Traumatic brain injury is the most common injury during childhood comprising 60% to 90% injuries in children. Pediatric traumatic brain injury has peculiarities as compared to adults, such as less severe injuries and better prognosis. The purpose of this work was to study the pattern of pediatric traumatic brain injury at the General Hospital, Douala, Cameroon. This was a retrospective cross-sectional study, from January 1st, 2008 to December 31st, 2017. Included were all complete medical records of children aged 0 to 15 years old treated for traumatic brain injury, and excluded records of obstetric trauma. Data analysis was done by SPSS software version 18.0. One hundred and three cases of pediatric head injuries were recorded during the study period (frequency 10.43%). The mean age was 7.42 ± 5.028 years, and the sex ratio was 2.67 in favor of boys. Road traffic accidents were the most common etiology (44.7%). 83.5% of the patients were transferred to the emergency department of the Douala General Hospital in second intention and by non-medical transport. The traumatic brain injury was mild in 61.20%. The brain computed tomography scan was performed in 99% of the cases and the most observed lesion was cerebral edema (32.74%). Twenty-eight patients underwent surgical operation. 90.28% of patients have recovered fully, and the global mortality was 3.88%. The prevalence of pediatric traumatic brain injuries at the General Hospital, Douala during the last ten years was 10.43%. Most of the patients recovered fully and the mortality was low.
Traumatic brain injury (TBI) can be defined as an alteration in brain function resulting from blunt or penetrating force to the head or as a non-congenital assault to the brain caused by mechanical energy to the head from external forces [
The child’s head anatomy and physiology differ from that of the adult: the head to body ratio is greater; skull bones are thinner, elastic and deformable; the brain is less or not fully developed; brain swelling is more frequent and hypovolemic shock can occur from blood loss due to scalp bleeding. Globally, the outcome of pediatric TBI is better compared to adults. Traumatic brain injuries (TBI) are the most frequent injuries during childhood, recorded in 60% to 90% of children with trauma, and TBI is the leading cause of death and disability in children. Hopefully, they are mild in 80% to 90% of the cases [
The most frequent modes of injury for PTBI are falls and road traffic accidents (RTA). Most of the studies report a male predominance with no difference concerning the outcome. The diagnosis imaging modality of choice is non-enhanced computed tomography (CT) scanning of the head [
The management of PTBI is still debated, especially for mild and moderate TBI. For severe PTBI, the controversy is less sharp and its management includes the prescription of CT scan of the head, admission to ICU, intubation and
Classification | GCS | Loss of consciousness | Post-traumatic amnesia |
---|---|---|---|
Mild | 13 - 15 | 0 - 30 minutes | <1 day |
Moderate | 9 - 12 | 30 minutes - 24 hours | 1 - 7 days |
Severe | 3 - 8 | >24 hours | >7 days |
GCS: Glasgow coma scale. Severity of TBI is classified based on the highest severity in any column.
mechanical ventilation, at a level I (pediatric) trauma center (having permanent neurosurgical team) [
Because of the aforementioned reasons, this study was conducted in order to have a better understanding and to improve the management of PTBI at our institution.
It was cross-sectional retrospective analysis of 103 cases of PTBI managed at the General Hospital, Douala, (GHD) Cameroon, from the 1st January 2008 to December 31st 2017. The GHD is a tertiary referral hospital with a level I trauma center comprising 3 full-time neurosurgeons with emergency (pediatric and adult), pediatric, surgical and resuscitation departments amongst other. It has a multiple barrettes CT scanner and a 0.4 tesla MRI (Toshiba, Tokyo, Japan). The study was granted ethical committee agreement and informed consent was obtained from patients ‘parents and confidentiality of the data gathered was respected. The study involved the medical records of all consecutive cases of PTBI. The inclusion criteria were as follows: patients aged zero to 15 years; all genders; definite diagnosis of TBI associated or not with extra cranial injury; complete medical records. The criteria for non-inclusion were as follows: obstetrical trauma, incomplete files, patients older than 15 years, non-head trauma patients. The sampling method was non-probabilistic consecutive recruitment.
The data concerning age, gender, mode of injury, past medical history, transportation means, complaints, physical examination findings, CT findings, management procedures and the outcome were gathered. The severity of the TBI was determined by the GCS score or the pediatric GCS for patients under 4 years of age (
During the study period, 987 cases of TBI were admitted at the emergency department of GHD, 103 cases were children giving a prevalence of 10.43% for PTBI. The PTBI patients comprised 75 boys and 28 girls, sex ratio, 2.67.
Eyes opening | |||
---|---|---|---|
Score | Age < 1 year | Age > 1 year | |
4 | Opens eyes spontaneously | Opens eyes spontaneously | |
3 | Opens to shout | Opens to verbal command | |
2 | Opens to pain | Opens to pain | |
1 | No eye opening | No eye opening | |
Motor response | |||
Score | Age < 1 year | Age > 1 year | |
6 | Normal movements | Obeys verbal commands | |
5 | Localizes to noxious stimuli | Localizes to noxious stimuli | |
4 | Flexion withdrawal | Flexion withdrawal | |
3 | Flexion/Decorticate posturing | Flexion/Decorticate posturing | |
2 | Extension/Decerebrate posturing | Extension/Decerebrate posturing | |
1 | No response to noxious stimuli | No response to noxious stimuli | |
Verbal response | |||
Score | 0 - 23 months old | 2 - 5 years old | >5 years old |
5 | Smiles/coos/cries appropriately | Appropriate words or phrases | Orientated (normal conversation) |
4 | Cries/consolable crying/screams | Inappropriate words | Confused§ |
3 | Irritable/inconsolable | Cries/screams | Inappropriate* |
2 | Grunts/agitated | Grunts | Incomprehensible# |
1 | None | None | None |
To obtain the GCS score, eye opening, verbal and motor responses points are added to each other. Minimum = 3; maximum = 15. §: conversation is possible, but signs of mental confusion are noticed. *: comprehensible words, but conversation is not possible. #: incomprehensible sounds such as grunting.
in 48.54%.
All patients but one had a brain CT scan (99%), five, a skull and two a cervical spine X-ray.
The management (
The overall mortality was 3.88% with 4 deaths. Ninety-three (90.28%) patients recovered fully and six (5.82%) had mild to moderate disability. The persisting
Variable | Number | Percent (%) |
---|---|---|
Mode of injury | ||
Road traffic accident | 46 | 44.66 |
Fall | 42 | 40.77 |
Assault | 07 | 06.80 |
Domestic accident | 04 | 03.88 |
Sport accident | 04 | 03.88 |
Transportation means | ||
Medical ambulance | 10 | 09.71 |
Non-medical vehicle | 93 | 90.29 |
Admission GCS score | ||
13 - 15 (mild TBI) | 63 | 61.16 |
09 - 12 (moderate TBI) | 34 | 33.01 |
≤8 (severe TBI) | 06 | 05.82 |
Clinical manifestations | ||
Loss of consciousness | 50 | 48.54 |
Scalp wound | 43 | 41.74 |
Periorbital ecchymosis | 40 | 38.83 |
Vomiting | 38 | 36.89 |
Headache | 31 | 30.09 |
Seizures | 28 | 27.18 |
Time interval* | ||
0 - 24 hours | 49 | 47.57 |
24 - 48 hours | 05 | 04.06 |
>48 hours | 49 | 47.57 |
Computed tomography findings | ||
Cerebral edema | 37 | 35.92 |
Skull fracture (depressed) | 35 (15) | 33.98 (14.56) |
Acute subdural hematoma | 19 | 18.44 |
Intra cerebral hematoma | 10 | 09.71 |
Epidural hematoma | 08 | 07.77 |
Subarachnoid hemorrhage | 02 | 01.94 |
Management | ||
Analgesics | 102 | 99.03 |
Antibiotics | 83 | 80.58 |
Mannitol | 52 | 50.48 |
Antiepileptic | 22 | 21.36 |
Oxygen therapy | 13 | 12.62 |
Blood transfusion | 07 | 06.79 |
Craniotomy§ | 22 | 21.36 |
Scalp wound suture | 06 | 05.82 |
Outcome | ||
Full recovery | 93 | 90.29 |
Persisting symptoms# | 06 | 05.82 |
Death | 04 | 03.88 |
GCS: Glasgow coma scale. *: time interval between trauma and admission. §: for removal of intracranial hematomas or depressed skull fractures. #: hemiparesis, one case; chronic headaches, five cases. TBI: traumatic brain injury.
disability consisted in hemiparesis in one case and chronic headaches in four. It is only the GCS score at admission which significantly influenced the outcome (
Most findings from this series such as age, gender, cause of trauma, were consistent with data from the literature [
Relation between time interval & admission GCS | Mild to moderate TBI (GCS 9 to 15) | Severe TBI (GCS ≤ 8) | Total | Chi-square | DDL | P value | |
---|---|---|---|---|---|---|---|
Delay < 24 h | 46 | 3 | 49 | 0.167 | 1 | 0.683 (NS) | |
Delay > 24 h | 51 | 3 | 54 | ||||
Total | 97 | 6 | 103 | ||||
Outcome & the GCS | |||||||
Full recovery | 90 | 3 | 93 | 14.96 | 1 | 0.001 | |
Disability* | 05 | 1 | 06 | ||||
Death | 02 | 2 | 04 | ||||
Total | 97 | 6 | 103 | ||||
Outcome & gender | Survivors | Deceased | Total | ||||
Boys | 72 | 3 | 75 | 0.01 | 1 | 0.92 (NS) | |
Girls | 27 | 1 | 28 | ||||
Total | 99 | 4 | 103 | ||||
Outcome & age | Survivors | Deceased | Total | ||||
0 - 2 | 21 | 0 | 21 | 1.92 | 3 | 0.955 (NS) | |
3 - 5 | 25 | 2 | 27 | ||||
6 - 10 | 19 | 1 | 20 | ||||
11 - 15 | 34 | 1 | 35 | ||||
Total | 99 | 4 | 103 | ||||
Outcome & treatment | Survivors | Deceased | Total | ||||
Non-operated | 72 | 3 | 75 | 0.003 | 1 | 0.955 (NS) | |
Operated | 22 | 1 | 28 | ||||
Total | 99 | 4 | 103 | ||||
GCS: Glasgow coma scale, TBI: traumatic brain injury, h: hour, NS: non-significant. *: one hemiparesis & five chronic headaches. The only significant prognostic factor was the GCS at admission. The mortality for mild and moderate TBI was 2.06% (2 deaths out of 97 children), while that of severe TBI was 33.33% (2 deaths out of 6 patients); the prevalence of persisting disability was 5.26% in the survivors with mild and moderate TBI (5/95), and 25% in survivors with severe TBI (1/4). Time interval between trauma & admission, gender, age, and treatment modality had no impact on the outcome.
The age distribution of children who sustained TBI varies amongst series. In the present series, children aged between 0 and 5 years were the most involved, followed by those between 11 and 15 years of age. This finding is similar to data reported by other authors [
The male predominance for TBI even in children is unanimously reported from the literature suggesting that males and hence boys, are more exposed to activities at risk for TBI [
The falls are the 1st mode of injury for pediatric TBI, mainly before six years of age, followed by road traffic accidents [
Most TBI are mild both in children and adults. This is consistent with findings from this series in which 61.20% of PTBI were mild (GCS 13 to 15). The predominance of mild and moderate TBI in children can be explain by many factors: in children up to two years of age, the skull is deformable and can absorb shock better than adult skull; most accidents occur at home and are therefore low-energy injuries; parents may be more worried even in cases of light blow and may be more prone to bring children to the hospital [
Concerning the clinical findings, the initial loss of consciousness was the most common symptom observed in 50 (48.50%) children, and this finding was consistent with reported data [
The CT scanning of the head is the imaging tool of 1st intention for patients with TBI [
In this series, 22 patients (21.36%) needed a craniotomy for intracranial hematomas or depressed skull fractures and six had sutured scalp wounds. Therefore, the prevalence for post-traumatic intracranial lesions requiring surgery was 13.59% (14 children). In the series from O’Lynnger et al. 20 to 32% of children with severe TBI needed a neurosurgical operation [
TBI can be detrimental on a developing brain with a negative impact on school performance and family functioning with a high economic cost, and this is particularly true for severe TBI in which mortality can reach 20% with 50% unfavorable outcome at six-month [
In conclusion, the frequency of pediatric TBI amongst patients admitted for TBI at the General Hospital, Douala, Cameroon for the last ten years was 10.43%. The pediatric TBI was more frequent in boys than in girls and affected most often early childhood and pre-adolescent children. The road traffic accident was the first mode of injury and implicated motorcycles most of the time, and falls were second after RTA. Most of the patients were transferred at the GHD in second intention by non-medical transport. Almost two-third of pediatric TBI was mild and the loss of consciousness was the most frequent symptom. The CT scan of the head was systematically done and it has revealed most often post-traumatic cerebral edema. The mortality was low and full recovery was the rule. The main limitation of the study was its retrospective aspect. For that reason, some medical files had incomplete data and we could analyze only data which were gathered.
We thank Miss NDIMBA Erica for her help with the corrections.
None.
Ndoumbe, A., Motah, M., Dah, A.R.A. and Moumi, M. (2019) Pediatric Traumatic Brain Injury Pattern at the General Hospital, Douala, Cameroon. Open Journal of Modern Neurosurgery, 9, 49-60. https://doi.org/10.4236/ojmn.2019.91007
CT: Computed Tomography. PTBI: Pediatric Traumatic Brain Injury. TBI: Traumatic Brain Injury. EDH: Epidural or Extradural Hematoma. GCS: Glasgow Coma Scale. GHD: General Hospital, Douala. ICU: Intensive Care Unit. LOC: Loss of Consciousness. SAH: Subarachnoid Hemorrhage. WHO: World Health Organization.