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Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury

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Abstract

Background

Many children with severe traumatic brain injury (TBI) receive magnetic resonance imaging (MRI) during hospitalization. There are insufficient data on how different patterns of injury on early MRI inform outcomes.

Methods

Children (3–17 years) admitted in 2010–2021 for severe TBI (Glasgow Coma Scale [GCS] score < 9) were identified using our site’s trauma registry. We used multivariable modeling to determine whether the hemorrhagic diffuse axonal injury (DAI) grade and the number of regions with restricted diffusion (subcortical white matter, corpus callosum, deep gray matter, and brainstem) on MRI obtained within 7 days of injury were independently associated with time to follow commands and with Functional Independence Measure for Children (WeeFIM) scores at the time of discharge from inpatient rehabilitation. We controlled for the clinical variables age, preadmission cardiopulmonary resuscitation, pupil reactivity, motor GCS score, and fever (> 38 °C) in the first 12 h.

Results

Of 260 patients, 136 (52%) underwent MRI within 7 days of injury at a median of 3 days (interquartile range [IQR] 2–4). Patients with early MRI were a median age of 11 years (IQR 7–14), 8 (6%) patients received cardiopulmonary resuscitation, 19 (14%) patients had bilateral unreactive pupils, the median motor GCS score was 1 (IQR 1–4), and 82 (60%) patients had fever. Grade 3 DAI was present in 46 (34%) patients, and restricted diffusion was noted in the corpus callosum in 75 (55%) patients, deep gray matter in 29 (21%) patients, subcortical white matter in 23 (17%) patients, and the brainstem in 20 (15%) patients. After controlling for clinical variables, an increased number of regions with restricted diffusion, but not hemorrhagic DAI grade, was independently associated with longer time to follow commands (hazard ratio 0.68, 95% confidence interval 0.53–0.89) and worse WeeFIM scores (estimate β − 4.67, 95% confidence interval − 8.33 to − 1.01).

Conclusions

Regional restricted diffusion on early MRI is independently associated with short-term outcomes in children with severe TBI. Multicenter cohort studies are needed to validate these findings and elucidate the association of early MRI features with long-term outcomes in children with severe TBI.

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Funding

Analytic support was provided by the University of Colorado Section of Pediatric Critical Care. Dr. Maddux received support from the Eunice Kennedy Shriver National Institutes of Health and Human Development (K23HD096018).

Author information

Authors and Affiliations

  1. Section of Critical Care, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital of Colorado, University of Colorado Anschutz Medical Campus, 13121 E. 17th Avenue, Ed2S, MS8414, Aurora, CO, 80045, USA

    Anna M. Janas, Christopher M. Ruzas & Aline B. Maddux

  2. Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA

    Kristen R. Miller

  3. Section of Neuroradiology, Department of Radiology, University of Colorado School of Medicine, Aurora, CO, USA

    Nicholas V. Stence

  4. Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine and Children’s Hospital of Colorado, Aurora, CO, USA

    Jordan M. Wyrwa

  5. Section of Child Neurology, Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital of Colorado, Aurora, CO, USA

    Ricka Messer

  6. Section of Critical Care, Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR, USA

    Peter M. Mourani

  7. Department of Critical Care Medicine, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA

    Ericka L. Fink

  8. Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA

    Ericka L. Fink

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  1. Anna M. Janas
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Contributions

AMJ, KRM, and ABM designed the research; KRM performed the statistical analysis; AMJ, NVS, and JMW collected data; all authors contributed to the interpretation of the data; AMJ drafted the manuscript; all authors made critical revisions to the manuscript for intellectual content; AMJ had primary responsibility for the final content; and all authors read and approved the final manuscript.

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Correspondence to Anna M. Janas.

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The authors declare that they have no conflict of interest.

Ethical Approval/Informed Consent

The study was approved by the Colorado Multiple Institutional Review Board (protocol #22-1376) and was conducted in accordance with institutional guidelines. Consent was not required (retrospective study).

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Janas, A.M., Miller, K.R., Stence, N.V. et al. Utility of Early Magnetic Resonance Imaging to Enhance Outcome Prediction in Critically Ill Children with Severe Traumatic Brain Injury. Neurocrit Care (2023). https://doi.org/10.1007/s12028-023-01898-9

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