorcycle road traffic crash (30, 30.6%) [Table 2].

Table 1

Demographic distribution of patients and pattern of injury

Demographic distribution of patients and pattern of injury, N = 168
Variable	Frequency, n (%)
Gender
Male	109 (64.9)
Female	59 (35.1)
Age groups (years)
0–5	75 (44.6)
6–10	53 (31.5)
11–15	40 (23.6)
Place of injury
Indoor	30 (18.0)
Outdoor	138 (82)
Mechanism of injury
Fall	47 (27.9)
Road traffic crash	101 (60.1)
Assault/blunt object	6 (3.6)
Others	14 (8.4)
Injury arrival time
0–6 h	115 (69)
6–12 h	27 (16.1)
12–24 h	7 (4.2)
>24 h	18 (10.7)
Post-op complication
Urinary tract infection	2 (1.2)
Bedsore	3 (1.8)
Others	3 (1.8)
None	21 (12.5)

Table 2

Demographic data and pattern of injury

Variables	Participants				Statistics
	Age group (years)
	0–5	6–10	11–15	Total	x2	P value
Place of head injury (N = 168)					6.415	0.04
Indoor	19 (11.3)	5 (3.0)	5 (3.0)	30 (18.0)
Outdoor	56 (33.3)	48 (28.6)	34 (20.0)	138 (82.0)
Mechanism of head injury (N = 168)					29.153	0.00
Fall	34 (20.2)	6 (3.5)	7 (4.2)	47 (27.9)
Traffic accident	37 (22.0)	42 (25.0)	22 (13.1)	101 (60.1)
Blunt object/assault	1 (0.6)	1 (0.6)	4 (2.4)	6 (3.6)
Others	3 (1.8)	4 (2.4)	7 (4.2)	14 (8.4)
Nature of fall (N = 47)					16.02	0.099
Furniture	3 (6.4)	0 (0)	0 (0)	3 (6.4)
Play	3 (6.4)	1 (2.1)	1 (2.1)	5 (10.6)
Stairs	6 (12.8)	0 (0)	0 (0)	6 (12.8)
Height	21 (44.7)	6 (12.8)	4 (8.5)	31 (66.0)
Dropped	0 (0)	0 (0)	1 (2.1)	1 (2.1)
Others	0 (0)	0 (0)	1 (2.1)	1 (2.1)
Nature of traffic accident (N = 98)					12.890	0.037
Pedestrian MVA	13 (13.2)	18 (18.4)	10 (10.2)	41 (41.8)
Pedestrian motorcycle	10 (10.2)	18 (18.4)	2 (2.0)	30 (30.6)
Passenger MVA	9 (9.2)	4 (4.1)	6 (6.1)	19 (19.4)
Passenger cyclist	4 (4.1)	1 (1.0)	2 (2.0)	7 (7.1)
CT scan finding (N = 79)					6.933	0.552
Fractures	13 (16.5)	6 (7.6)	4 (5.0)	23 (29.1)
Intracranial hematoma	4 (5.0)	7 (8.9)	6 (7.6)	17 (21.5)
Contusions	3 (3.8)	1 (1.3)	3 (3.8)	7 (8.9)
Edema	5 (6.3)	6 (7.5)	4 (5.0)	15 (19.0)
Multiples	8 (10.1)	4 (5.0)	5 (6.3)	17 (21.5)

MVA = motor vehicular accident; bold denotes statistically significant value

Loss of consciousness (LOC) was the most common presentation; 130 (77.4%) had immediate LOC, whereas 6 (3%) had early LOC. Similarly, 52 (30.9%) patients had post-traumatic seizure, of which 39 (23.2%) had immediate seizure and 15 (8.9%) had early post-traumatic seizure [Table 3]. There were associated injuries to the maxillofacial regions in 30 (17.8%) cases, to the extremities in 17 (10.1%), and to the skin in 18 (10.7%) cases [Figure 1].

Table 3

Clinical presentations, treatment, and outcome

Treatment outcome
Variables	Frequency, n (%)
Presenting symptoms
Loss of consciousness (LOC)
Immediate	130 (77.4)
Early	6 (3.6)
None	32 (19.0)
Seizure
Immediate	39 (23.2)
Early	15 (8.9)
None	114 (67.2)
Others symptoms
Vomiting	50 (29.7)
Ophthalmic	18 (10.7)
CN deficit	7 (4.1)
Long tract	7 (4.1)
Otalgia	5 (3.0)
Insomnia	1 (0.6)
Treatment given
Nonoperative	139 (82.7)
Operative	29 (17.3)
ICU admission
Yes	13 (7.7)
No	155 (92.3)
Outcome
Dead	10 (6.0)
Moderate disability	22 (13.1)
Good recovery	138 (81.0)
Disposal
Discharged	151 (89.9)
Dead	10 (6.0)
DAMA	7 (4.2)
Duration of hospital stay
<5 days	67 (39.9)
5–10 days	47 (28.0)
>10 days	54 (32.1)

DAMA = discharged against medical advice

Figure 1

Associated injury

Among 79 patients that had cranial CT scan done, the most common finding was cranial vault fractures (23, 29.1%) followed by intracranial hematoma (17, 21.5%) and combined morphological abnormality (17, 21.5%) [Table 2].

Nonoperative management was applied in 139 (82.7%) patients, whereas 29 (17.3%) had surgical intervention [Table 3]. The overall mortality rate was 6.0%, and half of the mortality was recorded among ICU admitted cases (P = 0.000) [Tables 3 and 4]. Good recovery was associated with good GCS (14–15) (P = 0.00) and care without need for ICU admission (P = 0.000), whereas injury arrival time and mechanism of injury had no statistically significant impact on recovery (P ≥ 0.05) [Table 4].

Table 4

Mechanism of injury, severity, and outcome

Variables	Outcome				Statistics
	Dead	Moderate disability	Good recovery	Total	x2	P value
Mechanism of injury
Fall	2 (4.3)	4 (8.7)	40 (87.0)	46 (100)	9.853	0.131
RTC	4 (3.9)	16 (15.7)	82 (80.4)	102 (100)
Assault/blunt	1 (16.7)	1 (16.7)	4 (66.7)	6 (100)
Others	3 (21.4)	1 (7.1)	10 (71.4)	14 (100)
Road traffic crash
Pedestrian MVA	3 (7.1)	7 (16.7)	32 (76.2)	42 (100)	16.483	0.011
Pedestrian MC	1 (3.0)	1 (3.0)	31 (94.0)	33 (100)
Passenger MVA	0 (0)	8 (40)	12 (60)	20 (100)
Passenger MC	0 (0)	0 (0)	7 (100)	7 (100)
Injury arrival time
0–6 h	5 (4.3)	15 (12.9)	96 (82.8)	116 (100)	11.203	0.083
6–12 h	3 (11.1)	2 (7.4)	22 (81.5)	27 (100)
12–24 h	2 (28.6)	1 (14.3)	4 (57.1)	7 (100)
>24 h	0 (0)	4 (22.2)	14 (77.8)	18 (100)
GCS
3–8	9 (32.1)	7 (25)	12 (42.9)	28 (100)	57.186	0.000
9–13	1 (1.6)	12 (19.7)	48 (78.7)	61 (100)
14–15	0 (0)	3 (3.8)	76 (96.2)	79 (100)
ICU admission
Yes	5 (38.5)	2 (15.4)	6 (46.2)	13 (100)	27.18	0.000
No	5 (3.2)	20 (12.9)	130 (83.9)	155 (100)

RTC = Road Traffic Crash; MVA = motor vehicular accident; MC = motor cycle

bold denotes statistically significant value

Among road traffic crash, pedestrian motor vehicular accident was most commonly associated with death (P = 0.01). GCS of 8 and below was associated with high mortality rate (9, 32.1%) (P = 0.000). Good recovery was recorded in 138 (81%) cases, whereas 22 (13.1%) had moderate disability and the overall mortality rate was 10 (6%) [Table 4].

Patients with severe TBI had the highest mortality accounting for 9/10 (70%) of the mortality, whereas none of the patients with mild TBI died (P = 0.000) [Table 4]. A statistically significant association existed between the age group of patients and the mechanism of head injury (0.00), and the age group and the location where the head injury occurred (P = 0.04). Association between age group and nature of traffic injury, nature of fall, or CT scan findings was not statistically significant [Table 2].

Discussion

This study showed that the male child is more at risk of childhood TBI than the female, and the under-five groups are particularly more vulnerable [Table 1]. The reason for the male preponderance was not obvious from the study. However, Shokunbi et al.[12] in Ibadan southwestern Nigeria also observed higher incidence in males within similar age bracket. Besides, children in the age group of 0–5 years are often left in the care of adolescent or young adults, who may be negligent or inexperienced in their role to care for and monitor the child.

Majority of events leading to injury occurred outdoor; road traffic accident and fall were found to be the most common ones, and the incidence was the highest among children in the age group of 6–10 years [Tables 1 and 2]. This is because close supervision and close monitoring by parents or older siblings reduces as the child gets older. By the age of 6 years, the child enjoys freedom to play with his/her peers. This also coincides with school age when the child spends hours away from home with increasing contacts with the hazards of the roads, transportation, and violent plays with schoolmates. This study also observed a statistically significant association between age group and cause of injury (P = 0.001) and place of injury (P = 0.04) [Table 2]. Pedestrian road vehicular and motorcycle accidents were the most common mechanism of injury across all age groups [Table 2]. Most roads are constructed without consideration for the pedestrian road users. The Federal Road Safety Corps in the country focuses its road safety campaigns on commercial and private vehicle owners and drivers with little or no education of the pedestrian and other road users. Not only that, pedestrian safety law still suffers poor implementation in our settings. Passenger motor vehicular or cyclist accident were important mechanism of injury, prevention of which can lead to a significant reduction in mortality from childhood brain injury.

Children in the age group of 0–5 years are still learning how to walk with steady gait. That explains the high incidence of fall among this age group (P = 0.00) [Table 2]. Negligence on the part of parents or caregiver is often a contributing factor. Fall is also a part of the mechanism of injury in passenger cyclist and motorcycle injury. Unfortunately, use of bicycle helmets is not a common practice in our society. Most of the time, the focus of law enforcement on the use of helmet is on the commercial motorcyclists (popularly called Okada rider) and not on the passenger who is equally predisposed to severe head injury. Even when offered by the commercial motorcyclists, most passengers often refuse using these helmets due to unfounded fear and suspicion that some of the cyclists are agents of kidnappers who use diabolical helmets to perpetrate their crimes.

Contrary to the findings in this study, Robertson et al.[9] found assault, child abuse, snowmobile accidents, and animal injury as common mechanisms of pediatric TBI in the US. Although snowmobile and animal sport are not common in our setting, criminal assault and abuse of the child may go unnoticed except with a high index of suspicion on the part of the clinician.

The incidence of mild TBI recorded in this study (79, 47.0%) [Table 4] is lesser than 60% and 74% as reported by Emejulu and Shokunbi[7] and Işık et al.,[13] respectively. Earlier study in Ilorin by Odebode and Abubakar,[14] which reported lower incidence of TBI (37.5%), was conducted at a time when neither CT scan nor neurosurgical service was available at our center to confirm and manage brain injury.

The fact that only 79 patients had cranial CT scan done [Table 2], may not be unconnected to the fact that majority of the children had mild TBI and CT was not indicated. Fracture was the most common abnormality observed on CT imaging and was the most common among the under-fives possibly due to the fragile nature of their thin skull. Many of the patients were managed nonoperatively [Table 3] in consistence with the severity of head injury. However, operative interventions were required in 29 (17.3%) patients on account of open skull fractures and for evacuation of intracranial hematomas. This rate of surgical intervention is about the same as 10.5% reported by Işık et al.[13] in an earlier study. Significant good outcome (138, 81%) reported in this study was similar to the findings by Nnadi et al.[10] in Calabar (92.1%). Only 46% of patients with severe TBI were admitted to the ICU contrary to the established guideline. Though this study did not specifically analyze the reasons for non-ICU admission in these patients, a probable reason could be lack of ICU bed space at the time of patient admission in the hospital. This factor may have affected the outcome of TBI in these patients. The few patients with poor outcome or mortality had severe TBI [Table 3 and 4]. Henry et al.[15] reported mortality rate of 8%, whereas Nnadi et al.[10] reported 7.9%, both of which were similar to the overall mortality rate of 6% reported in this study.

Injury arrival time was short in majority of cases [Table 4] and did not seem to have a statistically significant bearing on outcome (P = 0.083). Quick access to neurosurgical health facility, early hospital presentation and resuscitation do not always translate to good outcome. The severity of brain injury, presence of associated critical injuries and other factors also play a major role in the prognosis. Besides, this hospital-based study data may represent only the tip of the iceberg as many children with severe brain injury may have died before getting to the hospital. A community-based study is therefore necessary to prepare public health practitioners and pediatric injury prevention agencies for the task of effective reduction of the prevalence of head injuries among children in our setting. Education of the populace, children, parent, and teachers is also necessary in addition to reorientation of road safety law enforcement agents.

Despite its limitations, this study lends a significant contribution to the public health literature, namely in identifying an expanded listing of the top mechanisms of injury to the largest cause of morbidity and mortality in the pediatric population. Instead of focusing on and exploring a specific mechanism, we are able to examine the causes of brain injury as a whole.

Conclusion

TBI still constitutes a significant part of childhood morbidity and mortality in our setting; deaths and disabilities from these injuries are avoidable in most cases. The outlook can be better if preventive efforts are geared toward domestic and road safety campaign, including better orientation of road safety law enforcement agents and awareness programs for children, teachers, parents, and caregivers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.