SYNOPSIS OF PROPOSED THESIS

FOR
M.S. NEUROSURGERY

Pattern of Pediatric Head Injury

By
Dr. Fazal

Resident, M.S. Neurosurgery

Postgraduate Medical Institute, Lahore General Hospital,
Lahore.
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 APPROVAL OF SYNOPSIS FROM ETHICAL COMMITEE

Certified that we have read the synopsis Titled

” Pattern of Pediatric Head Injury”

Submitted by, Dr Fazal.

We have found it acceptable ethically and hence is approved for further

submission.
’
Prof. Dr. Nosheen Omer Convener
Prof. & Head of Anatomy Department,
PGMI, Lahore.

Prof. Zafar Iqbal Ch. Member

Prof & Head of Medicine Department,
PGMI/LGH, Lahore

Prof. Khahid Bashir Member

Prof. & Head of Anaesthesia Department,
PGMI/LGH, Lahore.

Dr Nudrat Sohail Member

Assistant Prof. of Gynaé & Obstet.
PGMI/LGH, Lahore.

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Name Dr.Fazal

Father’s Name

Neurosurgery Experience 18 months

Research supervisor

Name Prof. Nazir Ahmad

Designation Prof. of Neurosurgery

Qualification M.B.B.S, M.S. Neurosurgery

Present place of posting Principal Lahore General Hospital /PGMI

Acceptance of responsibility ____________________________________

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 Remarks and recommendation of the supervisor

This study has been launched to better define the Pattern of Pediatric Head Injury. I

hope that it shall improve our understanding of this specific group of patients and

shall help us to improve the care of these patients locally.

Signature of supervisor

__________________

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 Project Summary

Neurotrauma is one of the most important causes of death in the

pediatric age group. Head injury is responsible for both primary and secondary

brain damage. The outcome of children with brain injury depends on the

nature of the primary damage and on how well secondary brain damage can be

limited. Appropriate critical care management at the scene and in hospital can

prevent secondary brain damage that would otherwise result from cerebral

reactions.

This study shall be conducted at the Dept of Neurosurgery, Lahore

General Hospital, Lahore. This shall be an observational, analytical and

prospective study. The aim of the present study is to improve the care of

Paediatric Neurotrauma Patients and the objectives are to, to examine the

influence of socio-demographic characteristics and health care system factors

on Patients 12 years of age with a diagnosis of traumatic brain injury; To

document the outcome; Identification of high-risk groups; Identification of

Predictors of Outcome. This study will include 200 consecutive patients of less

than 12 years of age suffering from Head Injury presenting to us in Neuro-

Emergency. Patients shall be stratified according to the Severity of the Injury

by using Glasgow Coma Scale GCS at the time of presentation. Patients with

other systemic diseases shall be excluded from the study. Patient Factors,

Health Care System Factors and Patients Clinical Data will be collected

through a proforma. Data will be analyzed on computer using software

Microsoft Excel and SPSS. Data recording will be done on specified proforma,

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stored on Microsoft Excel, SPSS (statistical package for social sciences); the

results shall be evaluated by univariate and multivariate analysis. Assessment

will be done by using chi-square test and t-tests. Significant correlations and

differences shall be sought. The Conclusion will be drawn at one month after

discharge.

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 Introduction

Traumatic brain injury is a leading cause of death and disability in the pediatric

age group. Causes of injury have a different pattern as compared to adults and

vary with child’s developmental age; with more inflicted injuries in infants, fall-

related injuries among toddlers, sports-related injuries among middle-school-aged

children and motor vehicle crashes in older children.

Management is directed toward detecting and treating possible brain injury and

is based on the extent of the head injury. A proper medical management needs an

organized team approach ranging from pre-hospital care, emergency room and

Neurosurgical management. Prompt and early detection of mass lesions

(hematomas) and neurosurgical intervention is of paramount importance.

Due to rapidly changing social and demographic patterns in our society and

evolving Healthcare system there has been an impact on the care of this important

age group suffering from TBI . There is a lack of recent studies regarding the

spectrum of Paediatric head injury, in local population and there exists an urgent

need to analyze such data as incidence, demographics, pre-hospital and hospital

factors which are determinants of final outcome.

Such studies are necessary to elucidate these factors and that’s why we plan to

undertake this analysis of pediatric Neurotrauma at our institution which is the

leading care provider for these patients in the area. This will help us to better

define and highlight the gaps in the care and shall lead to identification of

vulnerable groups and individuals, providing us an opportunity to make

recommendations and guide policies with an aim to improve the care of these

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patients. Lastly, given limited resources, clearly delineating the optimal timing of

medical efforts will help prevent secondary injury and promote maximal

functional recovery in head-injured children

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 Literature Review

Accidents involving head injury are a major cause of pediatric death

and disability worldwide. Head injury is a leading cause of morbidity and

mortality in childhood. More than 1.5 million head injuries occur annually in

the United States, resulting in approximately 300,000 pediatric

hospitalizations, with males twice as likely as females to sustain a head injury.

[1]Overall, up to 90% of injury-related deaths among children are associated

with head trauma.[1]. No such recent Pediatric Neurotrauma data exists

locally.

In Pakistan a study by Raja IA etal. in year 2001 [2] covering the

Neurotrauma for adults and Pediatric groups was conducted to determine the

sociodemographic characteristics, morbidity, and mortality of patients with

head and spinal injury admitted to various neurosurgical centers in Pakistan

from July 1, 1995 to June 30, 1999. A total of 260,000 patients were admitted

with head injury over a 4-year period. The majority of patients presented

during second decade (i.e., 33.2%) followed by first and third decade. There

were 195,000 (75%) males, and 65,000 (25%) females with a ratio of 3:1.

Road traffic accident was the commonest cause of head trauma. Mild,

moderate, and severe head injury was observed in 135,200 (52%), 78,000

(30%), and 46,800 (18%) patients, respectively. Conservative management

was carried out in 176,800 (68%) patients. Surgery was required in 83,200

(32%), 50% of which had depressed skull fracture, simple or compound.

Follow-up period varied from 2 months to 2 years with a mean of 11 months.

Patient's outcome was assessed according to Glasgow Outcome Scale (GOS).

Good outcome was observed in 174,200 (67%). The total mortality was 46,800

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(18%). In this study, 2654 patients ranging in age from 5 to 70 years had spinal

injuries. There were 1922 males (72%) and 732 (28%) females. British

Medical Research Council Scale was used for assessment of motor power of

patients with spinal trauma. Of these, 780 patients (29%) had complete spinal

cord injury. Surgical intervention was performed in 1800 patients (68%) and

the rest were managed conservatively.

A recent French study by Ducrocq etal.[3] was conducted to describe

the results of an integrated pre- and in-hospital approach to critical care in a

large population of children with severe traumatic brain injury and to identify

the early predictors of their outcome. All children (1 month to 15 yrs) with

severe traumatic brain injury (Glasgow Coma Scale </=8) hospitalized were

followed. Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were

road traffic accidents and falls. Mean values for Glasgow Coma Scale,

Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and

28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was

<3 in 53% of the cases at discharge and 60% at 6 months.

There is a scarcity of data regarding childhood neurological injuries in

developing countries. In a recent study from Nepal Karim etal.[4] has

presented the the epidemiology of acute pediatric neurotrauma in Kathmandu

which was studied to assess the implications of these data for injury prevention

programs. They studied four hundred sixteen injured children. Spinal injuries

were relatively rare (4%) compared to head injuries (96%). Falls were the most

common cause of injuries (61%). It took significantly longer (p<0.001) for

children injured in rural Nepal (62%) to obtain neurosurgical care (30.1 h) than

those injured within Kathmandu (7.1 h). A Glasgow Outcome Score of 5 was

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obtained for 96%, 76%, and 22% of patients with mild, moderate, or severe

head injuries, respectively. The authors concluded that besides efforts to

improve prehospital transport and acute management of these injuries,

preventive measures that are applicable to their local scenario are urgently

needed and they should focus on health education programs directed at parents

and children and upgrading of road safety measures. Neurological injuries

must also be viewed in the context of the broader social issues that contribute

to injury.

Most of our understanding and most of our clinical management of

pediatric traumatic brain injury (TBI) is extrapolated from adults. Children are

not just “little adults”, and there are many important distinctions between the

developing and mature brain, particularly with regards to normal function,

pathophysiological response to injury, recovery and plasticity.

The developing brain is a unique physiological substrate and is

generally believed to be more resilient to injury than the adult brain. However,

in recent years, this dogma has been increasingly challenged. It is more correct

to state that the immature brain does have some inherent advantages with

regards to injury response and recovery; however, it also has clear

vulnerabilities that are to some extent based upon the underlying

developmental processes ongoing at the time of injury.

One fundamental distinction of pediatric TBI is purely physical. The

pediatric skull is thinner and more pliable than the adult. Particularly in

infants, the flexibility of the sutures and the presence of an open fontanelle

may result in significant alterations in the force transmitted to the brain by a

traumatic injury, as well as differences in the response to increased intracranial

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pressure resulting from posttraumatic cerebral edema. In the pediatric age

range, the size of the head relative to the body is also disproportionately large

when compared with adults. At the same time, the neck musculature is often

less developed and the cervical ligaments and joints are more flexible. These

factors are important considerations when evaluating a child with head injury,

particularly by a medical professional whose primary experience is with

adults.[5]

Mechanisms of injury also vary based on age. Toddlers are

significantly more likely to sustain TBI as a result of a fall, while older

children and teenagers are more likely to experience TBI due to vehicular

accidents and sports.[1-3] Assaults also increasingly contribute to TBI in

adolescents and young adults. Assaults (nonaccidental trauma) also occurs in

infants, and, while it may be difficult to initially diagnose, is of critical

important because of the severity of these injuries and the long term

implications for impaired development.[1]

In addition to the above factors, it is important to understand the

normal physiology of the developing brain. Brain water content is higher,

resulting in reduced brain compliance. Cerebral blood flow (CBF) shows age-

specific differences; in general, higher CBF is seen during development and

declines with maturation1. The maturing brain goes through a phase of

maximal synaptogenesis, followed by pruning and refinement of circuitry,

usually in an experience-dependent fashion. This period of maximal

connectivity is associated with increased levels of glucose metabolism[3],

higher levels of neurotrophic factors[4] and elevated excitatory amino acid

receptor binding and expression [5]. These age-dependent parameters may

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confer an increased excitability to the immature brain, factors that may

facilitate enhanced plasticity and recovery from injury. However, there is also

a potential downside, namely, that increased excitability also increases the risk

for early posttraumatic seizures[6] and excitotoxicity[6]. Furthermore, since

the young brain relies on some level of activity for normal development, post-

traumatic depression of neural activity, either physiologically or

pharmacologically enhanced (through the use of excitotoxicity inhibitors), may

actually be detrimental, resulting in lost developmental potential and even in

substantially increased levels of apoptosis[6. ]

In the literature, the influence of initial critical care management and

early complications on the outcome of children with severe head injury is not

clearly documented. Chiaretti etal.[7] prospectively examined the impact of

the management at the scene on outcome in 40 children admitted to their

Pediatric Intensive Care Unit with severe head injury (Glasgow Coma Scale <

or = 8). The outcome of these children was assessed using the Glasgow

Outcome Score (GOS). In their series the length of time before admission to

an intensive care unit appears to have influenced the outcome among

survivors.

The annual incidence of traumatic brain injury far exceeds the rates of

any other disease in the developed countries like United States, yet progress

toward age-relevant therapies, attention to patient’s needs, and research

funding needs improvement [8]. In our developing country with evolving

Healthcare System situation is worse and we need to identify different patterns

of injury in different age groups as it has resonance in clinical practice and

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provides a reference point for future clinical and neuropathological studies

and holds promise to improve the future management of such patients.

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 Aims and Objectives

Aim:

The aim of the present study is to improve the care of Paediatric Neurotrauma Patients

Objectives:

 To examine the influence of socio-demographic characteristics and health

care system factors on Patients 12 years of age with a diagnosis of

traumatic brain injury.

 To document the outcome

 Identification of high-risk groups.

 Identification of Predictors of Outcome

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 Patients & Methods:

Study design: This is an observational, analytical and prospective study.

Setting:

This study is to be conducted at the Dept of Neurosurgery, Lahore General Hospital,

Lahore.

Sample Size:

This study will include 200 consecutive patients of less than 12 years of age suffering

from Head Injury. Patients shall be stratified according to the Severity of the Injury by

using Glasgow Coma Scale GCS at the time of presentation and shall be grouped as:

 Mild -----GCS=13 to 15

 Moderate---- GCS=9 to 15

 Severe ------- GCS=3 to 8

Sample Selection:

Inclusion Criteria

This study will include all patients of less than 12 years of age suffering from Head

Injury, presenting to us at Neuro emergency LGH/ PGMI.

Exclusion criteria

Patients with other systemic diseases.

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 Methodology:
(Data Collection Procedure)

The following data will be collected through a proforma attached as Appendix

Patient Factors

 Age and Sex

 Resident of
 Schooling.
 Family Size
 Parents Education Level
 Parents Economic Status [Affording or Non affording]

Health Care System Factors

 First Medical Handling

 Time to Hospital
 Time to Definitive care

Clinical Data

 Time of Injury
 Mode of Injury
 GCS at Presentation
 Radiological Findings
 Diagnosis
 Treatment
 GCS at Discharge
 Hospital Stay
 Outcome at 1 Month Post Discharge {Glasgow Outcome Scale}Appendix

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Data collection tools/instruments:

 Proforma attached as appendix

 Data will be analyzed on computer using software Microsoft Excel and SPSS.

Statistical Analysis:

Data recording will be done on specified proforma, stored on Microsoft

Excel, SPSS (statistical package for social sciences); the results shall be

evaluated by univariate and multivariate analysis. Assessment will be done by

using chi-square test and t-tests. Significant correlations and differences shall

be sought. The Conclusion will be drawn at one month after discharge.

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 Outcome & Utilization:

The data will be a valid local documentation of the Pattern of Pediatric

Neurotrauma in our local population and shall provide standard reference for the

future studies. The results of the study will help us to make recommendations

and guide policies based on evidence, with an aim to improve the care of these

patients.

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 References:

1) Shireen M. Atabaki. Pediatric Head Injury. Pediatr. Rev. 2007;28;215-224

2) Raja IA, Vohra AH, Ahmed M. Neurotrauma in Pakistan..World J Surg.

2001 Sep;25(9):1230-7.

3) Ducrocq SC, Meyer PG, Orliaguet GA, Blanot S, Laurent-Vannier A,

Renier D, Carli PA..Epidemiology and early predictive factors of
mortality and outcome in children with traumatic severe brain injury:
experience of a French pediatric trauma center. Pediatr Crit Care
Med. 2006 Sep;7(5):461-7.

4) Karim Mukhida, Mohan R. Sharma, Sushil K,. Shilpakar. Pediatric

neurotrauma in Kathmandu, Nepal: implications for injury
management and control.Child's Nervous System.Volume 22,
Number 4 / April, 2006

5) Praveen Khilnani. Management of pediatric head injury Indian Journal of

Critical Care Medicine. . 2004: 8 : 2 : 85-92

6) Christopher C. Giza, M.D.Lasting Effects of Pediatric Traumatic Brain

Injury. Indian Journal of Neurotrauma. 2006, Vol. 3, No. 1, pp. 19-26

7) Chiaretti A, De Benedictis R, Della Corte F, Piastra M, Viola L, Polidori G,

Di Rocco C. The impact of initial management on the outcome of
children with severe head injury. Childs Nerv Syst. 2002 Feb;18(1-
2):54-60

8) Prins, Mayumi. Diet, ketones, and Neurotrauma. Epilepsia, Volume 49,

Supplement 8, November 2008 , pp. 111-113(3)

21
Annex 1

Proforma

COD No.---------------------------------------------

Hospital REG. No.----------------------------------

Parent /Guardian Name

-------------------------------------------------------------------------------------------------------

Address

-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
--------------------
Contact:

-------------------------------------------------------------------------------------------------------
-----

Patient Factors

Name
Age and Sex Age= Male Female
Resident of Rural Urban
Schooling. Going to school Not Going
Family Size No of Family Members including Parents=
Parents Education Mother None Primary Metric Graduate
Level Father None Primary Metric Graduate
Parents Economic
Affording Non affording
Status

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Health Care System Factors

First Medical Nearby Other EMERGENCY

LGH
Handling clinic Hospital services
Time to
In Hours/Minutes=
Hospital
Time to
In Hours/Minutes=
Definitive care

Clinical Data

Time of Injury In Am, Pm=

Sports
Mode of Injury Inflicted Fall RSA Others
related
GCS at
13-15 9-12 4-8
Presentation
Radiological Skull
Edema DAI Hematomas Focal
Findings fracture
Diagnosis
Treatment Observation Medical Surgical
GCS at Discharge 13-15 9-12 4-8
Hospital Stay In Days=
1 DEAD
2 VEGETATIVE STATE
3 SEVERE DISABILITY

Able to follow commands/ unable to live independen

Outcome at 1 Month Post Discharge

{Glasgow Outcome Scale} 4 MODERATE DISABILITY
Able to live independently; unable to return to work
5 GOOD RECOVERY

Able to return to work or school

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Doctors Name --------------------------------------------------------------------

Date ---------------------------------------------------------------------

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Annex II
Glasgow Coma Scale
GCS
Glasgow Coma Scale*
1 2 3 4 5 6
Opens eyes in Opens eyes Opens eyes
Does not
Eyes response to in response spontaneousl N/A N/A
open eyes
painful stimuli to voice y
Utters Oriented,
Makes no Incomprehensibl Confused,
Verbal inappropriat converses N/A
sounds e sounds disoriented
e words normally
Abnormal Flexion /
Makes no Localizes
Extension to flexion to Withdrawal Obeys
Motor movement painful
painful stimuli painful to painful Commands
s stimuli
stimuli stimuli

E + M + V = 3 to 15

For children under 5, the verbal response criteria are adjusted as follow

SCORE 2 to 5 YRS 0 TO 23 Mos.

5 Appropriate words or phrases Smiles or coos appropriately
4 Inappropriate words Cries and consolable
3 Persistent cries and/or screams Persistent inappropriate crying &/or screaming
2 Grunts Grunts or is agitated or restless
1 No response No response

*Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical

scale. Lancet 1974,2:81-84. PMID 4136544

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Annex III
Glasgow Outcome Scale (GOS)

1 DEAD
2 VEGETATIVE STATE
3 SEVERE DISABILITY

Able to follow commands/ unable to live independently

4 MODERATE DISABILITY
Able to live independently; unable to return to work or school
5 GOOD RECOVERY

Able to return to work or school

Reference:Jennett B, Bond M. “Assessment of outcome after severe brain damage.” Lancet

1975 Mar 1;1(7905):480-4

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Annex IV
Consent Form

I.D. Number____________________

I _____________________________________________acknowledge that

Doctor _____________________________________________________

Has informed me about his /her research titled

“Pattern of Pediatric Head Injury.” under supervision of Dr. Prof. Nazir Ahmed.

I am also informed regarding purpose, nature, aims and objectives of the study
/procedure as well as the expected risks and benefits. I know that all the information
in this process will be kept confidential and my name and other data will be utilized
only for research purposes. I have been informed that I can ask any type of question
related to the study. I have also been informed that this research is not just in benefit
of a single person but for the humanity at large. If after the briefing I refuse to
participate, there will be no obligation on my side. I shall be treated in routine. I may
withdraw myself from the study any time and I shall not force to continue.
I give my full consent and willingness to participate in this study.

Signature of Participant Signature of Doctor/researcher

Date_______________ Date ____________________

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