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Semi-quantitative Assessment Using [18F]FDG Tracer in Patients with Severe Brain Injury
Published on: November 9, 2018
Tripartite Stratification of the Glasgow Coma Scale in Children with Severe Traumatic Brain Injury and Mortality: An
Sarah Murphy1, Neal J Thomas2, Shira J Gertz3
1Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.
Insights
The Glasgow Coma Scale (GCS) is linked to mortality in severe pediatric traumatic brain injury (TBI). Stratifying GCS scores reveals significant differences in outcomes, especially when pupil response is considered.
Area of Science:
- Pediatric Neurology
- Trauma Surgery
- Critical Care Medicine
Background:
- The Glasgow Coma Scale (GCS) lacks validation in children under 5 and its clinical applicability is limited.
- Severe traumatic brain injury (TBI) in children requires accurate prognostic tools.
Purpose of the Study:
- To analyze GCS score distribution in pediatric TBI.
- To examine the relationship between injury characteristics and GCS scores.
- To assess the association of stratified GCS scores with mortality in severe pediatric TBI.
Main Methods:
- Analysis of the first 200 children (age 0-18) from a severe TBI study with GCS ≤8 and ICP monitoring.
- Tripartite stratification of GCS scores (Group A: 3; Group B: 4-5; Group C: 6-8).
- Statistical analysis using ANOVA and chi-square testing, including pupil response.
Main Results:
- Mortality rates varied significantly across GCS strata (Group A: 42.2%, Group B: 22.6%, Group C: 3.8%; p<0.001).
- Differences in neuromuscular blockade, intubation, pre-hospital events, coagulopathy, and pupil response were noted between groups.
- GCS score and pupil response combined improved mortality prediction.
Conclusions:
- GCS score at ICP monitor placement strongly correlates with mortality in pediatric TBI patients.
- A similar GCS-mortality relationship was observed in children under 5.
- Future models incorporating GCS and other factors may identify pediatric TBI subtypes.
Abstract:
The Glasgow Coma Scale (GCS) score has not been validated in children younger than 5 years and the clinical circumstances at the time of assignment can limit its applicability. This study describes the distribution of GCS scores in the population, the relationship between injury characteristics with the GCS score, and the association between the tripartite stratification of the GCS on mortality in children with severe traumatic brain injury (TBI). The first 200 children from a multi-center comparative effectiveness study in severe TBI (inclusion criteria: age 0-18 years, GCS ≤8 at the time of intracranial pressure [ICP] monitoring) were analyzed. After tripartite stratification of GCS scores (Group A, GCS 3; Group B, GCS 4 - 5; and Group C, GCS 6 - 8), analyses of variance and chi-square testing were performed. Mean age was 7.61 years ±5.33 and mortality was 19.1%. There was no difference in etiology or type/mechanism of injury between groups. However, groups demonstrated differences in neuromuscular blockade, endotracheal intubation, pre-hospital events (cardiac arrest and apnea), coagulopathy, and pupil response. Mortality between groups was different (42.2% Group A, 22.6% Group B, and 3.8% Group C; p < 0.001), and adding pupil response improved mortality associations. In children younger than 5 years of age, a similar relationship between GCS and mortality was observed. Overall, GCS score at the time of ICP monitor placement is strongly associated with mortality across the pediatric age range. Development of models with GCS and other factors may allow identification of subtypes of children after severe TBI for future studies.
