King's Outcome Scale Research Articles

Postoperative magnetic resonance imaging may predict poor outcome in children with severe traumatic brain injuries who undergo cranial surgery.

Multiple studies have evaluated the use of MRI for prognostication in pediatric patients with severe traumatic brain injury (TBI) and have found a correlation between diffuse axonal injury (DAI)-type lesions and outcome. However, there remains a limited understanding about the use of MRI for prognostication after severe TBI in children who have undergone cranial surgery. Children with severe TBI who underwent craniectomy or craniotomy at Primary Children's Hospital in Salt Lake City, Utah, between 2010 and 2019 were identified retrospectively. Of these 92 patients, 43 underwent postoperative brain MRI within 4 months of surgery. Susceptibility-weighted imaging (SWI) and FLAIR sequences were used to designate areas of hemorrhagic and nonhemorrhagic cerebral lesions related to DAI. Patients were then stratified based on the location of the DAI as read by a neuroradiologist as superficial, deep, or brainstem. The location of the DAI and other variables associated with poor outcome, including Glasgow Coma Scale (GCS) score, pediatric trauma score, mechanism of injury, and time to surgery, were analyzed for correlation with poor outcome. Outcomes were reported using the King's Outcome Scale for Childhood Head Injury (KOSCHI). In the 43 children with severe TBI who underwent postoperative brain MRI, the median GCS score on arrival was 4. The most common cause of injury was falls (14 patients, 33%). The most common primary intracranial pathology was subdural hematoma in 26 patients (60%), followed by epidural hematoma in 9 (21%). Fifteen patients (35%) had cerebral herniation and 31 (72%) had evidence of contusion. Variables associated with poor outcome included cerebral herniation (r = 0.338, p = 0.027) and location of DAI (r = 0.319, p = 0.037). In a separate analysis, brainstem DAI was shown to predict poor outcome, whereas location (no, superficial, or deep DAI) did not. Logistic regression showed that brainstem DAI (OR 22.3, p = 0.020) had a higher odds ratio than cerebral herniation (OR 10.5, p = 0.044) for poor outcome. Thirty-six children (84%) had a satisfactory outcome at last follow-up; 3 (7%) children died. The majority of children in this series who presented with a severe TBI and underwent craniectomy or craniotomy made a satisfactory recovery. In patients in whom there is a concern for poor outcome, the location of DAI-type lesions with SWI and FLAIR may assist in prognostication. The authors' results revealed that DAI-type lesions in the brainstem and evidence of cerebral herniation may indicate a poorer prognosis; however, more studies with larger cohorts are needed to make definitive conclusions.

Development of a nomogram to predict the outcome of moderate or severe pediatric traumatic brain injury.

OBJECTIVES:Traumatic brain injury (TBI) in children has become the major cause of mortality and morbidity in Thailand that has had an impact with economic consequences. This study aimed to develop and internally validate a nomogram for a 6-month follow-up outcome prediction in moderate or severe pediatric TBI.METHODS:This retrospective cohort study involved 104 children with moderate or severe TBI. Various clinical variables were reviewed. The functional outcome was assessed at the hospital discharge and at a 6-month follow-up based on the King's Outcome Scale for Childhood Head Injury classification. Predictors associated with the 6-month follow-up outcome were developed from the predictive model using multivariable binary logistic regression to estimate the performance and internal validation. A nomogram was developed and presented as a predictive model.RESULTS:The mean age of the samples was 99.75 months (standard deviation 59.65). Road traffic accidents were the highest injury mechanism at 84.6%. The predictive model comprised Glasgow Coma Scale of 3–8 (odds ratio [OR]: 16.07; 95% confidence interval [CI]: 1.27–202.42), pupillary response in one eye (OR 7.74; 95% CI 1.26–47.29), pupillary nonresponse in both eyes (OR: 57.74; 95% CI: 2.28–145.81), hypotension (OR: 19.54; 95%: CI 3.23–117.96), and subarachnoid hemorrhage (OR: 9.01, 95% CI: 1.33–60.80). The concordance statistic index (C-index) of the model's discrimination was 0.931, while the C-index following the bootstrapping and 5-cross validation were 0.920 and 0.924, respectively.CONCLUSIONS:The performance of a clinical nomogram for predicting 6-month follow-up outcomes in pediatric TBI patients was assessed at an excellent level. However, further external validation would be required for the confirmation of the tool's performance.

Application of machine learning to predict the outcome of pediatric traumatic brain injury

PurposeTraumatic brain injury (TBI) generally causes mortality and disability, particularly in children. Machine learning (ML) is a computer algorithm, applied as a clinical prediction tool. The present study aims to assess the predictability of ML for the functional outcomes of pediatric TBI. MethodsA retrospective cohort study was performed targeting children with TBI who were admitted to the trauma center of southern Thailand between January 2009 and July 2020. The patient was excluded if he/she (1) did not undergo a CT scan of the brain, (2) died within the first 24 h, (3) had unavailable complete medical records during admission, or (4) was unable to provide updated outcomes. Clinical and radiologic characteristics were collected such as vital signs, Glasgow coma scale score, and characteristics of intracranial injuries. The functional outcome was assessed using the King's Outcome Scale for Childhood Head Injury, which was thus dichotomized into favourable outcomes and unfavourable outcomes: good recovery and moderate disability were categorized as the former, whereas death, vegetative state, and severe disability were categorized as the latter. The prognostic factors were estimated using traditional binary logistic regression. By data splitting, 70% of data were used for training the ML models and the remaining 30% were used for testing the ML models. The supervised algorithms including support vector machines, neural networks, random forest, logistic regression, naive Bayes and k-nearest neighbor were performed for training of the ML models. Therefore, the ML models were tested for the predictive performances by the testing datasets. ResultsThere were 828 patients in the cohort. The median age was 72 months (interquartile range 104.7 months, range 2–179 months). Road traffic accident was the most common mechanism of injury, accounting for 68.7%. At hospital discharge, favourable outcomes were achieved in 97.0% of patients, while the mortality rate was 2.2%. Glasgow coma scale score, hypotension, pupillary light reflex, and subarachnoid haemorrhage were associated with TBI outcomes following traditional binary logistic regression; hence, the 4 prognostic factors were used for building ML models and testing performance. The support vector machine model had the best performance for predicting pediatric TBI outcomes: sensitivity 0.95, specificity 0.60, positive predicted value 0.99, negative predictive value 1.0; accuracy 0.94, and area under the receiver operating characteristic curve 0.78. ConclusionThe ML algorithms of the present study have a high sensitivity; therefore they have the potential to be screening tools for predicting functional outcomes and counselling prognosis in general practice of pediatric TBIs.

Acute surgical management of children with ruptured brain arteriovenous malformation.

Rupture of brain arteriovenous malformation (AVM) is the main etiology of intracerebral hemorrhage (ICH) in children. Ensuing intracranial hypertension is among the modifiable prognosis factors and sometimes requires emergency hemorrhage evacuation (HE). The authors aimed to analyze variables associated with HE in children with ruptured AVM. This study was a single-center retrospective analysis of children treated for ruptured AVM. The authors evaluated the occurrence of HE, its association with other acute surgical procedures (e.g., nidal excision, decompressive hemicraniectomy), and clinical outcome. Variables associated with each intervention were analyzed using univariable and multivariable models. Clinical outcome was assessed at 18 months using the ordinal King's Outcome Scale for Childhood Head Injury. A total of 104 patients were treated for 112 episodes of ruptured AVM between 2002 and 2018. In the 51 children (45.5% of cases) who underwent HE, 37 procedures were performed early (i.e., within 24 hours after initial cerebral imaging) and 14 late. Determinants of HE were a lower initial Glasgow Coma Scale score (adjusted odds ratio [aOR] 0.83, 95% CI 0.71-0.97 per point increase); higher ICH/brain volume ratio (aOR 18.6, 95% CI 13-26.5 per percent increase); superficial AVM location; and the presence of a brain herniation (aOR 3.7, 95% CI 1.3-10.4). Concurrent nidal surgery was acutely performed in 69% of Spetzler-Martin grade I-II ruptured AVMs and in 25% of Spetzler-Martin grade III lesions. Factors associated with nidal surgery were superficial AVMs, late HE, and absent alteration of consciousness at presentation. Only 8 cases required additional surgery due to intracranial hypertension. At 18 months, overall mortality was less than 4%, 58% of patients had a favorable outcome regardless of surgical intervention, and 87% were functioning independently. HE is a lifesaving procedure performed in approximately half of the children who suffer AVM rupture. The good overall outcome justifies intensive initial management.

Hemorrhage Expansion After Pediatric Intracerebral Hemorrhage.

Significant hemorrhage expansion (sHE) is a known predictor of poor outcome after an intracerebral hemorrhage (ICH) in adults but remains poorly reported in children. In a large inception cohort, we aimed to explore the prevalence of sHE, its associations with clinical outcomes, and its clinical-imaging predictors in children. Children admitted between January 2000 and March 2020 at a quaternary care pediatric hospital were screened for inclusion. Sample was restricted to children with 2 computed tomography scans within 72 hours of ICH onset, and a minimal clinical follow-up of months. sHE was defined as an increase from baseline ICH volume by 6 cc or 33% on follow-up computed tomography. Clinical outcome was assessed at 12 months with the King's Outcome Scale for Childhood Head Injury score and defined as favorable for scores ≥5. Fifty-two children met inclusion criteria, among which 8 (15%) demonstrated sHE, and 18 (34.6%) any degree of expansion. Children with sHE had more frequent coagulation disorders (25.0% versus 2.3%; P=0.022). After multivariable adjustment, only the presence of coagulation disorders at baseline remained independently associated with sHE (adjusted odds ratio, 14.4 [95% CI, 1.04-217]; P=0.048). sHE was independently associated with poor outcome (King's Outcome Scale for Childhood Head Injury <5A, odds ratio, 5.77 [95% CI, 1.01-38.95]; P=0.043). sHE is a frequent phenomenon after admission for a pediatric ICH and more so in children with coagulation defects. As sHE was strongly associated with poorer clinical outcomes, these data mandate a baseline coagulation work up and questions the need for protocolized repeat head computed tomography in children admitted for pediatric ICH.

Validation of the pediatric stroke outcome measure for classifying overall neurological deficit.

The pediatric stroke outcome measure (PSOM) is a standardized, disease-specific outcome measure. We aimed to validate the overall classification of neurological deficit severity using PSOM. We identified 367 neonates/children with arterial ischemic stroke (AIS) (Derivation Cohort). We analyzed the PSOM subscales (scored as 0 [no deficit], 0.5 [minimal/mild deficit; normal function], 1 [moderate deficit; slowing function], or 2 [severe deficit; missing function]) to derive severity levels using latent class analysis (LCA). We validated a severity classification scheme (PSOM-SCS) in: (a) children who had Pediatric Evaluation of Disability Inventory (PEDI; n = 63) and/or the Pediatric Quality-of-Life Inventory (PedsQL; n = 97) scored; and (b) an external cohort (AIS; n = 102) with concurrently scored modified Rankin Scale (mRS), King's Outcome Scale for Childhood Head-Injury (KOSCHI) and PSOM. Within the Derivation Cohort, LCA identified three severity levels: "normal/mild," "moderate," and "severe" (83.7%, 13.3%, and 3%, respectively). We developed severity classification based on PSOM subscale scores: "normal/mild"-normal function in all domains or slowing in one domain, "moderate"-slowing in ≥2 domains or missing function in one domain, and "severe"-missing function in ≥2 domains or slowing in ≥1 plus missing in one domain. PEDI and PedsQL both differed significantly across the severity groups. PSOM-SCS displayed high concordance with mRS (agreement coefficient [AC2] = 0.88) and KOSCHI (AC2 = 0.79). The PSOM-SCS constitutes a valid tool for classifying overall neurological severity emphasizing function and encompassing the full range of severity in pediatric stroke. Arithmetic summing of the PSOM subscales scores to assess severity classification is inadequate.The prior severity classification using PSOM overestimates poor outcomes.Three distinct severity profiles using PSOM subscales are identified.The PSOM-SCS is in moderate to excellent agreement with other disability measures.PSOM-SCS offers a valid tool for classifying the overall neurological deficit severity.

Long-term outcome of vein of Galen malformation.

To describe the long-term outcomes of children by the time they reached school age with vein of Galen aneurysmal malformation (VGAM). This was a retrospective observational study on a consecutive cohort of patients with VGAM. We included patients with at least one Francophone parent, aged between 6 and 11 years at the time of long-term evaluation. The neurological outcome was assessed with the King's Outcome Scale for Childhood Injury score and eight neurological and behavioural items from the Rivermead Postconcussion Symptoms questionnaire. All 52 patients (17 females, 32 males [data missing for n=3]) with at least one Francophone parent (5 fetuses and 47 children) were included. At the long-term evaluation time-point, 33 patients were alive and 19 patients had died. Risk of postnatal death was associated with severe neonatal cardiac failure (p=0.007) or isosystemic or suprasystemic pulmonary hypertension (p=0.014). Among survivors, 19 had a good outcome with normal schooling and 14 had a poor outcome. Moreover, among the good outcome patients, a large proportion had neurodevelopmental alterations. Long-term outcome of patients with VGAM appears to be less favourable than outcome described at the short- and medium-term, even in the absence of encephalomalacia at birth. Even patients with good outcome often have neuropsychological disorders that may have repercussions on learning and requiring appropriate rehabilitation or medical management. Long-term outcome appears to be less favourable than described at short- and medium-term follow-up. Even patients with good outcome at these time-points often have minor neuropsychological disorders.

Seizures and Outcome One Year After Neonatal and Childhood Cerebral Sinovenous Thrombosis

BackgroundPediatric cerebral sinovenous thrombosis is a treatable cause of brain injury, acute symptomatic seizures, and remote epilepsy. Our objective was to prospectively study epilepsy and outcomes in neonates and children one year after cerebral sinovenous thrombosis diagnosis. MethodsPatients with cerebral sinovenous thrombosis were enrolled prospectively from 21 international sites through the Seizures in Pediatric Stroke Study. Clinical data, including acute symptomatic seizures and cerebral sinovenous thrombosis risk factors, were collected at diagnosis. A neuroradiologist who was unaware of the diagnosis reviewed acute imaging. At one year, outcomes including seizure recurrence, epilepsy diagnosis, antiepileptic drug use, and modified Engel score were collected. Outcomes were assessed using the modified Rankin score and the King's Outcome Scale for Childhood Head Injury. ResultsTwenty-four participants with cerebral sinovenous thrombosis were enrolled (67% male, 21% neonates). Headache was the most common presenting symptom in non-neonates (47%, nine of 19). Nine (37.5%) presented with acute symptomatic seizures. Six (25%; 95% confidence interval, 10% to 47%) developed epilepsy by one-year follow-up. No clinical predictors associated with epilepsy were identified. King's Outcome Scale for Childhood Head Injury and modified Rankin scores at one year were favorable in 71%. Half of the patients who developed epilepsy (three of six) did not have infarcts, hemorrhage, or seizures identified during the acute hospitalization. ConclusionOur study provides a prospective estimate that epilepsy occurs in approximately one-quarter of patients by one year after diagnosis of cerebral sinovenous thrombosis. Later epilepsy can develop in the absence of acute seizures or parenchymal injury associated with the acute presentation.

Decompressive Craniectomy in Children with Severe Traumatic Brain Injury: A Multicenter Retrospective Study and Literature Review

Severe traumatic brain injury (TBI) is the most common cause of disability in children. Refractory increased intracranial pressure can be a therapeutic challenge. Decompressive craniectomy can be proposed when medical management is insufficient, but its place is not clearly defined in guidelines. The aim of this study was to identify prognostic factors in children with TBI. We performed a retrospective, multicenter study to analyze long-term outcomes of 150 children with severe TBI treated by decompressive craniectomy and to identify prognostic factors. A satisfactory neurologic evolution (represented by a King's Outcome Scale for Childhood Head Injury score >3) was observed in 62% of children with a mean follow-up of 3.5 years. Mortality rate was 17%. Prognostic factors associated with outcome were age, initial Glasgow Coma Scale score, presence of mydriasis, neuromonitoring values (maximal intracranial pressure >30 mm Hg), and radiologic findings (Rotterdam score ≥4). This study in a large population confirms that children with severe TBI treated by decompressive craniectomy can achieve a good neurologic outcome. Further studies are needed to clarify the use of this surgery in the management of children with severe TBI.

Clinical Relevance of Seizure in Pediatric Patients with Isolated Acute Subdural Hematoma without Parenchymal Brain Injury.

Isolated acute subdural hematoma (aSDH) in pediatric patients is rare, but it has a major impact on outcome. The purpose of this study was to determine incidence, seizure risk factors, and the outcome of pediatric patients with aSDH. Within a 10-year period (2007-2016), 10 children with aSDH were identified. Baseline characteristics and these parameters were analyzed: pediatric Glasgow Coma Scale (pGCS) score at admission and 24 hours after the operation, hematoma volume/side, and midline shift. Functional outcome was assessed at 3-month follow-up using the King's Outcome Scale for Childhood Head Injury score. Three subgroups were identified depending on age and etiology: birth-associated, nontraumatic, and traumatic aSDH. The overall incidence of seizures was 60%, and an even higher rate (75%) was observed in children < 1 month of age. Of those patients, two (67%) developed late seizures. Significant predictors for seizures were low pGCS score at admission (p = 0.03) and 24 hours after surgery (p = 0.03) as well as increased midline shift (p = 0.02). Patients with seizures tended to have an unfavorable outcome. Pediatric patients with aSDH are at high risk for seizures, particularly if the pGCS score is low at admission/24 hours after the operation and midline shows a shift. Determining seizure-prone pediatric patients may facilitate early antiepileptic treatment and promote better clinical outcomes.

Pediatric Extradural Hematoma: Clinical Assessment Using King's Outcome Scale for Childhood Head Injury.

Introduction:Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped off dural membrane and predominantly consists of venous blood in infants. The study aims to assess the outcome of pediatric EDH using King's Outcome Scale for Childhood Head Injury (KOSCHI).Materials and Methods:A total of 72 patients’ files were reviewed retrospectively with a diagnosis of EDH from January 2012 to December 2014. Predesigned proforma was filled using data from patient records. In addition, KOSCHI was calculated using recent telephone interviews.Results:Among 72 patients, 65.3% were male and 34.7% were female. Overall, road traffic accident was the most common cause (52.8%) followed by fall, assault, and sports injury. The most common symptom was more than two episodes of vomiting which was present in 51.4% of patients followed by loss of consciousness in 37.5%, ENT bleed in 33.3%, headache in 16.7%, and fits in 11.1% of patients. The median follow-up of our patients was 19 (6–40) months. Most of our patients made good recovery with 76.4% of our patients scoring 5b on KOSCHI.Conclusion:EDH is not uncommon among children with head injury. It should be suspected in every child with posttraumatic skull fracture or scalp hematoma. Prompt surgical intervention can give good long-term outcome.

Predictors of Outcome in Patients with Pediatric Intracerebral Hemorrhage: Development and Validation of a Modified Score.

Purpose To propose and validate a modified pediatric intracerebral hemorrhage (PICH) (mPICH) score and to compare its association with functional outcome to that of the original PICH score. Materials and Methods Data from prospectively included patients were retrospectively analyzed. Consecutive patients with nontraumatic PICH who had undergone clinical follow-up were included. The study population was divided into a development cohort (2008-2012, n = 100) and a validation cohort (2013-2016, n = 43). An mPICH score was developed after variables associated with poor outcome were identified at multivariate analysis (King's Outcome Scale for Childhood Head Injury score < 5a) in the development cohort. The accuracy of the score for prediction of poor outcome was evaluated (sensitivity, specificity). Discrimination and calibration of associations between the mPICH score and poor outcome cohorts were assessed (C statistics, Hosmer-Lemeshow test). Results The mPICH score assessed as follows: brain herniation, four points; altered mental status, three points; hydrocephalus, two points; infratentorial PICH, two points; intraventricular hemorrhage, one point; PICH volume greater than 2% of total brain volume, one point. An mPICH score greater than 5 was associated with severe disability or worse, with sensitivity of 97% (95% confidence interval [CI]: 83%, 100%) and specificity of 61% (95% CI: 49%, 73%). The C statistic was 0.81 (95% CI: 0.73, 0.89). In the validation cohort, sensitivity and specificity were 95.2% (95% CI: 76%, 99%) and 77% (95% CI: 55%, 92%), respectively. There was no significant difference between the observed and predicted risks of poor outcome (P = .46). Conclusion An mPICH score was developed as a simple clinical and imaging grading scale for acute prognosis in patients with PICH. © RSNA, 2017.

Pattern and outcome of pediatric head injuries in the Suez Canal Region: A follow-up study.

A significant number of children sustain head injuries every year. Despite this, few studies in Egypt have provided detailed information about these injuries. The aim of this study was to investigate the epidemiology and outcome of head injury among children presenting to the emergency department in the Suez Canal University Hospital. A clinical follow-up study including 70 patients, aged 18 years or less, who presented to the emergency department, with head injuries, in the period from March 2014 to February 2015. Patients were grouped according to their ages into three subgroups: <2, 2-5, and >5 years old. Collected data included patients' demographics, injury causes, severity, timing of injuries, and the eventual outcome after a follow-up period of 3 months. Severity of head injury was based on the general level of consciousness using the Pediatric Glasgow Coma Scale. The functional outcome at the final follow-up was assessed using the King's Outcome Scale for Childhood Head Injury. Male-to-female ratio was 1.4 : 1. The highest incidence was in the age group of 2-5 years. The main causes were traffic injury and falls (35.7% for each), followed by home injuries (21%) and sport-related injuries (7%). Regarding the severity of injury, 81% of children had mild injury, 13% had moderate injury, and 6% had severe injury. Concussion was the most common type of head injury (56%), followed by skull fractures (23%). The functional outcome was assessed at the time of discharge, and 3 months later. Good recovery was achieved in 91% of children; moderate disability was present in 7% of children; and less than 2% of the children showed sustained severe disability. Children aged 5 years or less comprised 75% of the children who presented to the hospital following head injury. Falls and road traffic accidents were the most common causes of injury. Most injuries were of mild severity, and concussion was the most common encountered type of injury. Assessment of functional outcome showed good recovery in most children. Enforcement of strict effective regulations and observing safety measures during driving by authorities is needed to reduce traffic accidents. Health education programs for parents about careful supervision and first aid should be provided to help prevent child head injury and its disastrous consequences.

Hydrocephalus associated with childhood nonaccidental head trauma.

OBJECTIVE The incidence of posttraumatic ventriculomegaly (PTV) and shunt-dependent hydrocephalus after nonaccidental head trauma (NAHT) is unknown. In the present study, the authors assessed the timing of PTV development, the relationship between PTV and decompressive craniectomy (DC), and whether PTV necessitated placement of a permanent shunt. Also, NAHT/PTV cases were categorized into a temporal profile of delay in admission and evaluated for association with outcomes at discharge. METHODS The authors retrospectively reviewed the cases of patients diagnosed with NAHT throughout a 10-year period. Cases in which sequential CT scans had been obtained (n = 28) were evaluated for Evans' index to determine the earliest time ventricular dilation was observed. Discharge outcomes were assessed using the King's Outcome Scale for Childhood Head Injury score. RESULTS Thirty-nine percent (11 of 28) of the patients developed PTV. A low admission Glasgow Coma Scale (GCS) score predicted early PTV presentation (within < 3 days) versus a high GCS score (> 1 week). A majority of PTV/NAHT patients presented with a subdural hematoma (both convexity and interhemispheric) and ischemic stroke, but subarachnoid hemorrhage was significantly associated with PTV/NAHT (p = 0.011). Of 6 patients undergoing a DC for intractable intracranial pressure, 4 (67%) developed PTV (p = 0.0366). These patients tended to present with lower GCS scores and develop ventriculomegaly early. Only 2 patients developed hydrocephalus requiring shunt placement. CONCLUSIONS PTV presents early after NAHT, particularly after a DC has been performed. However, the authors found that only a few PTV/NAHT patients developed shunt-dependent hydrocephalus.

Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes

Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation. Extent of delay in seeking medical attention may be related to patient outcome. A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6-12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case. All children were 3 years of age or younger (2.1-34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay. Patients presenting to medical care 6-12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.

PP10.5 – 2374: Mode of injury and mortality following traumatic paediatric head injury in a single centre series of 309 patients

Objective Paediatric traumatic brain injury (TBI) remains the leading cause of death in children aged >1 year. In the USA Trauma Bank, Haider found similar mortality for pedestrians and motor vehicle crashes (MVC), higher than falls, but four times the mortality for gunshot wounds. However, there are few European studies, data on outcome in survivors is limited and any relationship between mode of injury and CT findings has received little attention. Methods This was a retrospective review of all severe TBI admitted to a single European centre over 14 years. Demographics, mechanism of injury, and CT data were collected. Outcome was scored using the King's Outcome Scale for Children with Head Injury (KOSCHI)and logistic regression analysis with death as the outcome was conducted in 309 consecutive children Results 10 children were non-accidentally injured (NAI), 107 had fallen, 83 were pedestrians, 43 were in a MVC, 33 were riding a bike and 17 were struck by an object. CT scan was more likely to be normal after a fall (41%) compared with 29% of pedestrians, 26% of MVC victims and 8% of cyclists. Twenty-one (7%) died; mortality was lower (3%) in those who had fallen compared with rates for MVC (7%), pedestrians (10%) and cyclists (10%) and NAI (20%). Acute subdural haemorrage on initial CT was the most common finding associated with death (14%). Outcome in survivors was also related to mode of injury (p Conclusion Despite differences in aetiology of TBI between Europe and the US, with no gunshot wounds in our series, we also found that mortality is higher in pedestrians and cyclists and in NAI than following falls. Neuroimaging was often normal and outcome good after falls.

OP36 – 2640: King's Outcome Scale for Childhood Head Injury (KOSCHI) – Prospective and retrospective comparison of outcome, and level of agreement, within the neuro-rehabilitation cohort at Southampton Children's hospital

There is a need for standardised outcome assessment for survivors of paediatric traumatic brain injury (TBI). KOSCHI is associated with markers of injury severity. Inter-rater reliability is lacking comparing prospective (P) versus retrospective (R) categorisation. Objective To determine the inter-rater reliability between (P) and (R) KOSCHI scores at discharge. To utilise KOSCHI to evaluate outcome of Southampton (SCH) neuro-rehabilitation TBI cohort. Methods (P) scores were recorded on discharge of all patients 2–18 years with moderate/severe head injury requiring neurological rehabilitation (2005–2014) by specialist physiotherapists. A doctor identified all patients admitted with TBI aged 0–18 and retrospectively scored KOSCHI at discharge using casenotes (blind to (P) cohort). Once collated the agreement between (P) and (R) KOSCHI scores was calculated using Cohen's kappa coefficient (κ). Results 153 patients admitted: 10 died. Sixty-one (45 male, mean age 11 years (range 2–17 years) required neuro-rehabilitation; 15 classified as moderate (GCS 9–12), 46 as severe (GCS ≤8) TBI. κ scores between (P) and (R) showed moderate agreement (κ=0.41), with the agreement improving (moderate κ=0.5) when not utilising the sub-categories. (P) demonstrated the majority are discharged with “moderate disability” (28% KOSCHI 4a, 16% 4b). 32% have “good recovery” (11% documented complete recovery 5b). Poor outcomes less common: KOSCHI 2 “vegetative” (N=1), KOSCHI 3a (N=2), KOSCHI 3b (N=10, 16%). Of those ≤ 3b; the category 2 patient transferred locally to establish continuing care, 4 to another rehabilitation centre, 1 re-admitted for further rehabilitation. 13/61 completed their rehabilitation at Bursledon House (stand-alone rehabilitation unit within SCH). (R) also categorizes the majority of patients with moderate disability (21% 4a, 24% 4b). Conclusion To improve reliability and allow for changes to scores post discharge secondary to further rehabilitation or identification of emerging difficulties, KOSCHI scores should be completed at an agreed time frame post injury and completed prospectively.

Feasibility Study of the King's Outcome Scale for Childhood Head Injury in Children Attending a Rehabilitation Hospital

Feasibility Study of the King's Outcome Scale for Childhood Head Injury in Children Attending a Rehabilitation Hospital

Subclinical early posttraumatic seizures detected by continuous EEG monitoring in a consecutive pediatric cohort

Traumatic brain injury (TBI) is an important cause of morbidity and mortality in children, and early posttraumatic seizures (EPTS) are a contributing factor to ongoing acute damage. Continuous video-EEG monitoring (cEEG) was utilized to assess the burden of clinical and electrographic EPTS. Eighty-seven consecutive, unselected (mild - severe), acute TBI patients requiring pediatric intensive care unit (PICU) admission at two academic centers were monitored prospectively with cEEG per established clinical TBI protocols. Clinical and subclinical seizures and status epilepticus (SE, clinical and subclinical) were assessed for their relation to clinical risk factors and short-term outcome measures. Of all patients, 42.5% (37/87) had seizures. Younger age (p = 0.002) and injury mechanism (abusive head trauma - AHT, p < 0.001) were significant risk factors. Subclinical seizures occurred in 16.1% (14/87), while 6.9% (6/87) had only subclinical seizures. Risk factors for subclinical seizures included younger age (p < 0.001), AHT (p < 0.001), and intraaxial bleed (p < 0.001). SE occurred in 18.4% (16/87) with risk factors including younger age (p < 0.001), AHT (p < 0.001), and intraaxial bleed (p = 0.002). Subclinical SE was detected in 13.8% (12/87) with significant risk factors including younger age (p < 0.001), AHT (p = 0.001), and intraaxial bleed (p = 0.004). Subclinical seizures were associated with lower discharge King's Outcome Scale for Childhood Head Injury (KOSCHI) score (p = 0.002). SE and subclinical SE were associated with increased hospital length of stay (p = 0.017 and p = 0.041, respectively) and lower hospital discharge KOSCHI (p = 0.007 and p = 0.040, respectively). cEEG monitoring significantly improves detection of seizures/SE and is the only way to detect subclinical seizures/SE. cEEG may be indicated after pediatric TBI, particularly in younger children, AHT cases, and those with intraaxial blood on computerized tomography (CT).

The impact of attention deficit hyperactivity disorder on recovery from mild traumatic brain injury

Attention deficit hyperactivity disorder (ADHD) and traumatic brain injury (TBI) are significant independent public health concerns in the pediatric population. This study explores the impact of a premorbid diagnosis of ADHD on outcome following mild TBI. The charts of all patients with a diagnosis of mild closed head injury (CHI) and ADHD who were admitted to Children's Hospital of Pittsburgh between January 2003 and December 2010 were retrospectively reviewed after institutional review board approval was granted. Patient demographics, initial Glasgow Coma Scale (GCS) score, hospital course, and King's Outcome Scale for Childhood Head Injury (KOSCHI) score were recorded. The results were compared with a sample of age-matched controls admitted with a diagnosis of CHI without ADHD. Forty-eight patients with mild CHI and ADHD, and 45 patients with mild CHI without ADHD were included in the statistical analysis. Mild TBI due to CHI was defined as an initial GCS score of 13-15. The ADHD group had a mean age of 12.2 years (range 6-17 years), and the control group had a mean age of 11.14 years (range 5-16 years). For patients with mild TBI who had ADHD, 25% were moderately disabled (KOSCHI Score 4b), and 56% had completely recovered (KOSCHI Score 5b) at follow-up. For patients with mild TBI without ADHD, 2% were moderately disabled and 84% had completely recovered at follow-up (p < 0.01). Patients with ADHD were statistically significantly more disabled after mild TBI than were control patients without ADHD, even when controlling for age, sex, initial GCS score, hospital length of stay, length of follow-up, mechanism of injury, and presence of other (extracranial) injury. Patients who sustain mild TBIs in the setting of a premorbid diagnosis of ADHD are more likely to be moderately disabled by the injury than are patients without ADHD.