53 - Neurologic Deterioration and Routine Repeat Neuroimaging in Children with Traumatic Intracranial Hemorrhage

Poster Number: 53
Publication Number: 53.104

Pradip P. Chaudhari, Children's Hospital Los Angeles, Los Angeles, CA, United States; Richard Bachur, Boston Children's Hospital, Boston, MA, United States; Susan R. Durham, Children's Hospital Los Angeles, Los Angeles, CA, United States; Catherine J. Goodhue, Children's Hospital Los Angeles, Los Angeles, CA, United States; Danielle Levitt, Children's Hospital Los Angeles, Los Angeles, CA, United States; Janet E. Semple-Hess, Children's Hospital Los Angeles, Los Angeles, CA, United States; Leland Gao, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States; Jose A. Pineda, Children's Hospital Los Angeles, Los Angeles, CA, United States; Robinder Khemani, Children's Hospital Los Angeles, Los Angeles, CA, United States

Background:
Children with intracranial hemorrhage after blunt head trauma are often admitted for clinical monitoring and repeat neuroimaging, but few children with non-severe head injury deteriorate. Identifying children at low risk for clinically important neurologic deterioration would improve evidence-based care and reduce unnecessary radiation exposure from routine, repeat computed tomography (CTs).

Objective:
Our objective was to describe rates of clinically important neurologic deterioration and associated clinical characteristics and outcomes among children with acute traumatic intracranial hemorrhage.

Design/Methods:
We conducted a single center cross-sectional study of children < 18 years old seen in the ED from 05/01/2014-02/28/2020 with neuroradiographic evidence of intracranial hemorrhage secondary to blunt trauma. Data were abstracted from the electronic health record and trauma registry. We determined rates of the primary outcome, clinically important neurologic deterioration within 96 hours of ED arrival, which was defined as new or worsening neurologic signs/symptoms resulting in an acute (within 4 hours) change in clinical management. We additionally determined rates of secondary outcomes in children with and without deterioration, including any neurosurgical and/or critical medical interventions, ICU admission, mortality, and repeat neuroimaging.

Results:
We identified 156 eligible children with intracranial hemorrhage, with a median (IQR) age of 1.0 (0.5, 4.6) years (Table). Half (n=78) were initially admitted to the ICU and 7 (4.5%) died. Repeat neuroimaging was obtained in 57.1% (n=89). Ten percent (n=15) of children developed clinically important deterioration within 96 hours of ED arrival. 127 children (81.4%) presented with an initial Glasgow Coma Scale (GCS) category of mild (GCS≥14), including 7 of the 15 children who developed clinically important deterioration. Initial GCS (p < 0.001) and non-accidental trauma (p=0.005) were associated with deterioration. No children with non-severe initial GCS ≥9 and isolated, non-epidural hemorrhage after an accidental injury deteriorated, however 41% (25/61) received repeat neuroimaging.
Conclusion(s):
Clinically important neurologic deterioration occurred in 10% of children with traumatic intracranial hemorrhage and in 6% of children with an initial GCS≥14. Routine repeat neuroimaging is common among children who are low risk for deterioration. To better understand neurologic deterioration in this population, further exploration of the clinical course and risk factors for deterioration in a large, multicenter sample of children is warranted.

Characteristics and clinical outcomes of children with intracranial hemorrhage after blunt head trauma, stratified by presence of clinically important neurologic deterioration