Prognostic value of traumatic brainstem injury in early computed tomography in paediatric population

Abstract

Introduction: In India, children aged <16 years constitute 35% of the total population and contribute to 20–30% of all head injuries. Prognostication of severe TBI in children based on early imaging and biomarkers has been universally challenging. The Marshall, Rotterdam, Stockholm, and Helsinki CT scores were developed to use acute head CT images to predict mortality at 6 months. Notably, none include criteria related to traumatic brainstem injury (BSI). The objective of this study was to compare the long-term outcome of pediatric patients with BSI identified on CT, along with an effort to classify BSI based on lesion volume, lesion location, presence of subarachnoid hemorrhage (SAH) and intraventricular hemorrhage (IVH) and how, the presence of these subset of injuries affect the outcome.

Methods: A retrospective analysis of pediatric patients presenting with TBI was undertaken from 2019 to 2023. CT scans were reviewed for brainstem lesions and, when present, characterised by location, size, and type (traumatic axonal injury (TAI), contusion, and duret haemorrhage). Clinical, demographic, and outcome data were then compared with the type of lesion, position of lesion, lesion volume, presence/absence of SAH and IVH.

Results: We found that lesion volume of more than 1 cm³ is associated with a poorer GOSE score (p< 0.001). Similarly, lesions spanning both anterior and posterior quadrant are associated with poor outcome (GOSE: 3.4 +_ STD 2.9). We also found significant correlation with presence of SAH and IVH related to a poorer outcome (p < 0.001).

Conclusion: Early evidence from the current study suggests that certain TBI patients with BSI can have positive outcomes. BSI can further be classified into TAI, duret and brainstem contusions, each with variable outcome. Brainstem lesions with volume of >1 ml have been found to have a poorer outcome. Similarly, lesions spanning both quadrants tend to have a worse prognosis. Although there was no significant difference in outcome when compared with BSI – cases.  These findings suggest of patients with brainstem injuries may exist with divergent recovery potential after TBI.