JOURNAL READING

Traumatic brain injury in infants

and toddlers, 0-3 years old
Ciurea AV, Gorgan MR, Tascu A, Sandu AM, Rizea RE
“Bagdasar-Arseni” Clinical Emergency Hospital, Department of Neurosurgery, Bucharest, Romania

Journal of Medicine and Life Volume 4, Issue 3, July-September 2011, pp.234-243

dr. Franklin L. Sinanu

Pembimbing:
dr. Nunik Agustriani, Sp.B., Sp.BA.
Introduction
• Traumatic brain injury (TBI) is the leading cause of
death and disability in children.
• The most common causes of TBI in children: falls,
child abuse, motor vehicle accidents, sport accidents,
assaults, and instrumental delivery.
• Specific pediatric scales, adapted according to age,
must be used to correctly grade the severity of TBI in
children.
Introduction
• Traumatic pathology during the first 3 years of life is
completely different when compared with adults.
• “Children are not young adults”
Introduction
• Common neurotrauma pediatric scales are:
– Pediatric Coma Scale/Children Coma Scale (PCS)
– Children's Coma Score (CCS)
– Trauma Infant Neurological Score (TINS)
Introduction
• Outcome is graded by using neurotrauma
pediatric outcome scales, such as:
– KOSCHI (King's Outcome Scale for Childhood Head
Injury) score
– Glasgow Outcome Scale (GOS)
– Modified Rankin score
Introduction
• This journal is a presentation of the author’s 10 years
experience in neuropediatric traumatic brain injuries.
Material and Methods
• Retrospective analysis
• All cases with TBI, aged between 0 and 3 yrs old
which are admitted into the Department of Pediatric
Neurosurgery of “Bagdasar-Arseni” Clinical Hospital,
in Bucharest
• 1st of January 1999 and 31st of December 2008 (10
years)
Material and Methods
• Inclusion criteria:
– Age 0-3 yrs old
– TBI
– No history of previous head injury
– No multiple trauma
– No birth trauma
Results
• 312 consecutive cases of children 0-3 years old
were admitted.
• Most children presented with minor head
injuries, 283 cases (90.70%).
Results
Results
Results
Results
Results
Cephalhematoma (CPH)
• In study group, there were 58 children (18.59%) with
CPH.
• CPH, which does not spontaneously withdraw under
conservatory treatment, requires surgical treatment.
– Tapping (punctioning with a thick needle)
– Skin incisions and scalp dissection
Results
Linear skull fractures
– Were found in 124 children (39.74%)
– All should be admitted as an inpatient
– Linear skull fractures without any associated
intracranial pathology did not require surgery
Results
Results
Diastatic Skull fractures
– Diastatic skull fractures were found in 72 children
(23.08%).
– In children aged between 0 and 3 years old,
diastatic skull fractures carry a high risk of
transforming into a growing skull fracture (GSF).
– All children with diastatic skull fracture were kept
under careful observation for this reason.
Growing Skull Fracture
• A case of a 5 weeks old girl, with a history of minor
head trauma, 2 weeks before admission.
• The child presented with a progressive growing right
frontal cystic, nontender mass, underlying palpable
bony defect.
• CT-scan and 3D reconstruction CT-scan showed a
diastatic skull fracture, leptomeningeal cyst, and
brain herniation protruding through the bone defect.
Growing Skull Fracture
Results
Depressed skull fractures (ping-pong)
– Were found in 61 children (19.55%)
– Needs burr hole to elevate the bone

Depressed skull fractures (comminutive)

– Were found in 19 children (6.09%)
– Needs cranioplasty and duraplasty
Results
Craniocerebral wound/ Penetrating head injury
– 11 children (3.53%) had craniocerebral
wounds/penetrating head injury
– Surgery in penetrating head injuries is needed to
clean the wound, extract foreign bodies, and
hemostasis.
– If needed duraplasty.
Results
Extradural hematoma/ Epidural hematoma
(EDH)
– 26 children (8.33%) had EDH
– 3 cases with EDH presenting with hemorrhagic
shock
– One of the main goals of surgery is coagulation
of the bleeding source
Results
Results
Results

Fig. 8. Right parietal extradural hematoma (preoperative imaging)

Results
Diffuse brain swelling
– 18 children (5.77%) had diffuse brain swelling
– In 7 children the CT-scan revealed extensive
diffuse ischemia ("black brain"), which all were
comatose and had a poor outcome. Death
occurring in all 7 cases.
Results
Discussion
• Infants and toddlers had some anatomical and
functional particularities of central nervous
system (CNS).
• Due to age-related particularities, a specific,
distinctive posttraumatic response to external
damaging factors occurs, completely different in
children than in adults.
Discussion
• Infants and toddlers tolerate larger space-
occupying traumatic lesions compared with
adults, but consequences are similar.
Conclusion
• Neurotrauma pathology is very different in infants
and toddlers compared to different age patients.
• Accurate and rapid clinical and neuroimagistic
diagnosis is the key of success.
• The Pediatric Neurosurgical Department and
Pediatric Intensive Care Unit represent a vital
necessity.
Conclusion
• Long time follow-up is mandatory.
• CT-scan is the main investigation tool and must be
performed in all children with TBI, in the first
three hours.
• Hemorrhagic shock may rapidly occur in infants
and young children.
Conclusion
• Grow skull fracture is a specific posttraumatic
lesion in infants and young children.
• Surgery is always required to prevent neurological
deficits and/or seizures occurrence.
• Cranioplasty is not indicated in infants.
THANK YOU
SCALP
Pediatric Coma Scale (PCS)
(Simpson & Reilly, 1982)

Score Eyes response Verbal response Motor response

5 - Orientated Obeys command
4 Spontaneously Words Localizes pain
3 To speech Vocal sounds Flexion to pain
2 To pain Cries Extension to pain
1 None None None

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Pediatric Coma Scale (PCS)
(Simpson & Reilly, 1982)

Normal scores differ according to age

0-6 mths 9
6-12 mths 11
1-2 yrs 12
2-5 yrs 13
>5 yrs 14

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Pediatric Coma Scale (PCS)
(Simpson & Reilly, 1982)

PCS is used in evaluation of brain injury severity in preverbal children. Scores

must be adjusted according to child’s age:
• During the first 6 months, best verbal response is crying, so normal verbal
score expected is 2, and best motor response is usually flexion with a normal
motor score expected of 3.
• Between 6 and 12 months, a normal infant makes noises, so normal verbal
score expected is 3, an infant will usually locate pain, and so normal motor
score expected is 4.

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Pediatric Coma Scale (PCS)
(Simpson & Reilly, 1982)

• Between 12 months and 2 years, recognizable words are expected, so normal

verbal score expected is 4, and the infant will usually locate pain but not
obeys commands, so normal motor score expected is 4.
• Between 2 and 5 years, recognizable words are expected with a normal
verbal score expected of 4, and the infant will usually obeys commands, so
normal motor score expected is 5.
• Children older than 5 years are orientated, aware of their location (home,
hospital), so normal verbal score expected is 5.

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Children’s Coma Score (CCS)
(Raimondi & Hirschauer, 1984)
Score Ocular response Verbal response Motor response
4 Pursuit - Flexes and extends
Extra ocular muscles Withdraws from
3 (EOM) intact, Cries painful stimuli
reactive pupils
Fixed pupils or EOM Spontaneous
2 Hypertonic
impaired respiration
Fixed pupils or EOM
1 Apnea Flaccid
paralyzed

Maximum CCS assignable is 11, and minimal 3

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Trauma Infant Neurological Score (TINS)
Min/Max 0 1 2

Mechanism of Fall > l m or

1/2 - Fall < 1 m or mild blow
trauma penetrating injury

Intubated on
0/1 No Yes -
arrival
Fully alert, but
Alertness 0/2 Decreased Unconscious
arousable

Motor deficit 0/2 None Lateralizing signs No movement

Anisocoria or non Dilated and non

Pupils 0/2 Reactive bilaterally
reactive pupil reactive

Scalp injury 0/1 None Subgaleal hematoma -

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Trauma Infant Neurological Score (TINS)

• Total score ranges from 1 to 10 points. TINS score over 2

indicates the need for a CT-scan examination.
• In conclusion, TINS is very useful in TBI in 0-3 year old
children, because it evaluates mechanism of trauma,
neurological and general status of the patient and scalp injury.
• Also, TINS reflects outcome of these patients (at 10 points the
outcome is critical status).

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Glasgow Coma Scale (GCS)
Eyes opening/ocular response

0-1 year > 1 year Score

Spontaneously Spontaneously 4

To shout To verbal command 3

To pain To pain 2

No response No response 1

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Glasgow Coma Scale (GCS)
Motoric response
0-1 year > 1 year Score
Obeys command
6
Localizes pain Localizes pain
5
Flexion withdrawal Flexion withdrawal
4
Flexion abnormal (decorticate) Flexion abnormal (decorticate)
3

Extension (decerebrate) Extension (decerebrate)

2
No response No response
1

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
 Glasgow Coma Scale (GCS)
Verbal response
0-2 years 2-5 years > 5 years Score
Cries appropriately Appropriate words Oriented and converses
5

Cries Inappropriate words Disoriented and converses

4

Inappropriate crying or Screams Inappropriate words, cries

screaming 3

Grunts Grunts Incomprehensible sounds

2

No response No response No response 1

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Glasgow Coma Scale (GCS)
Grimace response
Score
Spontaneous normal facial activity
5
Less than usual spontaneous response to touch stimuli
4
Vigorous grimace to pain
3
Mild grimace to pain
2
No response to pain
1

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
Glasgow Coma Scale (GCS)
• Intubated children are unable to speak and they are evaluated
only with eye opening and motor response.
• The letter “T” is added to the score to indicate an intubated
patient: the maximal GCS score is 10T and the minimum score
is 2T.
• In conclusion, GCS score adapted from adults to infants and
young children it is a pediatric version of GCS, but it is difficult
to use in practical neuropediatric traumatology.

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.
 Glasgow Outcome Scale (GOS)
(Jennett & Bond, 1975)
Score Outcome
1 Death
2 Vegetative state
3 Severe disability
4 Moderate disability
Description  
D Death.
VG Patient exhibit no obvious cortical function.
Conscious, but disabled. Patient depends upon other for daily support
SD due to mental or physical disability or both.
Disabled, but independent. Patient is independent as far as daily life is
concerned. The disabilities found include varying degrees of dysphasia,
MD hemiparesis, ataxia, as well as intellectual and memory deficits and
personality changes.

Resumption of normal activities even though there may be minor

5 Good recovery GR neurological or physiological deficits.

GOS is the most common scale used to evaluate neurotrauma

patients, it is very practical, it is very easy to work with, and it is
well known by doctor of all specialties.
 Modified Rankin Score (1957)
Score Description  

0 No symptoms at all
No significant disability despite symptoms; able to carry out all usual duties and activities
1
Slight disability; unable to carry out all previous activities, but able to look after own affairs
2 without assistance
Moderate disability; requiring some help, but able to walk without assistance
3
Moderately severe disability; unable to walk without assistance and unable to attend to own
4 bodily needs without assistance
Severe disability; bedridden, incontinent and requiring constant nursing care and attention
5
6 Dead

Rankin score was first described in vascular pathology, and

extended afterwards for traumatic patients. It is more detailed
than GOS, providing more information regarding the patient’s
condition.
 KOSCHI Score (2010)
(King's Outcome Scale for Childhood Head Injury)
Score Description Definition  
1 Death death
breathing spontaneously; no ability to
2 Vegetative state
communicate verbally or nonverbally or to respond to commands
a) some purposeful movement or ability to
follow commands; may be conscious and able to communicate; unable to care for self
3 Severe disability b) exhibits high level of dependency but can assist with own care; fully conscious but with
PTA

a) mostly independent but requires supervision or help; has overt problems

Moderate b) age appropriately independent but with residual learning/behavior problems or
4
disability neurological sequels
a) HI resulted in new condition that does not affect well being or functioning
5 Good recovery
b) complete recovery with no detectable sequels

Ciurea AV., Sandu AM., Popescu M., Iencean SM., Davidescu B. Neurotrauma
pediatric scales. J Med Life. 2008 Oct-Dec;1(4):403-14.