Traumatic brain stem lesions in children

Abstract

Glasgow Coma Scale (GCS) scores on admission may be predictors of outcome in patients with brain injuries. This study correlated the outcomes of children with traumatic brain stem lesions with their initial GCS scores and morphological patterns of injury as shown on computed tomography (CT) or magnetic resonance (MR) imaging. During the last 16 years, we have treated 1,108 children with brain injuries. The entire series included only 21 (1.9%) children who had clinical signs of brain stem lesions with morphological correlates on CT or MR imaging. Clinical findings were assessed according to the GCS and compared with scores on the Glasgow Outcome Scale (GOS). Of these 21 children, 16 (76%) had morphological lesions seen on CT scans. In 5 (24%) of the children only the MR images revealed brain stem lesions and their CT scans were negative. Generalized severe brain swelling was present in 6 cases (28%). There was a significant difference in GOS scores between patients with initial GCS scores of 3 and 4 and those with GCS scores between 5 and 7 (P < 0.02). Children with intracranial pressure higher than 40 mmHg had poorer outcomes than patients whose intracranial pressure was lower, but the differences were not significant. Outcome did not correlate significantly with morphological patterns of injury or the presence of extracranial injuries. The GCS is a reliable indicator of severity of injury and of outcome in children with brain stem injuries. MR imaging was more sensitive than CT in detecting brain stem lesions.

Predicting Outcome after Pediatric Traumatic Brain Injury by Early Magnetic Resonance Imaging Lesion Location and Volume

“…Edgar and colleagues, in a retrospective study of 20 comatose TBI children, reported unfavorable GOS outcomes in 47% of those with traumatic brainstem lesions on either CT or MRI. 22 Patrick and colleagues, in a study of 32 children, examined 11 brain areas in the neuroaxis and found that injury to brainstem regions, but not cortical areas, were significantly associated with prolonged low response states and injury to BG and thalamic regions approached significance ( p = 0.07). 60 Our results disagree somewhat with findings by Blackman and colleagues, who reported that injury of decreasing-level (cortical to brainstem) injuries did not predict Functional Independence Measure for Children scores postdischarge from inpatient rehabilitation.…”

“…[17][18][19][20][21][22] Pediatric studies report associations of individual CT morphologies, such as diffuse swelling, cistern effacement, subarachnoid hemorrhage, subdural hemorrhage, and DAI, with increased mortality and morbidity; nonetheless, a normal head CT can be found in 40% of children with a poor outcome post-TBI. 11,12,23,24 Since the first report in 1986 by Jenkins and colleagues detailing the improved diagnostic accuracy of MRI in identifying brain lesions post-trauma, MRIbased techniques have been intensely studied as imaging biomarkers to predict mortality and functional outcomes in children and adults post-TBI.…”

“…11,12,23,24 Since the first report in 1986 by Jenkins and colleagues detailing the improved diagnostic accuracy of MRI in identifying brain lesions post-trauma, MRIbased techniques have been intensely studied as imaging biomarkers to predict mortality and functional outcomes in children and adults post-TBI. 22,[24][25][26][27][28][29][30][31][32][33][34] Despite the more routine use of brain MRI to assess neuropathological injuries after pediatric TBI, there remains no clear consensus among clinicians who care for children with TBI on the significance of early MRI lesions on long-term functional outcome.…”

Prognostic Factors in Children with Severe Diffuse Brain Injuries: A Study of 74 Patients

“…Though severe head injury in children has been extensively studied, most reports include mass lesions in addition to DBI [3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13]. Fewer reports exist in literature dealing with severe DBI alone and their outcome in children [2, 14, 15]. The outcome in children with severe DBI is influenced by the mechanical properties of the child’s brain and skull [16, 17].…”

“…While Bruce et al [3]and Berger et al [18]have indicated that children with severe DBI have a favourable prognosis, Humphreys et al [19]and Aldrich et al [15]reported very high mortality rates of 39 and 54%, respectively. Several studies have documented age at injury [6, 11, 20, 21], post-resuscitation Glasgow coma score (GCS) [4, 6, 9, 11, 12, 14, 21, 22], pupillary reaction and oculocephalic reflex [4, 8, 22, 23, 24], duration of coma [11], and CT scan evidence of diffuse cerebral oedema and traumatic subarachnoid haemorrhage [2, 4, 10, 11, 13, 15]as the most significant prognosticators of outcome in children with severe head injury. However, few have evaluated the relative importance of these factors in predicting outcome.…”