Management of children with mild traumatic brain injury and intracranial hemorrhage

Background: Traumatic brain injury (TBI) is a significant public health problem affecting tens of thousands of children each year, and an important subset of these patients sustains intracranial hemorrhage (ICH). The purpose of this study was to test the hypothesis that we could identify a subset of children with traumatic ICH who could be monitored on a general neurosurgery ward with a low risk of clinical deterioration. Methods: We performed a retrospective review of pediatric patients 18 years or younger with mild TBI (Glasgow Coma Scale [GCS] score 14-15) and traumatic ICH admitted to Saint Louis Children's Hospital between 2006 and 2011. We excluded patients with injuries unrelated to the TBI that would require intensive care unit (ICU) admission and those with penetrating intracranial injuries. Results: We identified 118 patients meeting inclusion criteria. Repeat neuroimaging was obtained in 69 (58%) of 118 patients. Radiologic progression was noted in 6 (8.7%) of 69 patients, with a trend toward more frequent progression in patients with epidural hematoma (EDH) versus other ICH (3 [20%] of 15 vs. 3 [5.6%] of 54; p = 0.11). Of 118 patients, 8 (6.8%) experienced clinically important neurologic decline (CIND) and 6 (5.1%) required neurosurgical intervention. Both CIND and the need for neurosurgical intervention were significantly higher in patients with EDH (21% each) compared with those with other types of ICH (4% and 2%, respectively) (p = 0.02, p < 0.01). Based on these results, we developed a preliminary management framework to assist in determining which patients can be safely observed on a neurosurgery ward without an ICU admission. Specifically, those patients without EDH, intraventricular hemorrhage, coagulopathy, or concern for a high-risk neurosurgical lesion (e.g., arteriovenous malformation) may be safely observed on the ward. CONCLUSIONS: These results demonstrate that few children with mild TBI and ICH experience CIND and the preliminary framework we developed assists in identifying which patients can safely avoid ICU admission. This framework should be validated prospectively and externally. LEVEL OF EVIDENCE: Therapeutic/care management, level IV.