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Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED
Roger Zemek1, Nick Barrowman2, Stephen B Freedman3
1Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada.
Insights
A new clinical risk score helps identify children at risk for persistent postconcussion symptoms (PPCS) after a head injury. This tool aids clinicians in stratifying risk for ongoing concussion symptoms in pediatric patients.
Area of Science:
- Pediatric Emergency Medicine
- Neurology
- Clinical Risk Stratification
Background:
- Approximately one-third of children with acute concussion develop persistent postconcussion symptoms (PPCS).
- There is a lack of validated tools to identify children at risk for PPCS.
- Early identification of at-risk children is crucial for timely intervention and management.
Purpose of the Study:
- To derive and validate a clinical risk score for predicting PPCS in children presenting to the emergency department.
- To develop a pragmatic tool for clinicians to assess PPCS risk.
Main Methods:
- A prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled children aged 5-18 years with acute head injury.
- Patients were enrolled within 48 hours of injury across 9 pediatric emergency departments.
- Follow-up was conducted at 28 days post-injury to assess for PPCS using the Postconcussion Symptom Inventory.
Main Results:
- A total of 3063 children were enrolled, with 2584 completing 28-day follow-up.
- Persistent postconcussion symptoms (PPCS) were present in 31.0% of patients.
- A 12-point risk score model was developed, including factors like female sex, older age, migraine history, prior concussion, headache, noise sensitivity, fatigue, slow responses, and balance errors. The model showed modest discrimination (AUC 0.71 in derivation, 0.68 in validation).
Conclusions:
- A clinical risk score demonstrated modest ability to stratify PPCS risk in children with concussion.
- Further external validation and assessment of clinical utility in office settings are recommended before widespread adoption.
- The score aids in identifying children at risk for persistent postconcussion symptoms.
Importance:
Approximately one-third of children experiencing acute concussion experience ongoing somatic, cognitive, and psychological or behavioral symptoms, referred to as persistent postconcussion symptoms (PPCS). However, validated and pragmatic tools enabling clinicians to identify patients at risk for PPCS do not exist.
Objective:
To derive and validate a clinical risk score for PPCS among children presenting to the emergency department.
Design, Setting, And Participants:
Prospective, multicenter cohort study (Predicting and Preventing Postconcussive Problems in Pediatrics [5P]) enrolled young patients (aged 5-<18 years) who presented within 48 hours of an acute head injury at 1 of 9 pediatric emergency departments within the Pediatric Emergency Research Canada (PERC) network from August 2013 through September 2014 (derivation cohort) and from October 2014 through June 2015 (validation cohort). Participants completed follow-up 28 days after the injury.
Exposures:
All eligible patients had concussions consistent with the Zurich consensus diagnostic criteria.
Main Outcomes And Measures:
The primary outcome was PPCS risk score at 28 days, which was defined as 3 or more new or worsening symptoms using the patient-reported Postconcussion Symptom Inventory compared with recalled state of being prior to the injury.
Results:
In total, 3063 patients (median age, 12.0 years [interquartile range, 9.2-14.6 years]; 1205 [39.3%] girls) were enrolled (n = 2006 in the derivation cohort; n = 1057 in the validation cohort) and 2584 of whom (n = 1701 [85%] in the derivation cohort; n = 883 [84%] in the validation cohort) completed follow-up at 28 days after the injury. Persistent postconcussion symptoms were present in 801 patients (31.0%) (n = 510 [30.0%] in the derivation cohort and n = 291 [33.0%] in the validation cohort). The 12-point PPCS risk score model for the derivation cohort included the variables of female sex, age of 13 years or older, physician-diagnosed migraine history, prior concussion with symptoms lasting longer than 1 week, headache, sensitivity to noise, fatigue, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The area under the curve was 0.71 (95% CI, 0.69-0.74) for the derivation cohort and 0.68 (95% CI, 0.65-0.72) for the validation cohort.
Conclusions And Relevance:
A clinical risk score developed among children presenting to the emergency department with concussion and head injury within the previous 48 hours had modest discrimination to stratify PPCS risk at 28 days. Before this score is adopted in clinical practice, further research is needed for external validation, assessment of accuracy in an office setting, and determination of clinical utility.
