INTRODUCTION

Pediatric neurotrauma (pNT) includes pediatric traumatic brain injury (TBI) and spinal cord injury [1]. It is one of the most common neurosurgical causes of morbidity and mortality and the leading cause of long-term disability among children and young adults worldwide [2]. Moreover, pNT is the primary cause of mortality and morbidity among children in low- and middle-income countries [3,4]. Children and adolescents are particularly vulnerable to repetitive TBI, which can result in delayed developmental milestones and mental health issues [5]. A recent systematic review reported an overall incidence of posttraumatic epilepsy of 11% to 19% following pNT, with significant predictors including severe TBI and intracranial hemorrhage [6].

Between 80% and 90% of pNT cases are classified as mild, defined by an initial Glasgow Coma Scale (GCS) score of 13 to 15, a loss of consciousness lasting less than 30 minutes, and posttraumatic amnesia lasting under 24 hours [1]. This spectrum also includes concussions, characterized by loss of consciousness with normal computed tomography (CT) images [7]. Although most patients with mild pNT are discharged from the emergency department without requiring neurosurgical intervention, emerging evidence linking mild TBI with long-term motor, psychosocial, and learning disabilities in children emphasizes the need for careful management and follow-up [1,8,9].

There are relatively few studies on pNT, resulting in limited evidence to guide treatment in the pediatric population [10]. One topic of debate is the threshold for treating elevated intracranial pressure [10,11]. Another controversial area is the use of decompressive craniectomy in children, which poses challenges in managing large cranial defects and is associated with complications such as disrupted cerebrospinal fluid dynamics (including hydrocephalus and hygromas), infection, and seizures [12].

Research in pNT is essential to raise awareness and establish age-appropriate guidelines for interventions aimed at reducing pNT incidence and improving long-term outcomes. The incidence and distribution of pNT by age and sex remain understudied, with significant gaps in epidemiological and clinical data [3]. Therefore, we aimed to estimate the epidemiological parameters, clinical presentations, surgical interventions, and outcomes in our patient population with pNT.

METHODS

Ethics statement

This study was approved by the Institutional Ethics Committee of Command Hospital (Central Command) (No. IEC(CHCC)17/20). Written informed consents for publication of the research details and clinical images were obtained from the patients’ parents or guardians.

Study design

This multicentric, ambispective (retrospective and prospective) study was conducted at five tertiary care pediatric neurosurgical centers in Northern India. The study period spanned from January 2011 to December 2022, and cases were followed for a minimum of 1 year.

Patient population

The study included pediatric patients (<16 years) of either sex admitted to any of the five participating institutes with a history of head injury. According to hospital policy, all children with a history of head injury were admitted for observation, regardless of symptoms. Children with bleeding disorders or other nontraumatic causes of altered sensorium were excluded. Additionally, patients whose parents or guardians were unwilling to admit their child, refused consent, or were unlikely to be followed for 1 year were excluded (Fig. 1).

Treatment

According to hospital policy, children presenting with a history of neurotrauma and suspected head injury were initially admitted to the pediatric ward, while those with symptoms indicative of moderate or severe head injury were transferred to the pediatric intensive care unit for close monitoring. All patients were evaluated following Advanced Trauma Life Support (ATLS) principles. A detailed history was obtained from the child, parents, or relatives, followed by a clinical examination that included the pediatric GCS (pGCS) for children up to 4 years and the standard GCS for older children (>4 years). All children underwent noncontrast CT of the head and cervical spine. They were managed with nothing by mouth and intravenous fluids. Based on CT findings and clinical condition, additional interventions such as oxygen supplementation, ventilatory support, antiepileptics, osmotic diuretics, 3% hypertonic saline, antacids, head elevation, and/or analgesics were provided. Surgical intervention and repeat portable CT imaging were performed for moderate to severe head injuries as required.

Data collection

Data were collected from emergency department records, pediatric ward and pediatric intensive care unit admission discharge logs, operating room records, and outpatient department follow-up registers. Clinical data recorded included age, sex, mechanism of injury, pGCS, GCS, CT findings, specific medical treatments (e.g., anticonvulsants for seizure prophylaxis), surgical treatments performed in accordance with Brain Trauma Foundation guidelines, any postoperative complications, and outcomes as measured by the Glasgow Outcome Score (GOS) [13–15]. Outcomes were assessed using the GOS during a 1-year follow-up, and any complications were noted.

Statistical analysis

The data were entered into a predefined Microsoft Excel sheet (Microsoft Corp) and subsequently analyzed using IBM SPSS ver. 22.0 (IBM Corp). Continuous data were described using the median and range, while categorical data were presented as numbers, percentages, or both.

RESULTS

Patient demography

A total of 2,250 children were included in the study, with 1,744 (77.5%) being male (Fig. 1). The most common age group was 6 months to 2 years (840 children, 37.3%), followed by 5 to 10 years (660 children, 29.3%) (Fig. 2). The most common mechanism of neurotrauma was a fall from height (1,454 children, 64.6%), followed by road traffic accidents (588 children, 26.1%). Other mechanisms (208 children, 9.2%) included sports injuries, recreational injuries, assault, falls due to objects striking the head, and collisions with static objects such as doors, televisions, and windows. One child presented with bilateral periorbital ecchymosis and multiple facial bone fractures (Fig. 3A), while another was admitted following an electric shock and subsequent fall, resulting in a contusion of the left cerebellar hemisphere (Fig. 4). Analysis by age revealed that falls from height were most common in children under 10 years, whereas road traffic accidents were more frequent in children over 10 years (Table 1).

Clinical and radiological features

The most common presenting symptom was persistent vomiting, observed in 1,735 children (77.1%), followed by loss of consciousness in 765 children (34.0%). Nasal bleeding occurred in 45 children (2.0%), posttraumatic seizures in 23 (1.0%), and optic atrophy in 2 (0.1%). Among the 2,250 children, 1,903 (84.6%) had mild neurotrauma, 320 (14.2%) had moderate, and 27 (1.2%) had severe injury. Radiological findings included contusions in 207 children (9.2%), extradural hematoma in 72 (3.2%), subdural hematoma in 18 (0.8%), and diffuse axonal injury grades III and IV in 58 (2.6%). Skull fractures were identified in 306 children (13.6%), most of which were associated with intraparenchymal injury (Fig. 5). In 1,755 children (78.0%), CT scans of the head were essentially normal. These clinical and radiological features are summarized in Table 2. Additionally, 180 children (8.0%) sustained one or more associated injuries (a total of 240 injuries), involving maxillofacial, chest, abdominal, and spinal regions, with some cases including multiple rib and long bone fractures (Table 3).

Treatment

Surgical intervention was performed in 19 children (0.8%): 9 (0.4%) underwent craniotomy for elevation or removal of fracture fragments, 6 (0.3%) required craniotomy for evacuation of an extradural hematoma, and 4 (0.2%) underwent decompressive craniectomy for evacuation of a subdural hematoma. No complications such as cerebrospinal fluid leak or meningitis were observed. In cases of severe head injury, tracheostomy was performed in five children (0.2%), and percutaneous endoscopic gastrostomy was also performed in five children (0.2%). Ten children (0.4%) required readmission due to issues including decannulation of a prior tracheostomy, percutaneous endoscopic gastrostomy site complications, and fever. During the 1-year follow-up, decannulation was successful in four patients (80% of those with tracheostomy). Four children with severe head injuries required emergency laparotomy for hemoperitoneum; of these, two underwent splenectomy. Twelve children (0.5%) sustained spinal injuries, and two (0.1%) required spinal fixation; the youngest of these was an 18-month-old female patient who sustained injury following a road traffic accident (Fig. 3B). Hospitalization duration varied with injury severity: children with mild head injuries had a mean hospital stay of 2.8 days (range, 1–3 days), those with moderate injuries had a mean of 8.2 days (range, 7–10 days), and children with severe head injuries had the longest stays, with a mean of 39.4 days (range, 30–90 days).

Children with mild head injury required a brief period of hospitalization (mean, 2.8 days; range, 1–3 days). Children with moderate head injuries required longer hospitalization (mean, 8.2 days; range, 7–10 days), and children having severe head injuries required the longest period of hospitalization (mean, 39.4 days; range, 30–90 days).

Complications and outcomes

Outcomes were assessed using GOS. GOS score of 1 was observed in 2 children (0.1%), 2 in 4 (0.2%), 3 in 6 (0.3%), 4 in 7 (0.3%), and 5 in 2,231 children (99.2%). Two children (0.1%) died from their injuries: one from a torso injury and the other from a severe head injury. At 1 year of follow-up, 10 children (0.4%) exhibited intellectual and learning deficits, as assessed by a pediatrician and psychiatrist, all of whom had sustained grade IV diffuse axonal injuries.

DISCUSSION

Our study demonstrated that boys are more prone to pNT, with the most vulnerable age group being 6 months to 2 years. We found that falls from height were the most common mechanism of injury, and persistent vomiting was the predominant clinical presentation. Abnormal CT head images were observed in 278 children (12.4%), with contusions being the most frequent finding. Although only 19 patients (0.8%) required surgical intervention, long-term complications in the form of learning deficits were observed in 10 patients (0.4%).

We speculate that the predominance of neurotrauma in the 6-month to 2-year age group is likely due to this being the stage when children begin to crawl and walk. The male predominance may reflect the more adventurous behaviors typically observed in boys. A study from Nigeria, which included 163 pNT patients, demonstrated a similar trend, although the male predominance (71.8%) was slightly lower than that observed in our study (77.5%) [16]. Another study from China reported that the most common age group was 0 to 2 years, comprising 50.1% of total pNT cases [17]. Similar findings and explanations have been reported in studies from both high- and low-income countries [18,19].

Although falls from height were the most common mode of injury in our study (64.6%), this finding varies across studies. Research from the United States and Nigeria has identified motor vehicle crashes as the most common cause of pNT requiring hospitalization, with rates of 38.9% and 63.2%, respectively [20]. However, another study from Nigeria found that falls (35.7%) were the most common cause of pNT [18], similar to our findings.

In our cohort, while vomiting was the most common presentation, we observed that the incidence of loss of consciousness increased with age, becoming the predominant presentation in children aged 10 to 16 years (182 of 240 patients, 75.8%). Another study reported that loss of consciousness was the most common clinical feature at admission (47%) [18], although this proportion was lower than in our study. Conversely, a study from a low-income country found that posttraumatic seizures were the most common presentation at admission (57 patients, 35.0%) [16]. This difference may be attributable to a higher number of moderate and severe pNT cases in their cohort (91 patients, 55.9%).

CT head imaging revealed abnormalities in 495 children (22.0%). The most common abnormality was skull fracture, present in 306 children (13.6%), while brain contusions were the most frequent intraparenchymal injury, observed in 207 children (9.2%). The normal CT group also included patients who experienced multiple episodes (more than two) of vomiting that warranted hospitalization, imaging, and observation, likely due to concussion injuries. The incidence of brain contusion increased with age, reaching its peak in the 10- to 16-year age group (37 of 240 patients, 15.4%). Our findings differ from another study in which abnormal CT images were found in 104 pNT cases (83.2%), with skull fracture being the most common abnormality [16]. This discrepancy may be attributed to the lower proportion of severe pNT cases in our cohort and our hospital policy of performing noncontrast CT head for all children with a history of head injury.

Surgical intervention was required in only 19 children (0.8%) and was associated with mortality in 2 children (0.1%). The mortality rate in our study was considerably lower than that reported in an Australian study, which documented a mortality rate of 0.87% (13 of 1,489) [21]. In contrast, other studies reported surgical intervention rates of 19.6% (32 of 163) [16] and 46.5% (46 of 99) [22] in pNT patients. The mortality rate in a Brazilian study was 3.21% [23]. These differences may be due to the higher proportion of mild and moderate injuries in our cohort—a consequence of our hospital policy to admit all children with a history of head injury, even if asymptomatic at presentation. A comparative table summarizing our findings with similar studies is provided in Table 4 [18,19,21,24].

Long-term complications, specifically learning deficits, were observed in 10 children (0.4%) in our study—a rate significantly lower than that reported in a study from a developing country, where depressed mentation was noted in 10 children (3.2%) with brain injury [24].

Limitations

Being partly retrospective, the study had limitations such as missing older data; however, this was mitigated by contacting the parents or guardians of these patients, most of whom responded positively. Additionally, due to hospital policy, a large number of asymptomatic children were admitted, resulting in an overwhelming proportion of mild pNT cases. The limited duration of follow-up to assess the persistence, progression, or recovery of neurological deficits post pNT represents another limitation, which is currently being addressed. Nonetheless, this is the largest study on pNT from India, and its multicenter collaboration is a significant strength.

Conclusions

Our study observed that pNT is most common in children aged 6 months to 2 years, with a clear male predominance. The most frequent cause of pNT in our cohort was a fall from height, and the majority of patients sustained mild head injuries that required only observation and resulted in excellent outcomes. Surgical intervention was necessary in only a few cases, and mortality was rare. This study highlights the epidemiological pattern of pNT in our patient population and delineates various causes of such trauma. Our findings may provide valuable insights for parental education regarding prevention, improved childcare, and the strict enforcement of basic road traffic laws.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Data curation: all authors; Formal analysis: AKK, AK, KM; Methodology: all authors; Project administration: SKK, AKK, AK; Visualization: all authors; Writing–original draft: AKK, AK, KM; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Flowchart of the study. OPD, outpatient department; PICU, pediatric intensive care unit; pNT, pediatric neurotrauma.

Fig. 2.

Distribution of children having neurotrauma by age and sex.

Fig. 3.

Images of a patient. (A) Bilateral periorbital ecchymosis resulting from multiple facial fractures. (B) Intraoperative image showing posterior fixation of C1 and C2 using coated polyester suture. The patient’s parent provided written informed consent for publication of the clinical images.

Fig. 4.

Noncontrast computed tomography of the head (brain window) demonstrating (A) a contusion of the left cerebellar hemisphere (arrow) and (B) a linear occipital bone fracture.

Fig. 5.

Multimodal imaging findings. (A) Computed tomography (CT; sagittal view) depicting an anterior arch fracture of C1 and an odontoid process fracture of C2 with instability. (B) Magnetic resonance imaging of the cervical spine showing cord compression in the occipitocervical region. (C) Noncontrast CT of the head (bone window) demonstrating a depressed fracture in the left parietal region. (D) CT showing a linear displaced fracture.

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Figure & Data

References

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