H.E. Kim1, J. Cyprich1, A. Covington1, S. Vazquez1, B. Putnam1, J.A. Keeley1 1Harbor-UCLA Medical Center, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Torrance, CA, USA
Introduction: Progressive hemorrhagic injury (PHI) after traumatic brain injury (TBI) is associated with increased morbidity and mortality. Predictors of PHI in children with TBI are not well defined, and the role of repeat imaging is controversial in this age group. We sought to identify predictors of PHI in pediatric TBI.
Methods: A retrospective review of patients aged 5-17 admitted with TBI who underwent repeat imaging between 2015-2023 was conducted at a level 1 trauma center. Patient demographics, injury characteristics, imaging findings, and outcomes were compared between patients with and without PHI. Multivariable logistic regression was performed to determine independent predictors of PHI.
Results: A total of 125 patients met inclusion criteria. Ninety-six patients (76.8%) were male with a median age of 14 (IQR: 10-16). Thirty patients (24.0%) had severe TBI, defined as Glasgow Coma Scale (GCS) score of 3-8. The most common types of intracranial hemorrhage identified on imaging were subdural (54.5%) and subarachnoid hemorrhage (36.8%). Midline shift was present in 25 patients (20.0%), while 75 patients (60.0%) had a concomitant skull fracture. Of the 17 patients (13.6%) requiring an operative intervention, 14 craniotomies (11.2%) and 3 craniectomies (2.4%) were performed. Forty patients (32.0%) were identified with PHI on repeat imaging, of which 7 (17.5%) had underwent operative intervention. While there was no statistical significance between surgical procedure and PHI (p=0.383), patients with PHI were more severely injured (median injury severity scale (ISS) score 22 vs 17, p=0.01) with lower admission GCS scores (median 13 vs 15, p=0.02) and were more likely to have an associated skull fracture (75.0% vs 52.9%, OR 2.7, 95%CI 1.2-6.1, p=0.02). Patients with PHI more often required external ventricular drain placement (20.0% vs 4.7%, OR 5.1, 95%CI 1.4-18, p=0.02), were less likely to be discharged home (62.5% vs 81.2%, OR 0.4, 95%CI 0.2-0.9, p=0.02), and more likely to die from their injuries (12.5% vs 0%, p = 0.003) compared to patients without PHI. On multivariable analysis adjusting for ISS and admission GCS, skull fracture remained significantly predictive of PHI (aOR 2.8, 95%CI 1.2-6.6, p=0.02).
Conclusion: Our study suggests that skull fracture is an independent predictor of PHI in children with TBI, potentially identifying a subset of pediatric patients in whom repeat imaging is warranted.