Child's Nervous System

, Volume 34, Issue 4, pp 673–680 | Cite as

Prognostic factors of acute neurological outcomes in infants with traumatic brain injury

  • Shunsuke AmagasaEmail author
  • Satoshi Tsuji
  • Hikoro Matsui
  • Satoko Uematsu
  • Takashi Moriya
  • Kosaku Kinoshita
Original Paper



The purpose of this study is to clarify risk factors for poor neurological outcomes and distinctive characteristics in infants with traumatic brain injury.


The study retrospectively reviewed data of 166 infants with traumatic intracranial hemorrhage from three tertiary institutions in Japan between 2002 and 2013. Univariate and multivariate analyses were used to identify clinical symptoms, vital signs, physical findings, and computed tomography findings associated with poor neurological outcomes at discharge from the intensive care unit.


In univariate analysis, bradypnea, tachycardia, hypotension, dyscoria, retinal hemorrhage, subdural hematoma, cerebral edema, and a Glasgow Coma Scale (GCS) score of ≤ 12 were significantly associated with poor neurological outcomes (P < 0.05). In multivariate analysis, a GCS score of ≤ 12 (OR = 130.7; 95% CI, 7.3–2323.2; P < 0.001), cerebral edema (OR = 109.1; 95% CI, 7.2–1664.1; P < 0.001), retinal hemorrhage (OR = 7.2; 95% CI, 1.2–42.1; P = 0.027), and Pediatric Index of Mortality 2 score (OR = 1.6; 95% CI, 1.1–2.3; P = 0.018) were independently associated with poor neurological outcomes. Incidence of bradypnea in infants with a GCS score of ≤ 12 (25/42) was significantly higher than that in infants with GCS score of > 12 (27/90) (P = 0.001).


Infants with a GCS score of ≤ 12 are likely to have respiratory disorders associated with traumatic brain injury. Physiological disorders may easily lead to secondary brain injury, resulting in poor neurological outcomes. Secondary brain injury should be prevented through early interventions based on vital signs and the GCS score.


Infant Traumatic brain injury Glasgow Coma Scale Secondary brain injury 


Compliance with ethical standards

Ethical approval

The Ethical Board of Nagano Children’s Hospital approved this retrospective study (Receipt number 27-57).

Conflict of interest

The authors declare that they have no conflicts of interest.


  1. 1.
    Langlois JA, Rutland-Brown W, Thomas KE (2005) The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 20(3):229–238. CrossRefPubMedGoogle Scholar
  2. 2.
    MRC CRASH Trial Collaborators, Perel P, Arango M, Clayton T, Edwards P, Komolafe E, Poccock S, Roberts I, Shakur H, Steyerberg E, Yutthakasemsunt S (2008) Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336(7641):425–429. CrossRefPubMedCentralGoogle Scholar
  3. 3.
    Steyerberg EW, Mushkudiani N, Perel P, Butcher I, Lu J, McHugh GS, Murray GD, Marmarou A, Roberts I, Habbema JD, Maas AI (2008) Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 5(8, discussion e165):e165. CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Lingsma HF, Roozenbeek B, Steyerberg EW, Murray GD, Maas AI (2010) Early prognosis in traumatic brain injury: from prophecies to predictions. Lancet Neurol 9(5):543–554. CrossRefPubMedGoogle Scholar
  5. 5.
    Heather NL, Derraik JG, Beca J, Hofman PL, Dansey R, Hamill J, Cutfield WS (2013) Glasgow Coma Scale and outcomes after structural traumatic head injury in early childhood. PLoS One 8(12):e82245. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Tude Melo JR, Di Rocco F, Blanot S, Oliveira-Filho J, Roujeau T, Sainte-Rose C, Duracher C, Vecchione A, Meyer P, Zerah M (2010) Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery 67(6):1542–1547. CrossRefGoogle Scholar
  7. 7.
    Randolph LC, Takacs M, Davis KA (2002) Resuscitation in the pediatric trauma population: admission base deficit remains an important prognostic indicator. J Trauma 53(5):838–842. CrossRefPubMedGoogle Scholar
  8. 8.
    Campbell CG, Kuehn SM, Richards PM, Ventureyra E, Hutchison JS (2004) Medical and cognitive outcome in children with traumatic brain injury. Can J Neurol Sci 31(02):213–219. CrossRefPubMedGoogle Scholar
  9. 9.
    Scavarda D, Gabaudan C, Ughetto F, Lamy F, Imada V, Lena G, Paut O (2010) Initial predictive factors of outcome in severe non-accidental head trauma in children. Childs Nerv Syst 26(11):1555–1561. CrossRefPubMedGoogle Scholar
  10. 10.
    Rhine T, Wade SL, Makoroff KL, Cassedy A, Michaud LJ (2012) Clinical predictors of outcome following inflicted traumatic brain injury in children. J Trauma Acute Care Surg 73(4 Suppl 3):S248–S253. CrossRefPubMedGoogle Scholar
  11. 11.
    Ilves P, Lintrop M, Talvik I, Sisko A, Talvik T (2010) Predictive value of clinical and radiological findings in inflicted traumatic brain injury. Acta Paediatr 99(9):1329–1336. CrossRefPubMedGoogle Scholar
  12. 12.
    Chung CY, Chen CL, Cheng PT, See LC, Tang SF, Wong AM (2006) Critical score of Glasgow Coma Scale for pediatric traumatic brain injury. Pediatr Neurol 34(5):379–387. CrossRefPubMedGoogle Scholar
  13. 13.
    Shein SL, Bell MJ, Kochanek PM, Tyler-Kabara EC, Wisniewski SR, Feldman K, Makoroff K, Scribano PV, Berger RP (2012) Risk factors for mortality in children with abusive head trauma. J Pediatr 161(4):716–722. CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Bahloul M, Ben Hamida C, Chelly H, Chaari A, Kallel H, Dammak H, Rekik N, Bahloul K, Ben Mahfoudh K, Hachicha M, Bouaziz M (2009) Severe head injury among children: prognostic factors and outcome. Injury 40(5):535–540. CrossRefPubMedGoogle Scholar
  15. 15.
    Kapapa T, König K, Pfister U, Sasse M, Woischneck D, Heissler H, Rickels E (2010) Head trauma in children, part 1: admission, diagnostics, and findings. J Child Neurol 25(2):146–156. CrossRefPubMedGoogle Scholar
  16. 16.
    Chiaretti A, Piastra M, Pulitanò S, Pietrini D, De Rosa G, Barbaro R, Di Rocco C (2002) Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst 18(3-4):129–136. CrossRefPubMedGoogle Scholar
  17. 17.
    Ducrocq SC, Meyer PG, Orliaguet GA, Blanot S, Laurent-Vannier A, Renier D, Carli PA (2006) 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 7(5):461–467. CrossRefPubMedGoogle Scholar
  18. 18.
    White JR, Farukhi Z, Bull C, Christensen J, Gordon T, Paidas C, Nichols DG (2001) Predictors of outcome in severely head-injured children. Crit Care Med 29(3):534–540. CrossRefPubMedGoogle Scholar
  19. 19.
    Downard C, Hulka F, Mullins RJ, Piatt J, Chesnut R, Quint P, Mann NC (2000) Relationship of cerebral perfusion pressure and survival in pediatric brain-injured patients. J Trauma 49(4):654–658. CrossRefPubMedGoogle Scholar
  20. 20.
    Hackbarth RM, Rzeszutko KM, Sturm G, Donders J, Kuldanek AS, Sanfilippo DJ (2002) Survival and functional outcome in pediatric traumatic brain injury: a retrospective review and analysis of predictive factors. Crit Care Med 30(7):1630–1635. CrossRefPubMedGoogle Scholar
  21. 21.
    Chiaretti A, De Benedictis R, Della Corte F, Piastra M, Viola L, Polidori G, Di Rocco C (2002) The impact of initial management on the outcome of children with severe head injury. Childs Nerv Syst 18(1-2):54–60. CrossRefPubMedGoogle Scholar
  22. 22.
    Jagannathan J, Okonkwo DO, Yeoh HK, Dumont AS, Saulle D, Haizlip J, Barth JT, Jane JA Sr, Jane JA Jr (2008) Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure. J Neurosurg Pediatr 2(4):240–249. CrossRefPubMedGoogle Scholar
  23. 23.
    Giza CC, Mink RB, Madikians A (2007) Pediatric traumatic brain injury: not just little adults. Curr Opin Crit Care 13:143–152CrossRefPubMedGoogle Scholar
  24. 24.
    Keenan HT, Bratton SL (2006) Epidemiology and outcomes of pediatric traumatic brain injury. Dev Neurol 28:256–263Google Scholar
  25. 25.
    Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH (2003) A population-based study of inflicted traumatic brain injury in young children. JAMA 290(5):621–626. CrossRefPubMedGoogle Scholar
  26. 26.
    Freeman SS, Udomphorn Y, Armstead WM, Fisk DM, Vavilala MS (2008) Young age as a risk factor for impaired cerebral autoregulation after moderate to severe pediatric traumatic brain injury. Anesthesiology 108(4):588–595. CrossRefPubMedGoogle Scholar
  27. 27.
    Philip S, Udomphorn Y, Kirkham FJ, Vavilala MS (2009) Cerebrovascular pathophysiology in pediatric traumatic brain injury. J Trauma 67(Supplement):S128–S134. CrossRefPubMedGoogle Scholar
  28. 28.
    Amagasa S, Matsui H, Tsuji S, Moriya T, Kinoshita K (2016) Accuracy of the history of injury obtained from the caregiver in infantile head trauma. Am J Emerg Med 34(9):1863–1867. CrossRefPubMedGoogle Scholar
  29. 29.
    Fiser DH (1992) Assessing the outcome of pediatric intensive care. J Pediatr 121(1):68–74. CrossRefPubMedGoogle Scholar
  30. 30.
    Fleming S, Thompson M, Stevens R, Heneghan C, Plüddemann A, Maconochie I, Tarassenko L, Mant D (2011) Normal ranges of heart rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet 377(9770):1011–1018. CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Moss AJ (1981) Blood pressure in infants, children and adolescents. West J Med 134(4):296–314PubMedPubMedCentralGoogle Scholar
  32. 32.
    James HE (1986) Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann 15(1):16–22. CrossRefPubMedGoogle Scholar
  33. 33.
    Gennarelli TA, Wodzin E (2006) AIS 2005: a contemporary injury scale. Injury 37(12):1083–1091. CrossRefPubMedGoogle Scholar
  34. 34.
    Slater A, Shann F, Pearson G, Paediatric Index of Mortality (PIM) Study Group (2003) PIM2: a revised version of the paediatric index of mortality. Intensive Care Med 29:278–285CrossRefGoogle Scholar
  35. 35.
    Boyd CR, Tolson MA, Copes WS (1987) Evaluating trauma care: the TRISS method. Trauma score and the injury severity score. J Trauma 27(4):370–380. CrossRefPubMedGoogle Scholar
  36. 36.
    Hall JR, Reyes HM, Meller JL, Loeff DS, Dembek R (1996) The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 31(1):72–76. CrossRefPubMedGoogle Scholar
  37. 37.
    Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G (2014) The Glasgow coma scale at 40 years: standing the test of time. Lancet Neurol 13(8):844–854. CrossRefPubMedGoogle Scholar
  38. 38.
    Zebrack M, Dandoy C, Hansen K, Scaife E, Mann NC, Bratton SL (2009) Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics 124(1):56–64. CrossRefPubMedGoogle Scholar
  39. 39.
    Dunham CM, Barraco RD, Clark DE, Daley BJ, Davis FE 3rd, Gibbs MA, Knuth T, Letarte PB, Luchette FA, Omert L, Weireter LJ, Wiles CE 3rd, EAST Practice Management Guidelines Work Group (2003) Guidelines for emergency tracheal intubation immediately after traumatic injury. J Trauma 55:162–179CrossRefPubMedGoogle Scholar
  40. 40.
    Duhaime AC, Christian CW, Rorke LB, Zimmerman RA (1998) Non-accidental head injury in infants-the “shaken-baby syndrome.”. N Engl J Med 338(25):1822–1829. CrossRefPubMedGoogle Scholar
  41. 41.
    Piteau SJ, Ward MG, Barrowman NJ, Plint AC (2012) Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics 130(2):315–323. CrossRefPubMedGoogle Scholar
  42. 42.
    Kemp AM, Jaspan T, Griffirhs J, Stoodley N, Mann MK, Tempest V, Maguire SA (2011) Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Arch Dis Child 96(12):1103–1112. CrossRefPubMedGoogle Scholar
  43. 43.
    Kelly P, John S, Vincent AL, Reed P (2015) Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team. Arch Dis Child 100(12):1123–1130. CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Deans KJ, Minneci PC, Lowell W, Groner JI (2013) Increased morbidity and mortality of traumatic brain injury in victims of nonaccidental trauma. J Trauma Acute Care Surg 75(1):157–160. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Shunsuke Amagasa
    • 1
    • 2
    Email author
  • Satoshi Tsuji
    • 3
  • Hikoro Matsui
    • 1
  • Satoko Uematsu
    • 3
  • Takashi Moriya
    • 2
  • Kosaku Kinoshita
    • 4
  1. 1.Department of Pediatric Intensive CareNagano Children’s HospitalNaganoJapan
  2. 2.Department of Emergency and Critical Care Medicine, Saitama Medical CenterJichi Medical UniversitySaitamaJapan
  3. 3.Department of Emergency Medicine and Transport ServiceNational Center for Child Health and DevelopmentTokyoJapan
  4. 4.Division of Emergency and Critical Care Medicine, Department of Acute MedicineNihon University School of MedicineTokyoJapan

Personalised recommendations