Volume 33, Issue 2 (6-2024)                   JGUMS 2024, 33(2): 240-253 | Back to browse issues page

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Shokri B, Bagheri Bavandpouri S R, Asadzade S, Alimohammadi E. Investigating the Factors Associated With Poor Clinical Outcomes of Children With Moderate to Severe Traumatic Brain Injury: A Retrospective Observational Study. JGUMS 2024; 33 (2) :240-253
URL: http://journal.gums.ac.ir/article-1-2622-en.html
Investigating the Factors Associated With Poor Clinical Outcomes of Children With Moderate to Severe Traumatic Brain Injury: A Retrospective Observational Study
Bita Shokri1 , Seyed Reza Bagheri Bavandpouri2 , Sahel Asadzade3 , Ehsan Alimohammadi *2
1- Clinical Research Development Center, Taleghani Hospitals, Imam Ali Hospitals, Kermanshah University of Medical Sciences, Kermanshah,Iran.
2- Department of Neurosurgery, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran.
3- Medical doctor, Faculty of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran.
Keywords: Glasgow outcome scale, Clinical outcomes, Traumatic brain injury
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Introduction
Traumatic brain injury (TBI) is one of the main causes of death and disability in children [10, 11]. This type of injury occurs due to a blow to the head, caused by falling, car accidents, sports accidents, etc. The TBI can lead to undesirable clinical outcomes that affect the lives of children and their families. It can be divided into primary and secondary injuries [14, 15]. The primary TBI is an irreversible event defined as direct physical injury to the brain such as compression, displacement, deformation, shearing, tearing, or crushing of brain and blood vessels [2]. The secondary TBI is an indirect injury to the head caused by neurological cascades of events that can eventually lead to the neuronal cell death [16]. To improve the optimal forecasting and management of TBI in children, it is important to understand the factors associated with adverse clinical consequences. Many studies in the field of TBI have been conducted on adults; there is scant research on children and adolescents. In this study, we aim to examine the factors associated with adverse clinical consequences of TBI in children with moderate to severe TBI.

Methods
In this study, all children and adolescents (aged ≤18 years) with moderate to severe TBI (based on the Classification System for TBI Severity) [10] referred to our center from May 2013 to June 2020 were evaluated. The entry criteria were the occurrence of TBI, a Glasgow coma scale (GCS) score ≤13 [3], and age <18. Those with death due to non-brain injuries in the first 24 hours were excluded from the study. Demographic, clinical, radiology and laboratory data were investigated. These data included: age, sex, cause of trauma, GCS at the time of admission, pupil reaction to light, Rotterdam computer tomography (CT) score, hospitalization length, anemia during admission, and high blood sugar during admission. All patients were managed in accordance with the advanced trauma life support protocol for severe head injury where mass lesions are discharged with surgery and all unconscious patients with GCS≤8 are intubated and underwent mechanical ventilation [19]. 
All patients underwent CT scanning at the time of admission. The CT scans were classified by the main author retrospectively based on the Rotterdam classification system [20]. The clinical outcomes at the time of discharge from the hospital were evaluated using the Glasgow outcome scale (GOS) [7]. This scale grades the outcomes as 5= good recovery; 4= moderate disability; 3= severe disability; 2= ​​persistent vegetative; and 1= death. The data was analyzed using SPSS software, version 23 (SPSS Inc. Chicago, Illinois). Descriptive statistics were reported as median (range) for continuous variables and frequency (percentage) for discrete variables. We used the Chi-Square test or Fisher's exact test to evaluate the difference between ratios. The student T-test was used to evaluate continuous variables. Binary logistic regression analysis was used to evaluate the independent relationship between different variables and clinical results. P<0.05 was considered statistically significant.

Results
In this study, 374 children with moderate to severe TBI were evaluated, of whom 197 (52.7%) were boys and 177 (47.3%) were girls. Their mean age during injury was 7.37±3.11 years. The baseline characteristics of patients are shown in tables 1 and 2.




The univariate regression analysis showed that the GCS score, pupillary light reflex, the Rotterdam CT score, anemia during admission, and high blood sugar during admission were associated with adverse outcomes of TBI in children (P<0.05). Multiple regression analysis results showed the GCS score (OR=3.2; 95% CI: 1.78-5.24; P<0.001), pupillary light reflex (OR=1.97; 95% CI: 1.34-2.99; P=0.024), and the Rotterdam CT score (OR=2.61; 95% CI: 1.72-4.13; P=0.020) had a relationship with clinical outcomes.

Conclusion
The GCS score, pupillary light reflex, and the Rotterdam CT score can predict adverse clinical outcomes in children with moderate to severe TBI. The results of this study can be used to improve the management of these patients.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the ethics committee of Kermanshah University of Medical Sciences (Code: IR.KUMS.REC.1399.248).

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Methodology, supervision: Ehsan Alimohammadi and Seyed Reza Bagheri Bavandpouri; Data collection: Sahel Asadzade and Bita Shokri; Initial draft preparation: Bita Shokri and Ehsan Alimohammadi; Conceptualization, investigation, editing & review: All authors.

Conflicts of interest
The authors declare no conflict of interest.


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Review Paper: Applicable | Subject: Special
Received: 2023/07/17 | Accepted: 2023/11/22 | Published: 2024/06/30
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