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A meta-analysis of variables that predict significant intracranial injury in minor head trauma
J Dunning1, J Batchelor, P Stratford-Smith
1Emergency Medicine Research Group (EmeRGe), Manchester Royal Infirmary, UK. joeldunning@doctors.org.uk
Insights
Skull fractures and focal neurological signs strongly predict intracranial hemorrhage in children with head injuries. Headache and vomiting are not reliable indicators, highlighting the need for refined diagnostic guidelines.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Clinical Neurology
Background:
- Conflicting evidence exists on predicting intracranial pathology in pediatric minor head injuries.
- Clinical symptoms, signs, and imaging vary in their predictive value.
- Need for a comprehensive assessment of these predictors for intracranial hemorrhage (ICH).
Purpose of the Study:
- To conduct a meta-analysis evaluating predictors of intracranial hemorrhage (ICH) in children.
- To assess the significance of clinical factors and imaging in pediatric head injury.
Main Methods:
- Systematic literature search of Medline, Embase, Experts, and grey literature.
- Inclusion of control or nested case-control studies involving children with head injury.
- Data extraction on skull radiography, symptoms, signs, and head computed tomography (CT) for ICH.
Main Results:
- Sixteen studies included, with pooled patient numbers ranging from 1136 to 22,420.
- Significant predictors of ICH: skull fracture (RR 6.13), focal neurology (RR 9.43), loss of consciousness (LOC) (RR 2.23), and GCS <15 (RR 5.51).
- Non-significant predictors: headache (RR 1.02) and vomiting (RR 0.88); seizures showed variable predictive ability (RR 2.82).
Conclusions:
- Statistically significant correlations found between ICH and skull fracture, focal neurology, LOC, and abnormal GCS.
- Headache and vomiting are not predictive of ICH in this population.
- Further research is needed to refine predictive variables and develop improved clinical guidelines.
Background:
Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury.
Aims:
To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population.
Methods:
The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected.
Outcome Variable:
CT presence or absence of ICH.
Results:
Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0).
Conclusions:
There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.
