Welcome everybody to our lecture on the injury mechanisms and severity in pediatric traumatic brain injury patients admitted to the ward or intensive care unit, the European perspective. My name is Alexander Jünzi and I'm speaking on behalf of all co-authors of this study. Welcome. Traumatic brain injury, TBI, is considered to be the leading cause of death and disability in children. There are several works and reviews about this neurological and psychological deficits resulting from TBI can be a high burden for patients and their relatives, deeply affecting the child's physical, cognitive, and behavioral development. While pediatric TBI encompasses a wide range of traumatic brain pathologies, it differs from adult TBI in terms of partophysiology, injury causes, and management. Unfortunately, pediatric TBI nevertheless remains severely understudied, because prevention plays a critical role in pediatric TBI, as the vast majority of brain injuries in children occur unintentionally. We aim to study injury characteristics and patterns of pediatric TBI in Europe, which might provide information for new preventive efforts. Welcome. We use data from the collaborative European neurotrauma effectiveness research in traumatic brain injury, the SENDER-TBI core study, and the SENDER-TBI registry. The SENDER-TBI core study is a multi-center, prospective, longitudinal, and observational cohort study, which was conducted in Europe and Israel. Eligibility criteria for this study were a clinical diagnosis of TBI, presentation within 24 hours of injury, an indication for brain CT scanning, and informed consent. And patients were recruited from December 2014 through December 2017 from 59 active centers and enrolled in three strata. That's really important. Those strata were differentiated by care paths, and they were ER, the ER stratum, patients discharged from the ER directly, the admission stratum, patients admitted to the hospital ward, and the intensive care unit stratum, patients admitted primarily to the ICU. Besides the core study, SENDER-TBI also included patients in a registry with observational data from an even larger cohort. This was meant to permit validation and generalization of results from the core dataset, but it included fewer variables, and in particular, no fallout data, such as the outcome scale extended, which was performed for all core study patients after 6 and 12 months. Welcome. For the present sub-study, all patients within the SENDER-TBI core and registry datasets were screened and included if they met the following inclusion criteria. A, age at presentation, maximum 18 years, so 18 years and everything below, children, and then admission to either the regular ward, so admission stratum, or the ICU stratum. Therefore, patients in the ER stratum, so patients that were discharged directly from the ER, were excluded. Welcome. From the 4,509 patients enrolled in the SENDER-TBI core study, after applying inclusion-exclusion criteria, 227 pediatric patients could be included. Of those, 95 had been admitted to the regular ward and 132 to the ICU. Welcome. In a registry with over 20,000 patients, 687 patients met the inclusion criteria and could be enrolled. Overall, two-thirds of pediatric TBI patients in this study were males, and the mean age was 14 years in the core study and 12 years in the registry. While the proportion of patients admitted to the regular ward was high in the registry dataset with 62%, more patients were admitted to the ICU in the SENDER-TBI core study with 58%, so that's basically the only real difference. All remaining patient characteristics were comparable between the core study and the registry, and key findings in the core study could be confirmed in the larger registry dataset. Welcome. Let's talk about injury mechanisms first. So, the most common places of injury of TBI for pediatric patients in Europe were streets and highways in 52% of cases, especially in the ICU stratum, where more than 60% of injuries occurred in that setting. Injuries that occurred at home and sport recreational places came second, as you can see here, and accounted together for more than 30% of injuries in the admissions stratum. Correspondingly, road traffic incidents, RTIs, were overall the most common cause of pediatric TBIs because of its high prevalence in the ICU stratum. You can see this here, 58%. Whereas incidental falls were the most common cause of injury in the admissions stratum, 43%, and overall the second most common cause of pediatric TBIs. Now, that's really important. In road traffic incidents, the young patients were involved as pedestrians in one third of cases, so the rest is either cyclists, scooter drivers, or in the cars. And even more important, notably, more than half, so 52% of patients involved in an accident as cyclists, scooter drivers, or motorbikers did not wear safety helmets. Welcome. Let's talk about injury severity of pediatric TBI patients. 22% of those patients presented with mild TBI, moderate TBI occurred in 12%, and 61% of the vast majority of patients had a severe TBI. Concurrent injuries in other body regions were very common, especially in the ICU stratum, and overall it was 77%. And in the ICU stratum, 28% of patients had no motor response to stimuli at all, and one in 10 patients had two unresponsive pupils at admission. GCS, as well as GCS motor score at admission, was significantly higher in the admissions stratum compared to the ICU stratum, so this was rather expected. ICU stratum, mean GCS, overall 11 points. And as expected, also the total injury severity score in the ICU stratum was significantly higher than in the admissions stratum. Neurological deficits were in total rather rare, but they occurred significantly more often in the ICU stratum than in the admissions stratum. Welcome. In pediatric TBI patients within the core dataset, an intercranial abnormality was detected in more than 60% of all patients in the initial brain CT scan. So remember, all patients in the standard TBI study received a CT scan, so all of those patients have available CT imaging data. The most common pathologies were traumatic subarachnoid hemorrhage, and 29% of patients followed by contusion, 27%, epidural hematoma, 25%, and acute subdural hematoma, only 19%. As expected, the prevalence of those pathologies was higher among ICU patients, as you can see in this graph. Interestingly, a skull fracture was really present in almost half of all patients overall. Welcome. An intercranial surgery was performed in 33% of ICU patients, while 28% underwent an exocranial surgery. So overall, surgical treatment was necessary in 62% of ICU patients, which is quite a lot. This, however, differed significantly from patients in the admission stratum, where no intercranial surgeries were performed, and where exocranial surgeries were rare, where 3% of intercranial surgeries were performed and exocranial surgeries were rare. At six-month follow-up, welcome. In multivariate analysis, only total GCS score as well as the occurrence of secondary insults were significant predictors for an ephemeral outcome six months after the injury. Those are the secondary insults recorded for a patient cohort, and as you can see, all of them were significantly associated with an ephemeral outcome after TBI. Welcome to sum of findings up. I think we can conclude that road traffic incidents and incidental falls have been the most common cause of pediatric TBI in Europe in the recent years. Again, it's really noteworthy to mention that more than half of children in RTIs did not wear a helmet. The severity of traumatic brain injuries seen in children is very serious, especially when admitted to the ICU, and concurrent injuries, for example, occur very frequently. However, outcome is favorable in more than 90% of pediatric TBI patients, which is really good. It's a really good finding. Predictors for an unfavorable outcome remain overall trauma severity and occurrence of secondary insults. Those are factors that might be improved by further preventive measures and more precise ICU care. Welcome. Thank you very much for your attention.

traumatic brain injury

pediatric patients

severity of TBI

road traffic incidents

falls