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Neurobehavioral Conditions Increase Risk of Persistent Symptoms in Noncritical Pediatric TBI

Key findings

  • In a nationwide cohort of 45 children and adolescents with noncritical traumatic brain injury, parent-reported cognitive and somatic symptoms were still elevated two weeks after injury
  • Three months postinjury, the median cognitive symptom level had returned to baseline, but somatic symptoms were still elevated
  • Loss of consciousness predicted worse cognitive and somatic symptoms at two weeks, however, it was not related to symptoms at three months
  • Neither intra-axial nor extra-axial lesions were predictive of worse cognitive or somatic symptoms at two weeks and three months, but at three months, extra-axial lesions predicted less severe cognitive symptoms
  • A history of a neurobehavioral condition (attention-deficit/hyperactivity disorder, anxiety, depression and/or a learning disability) was the strongest predictor of persistent symptoms three months after injury

Children with mild traumatic brain injury (TBI) who are expected to have few long-term consequences may have symptoms several months to a year after injury. But the prediction of late effects is difficult, since patients who have a rapid return to normal mental status are unlikely to be referred for inpatient rehabilitation and often have little systematic clinical follow-up.

By analyzing data from an ongoing national study, Ann-Christine Duhaime, MD, director of Pediatric Neurosurgery in the Department of Neurosurgery at Massachusetts General Hospital, and colleagues studied the relationship between lesions and environmental factors that predict persistent symptoms, both within the first few weeks of injury and beyond the expected recovery period. Their findings, published in the Journal of Neurotrauma, should help clinicians educate families about expectations, make recommendations about when to return to school and play, and when necessary, make referrals for follow-up care and support services.

Study Methods

The researchers used data on 45 children enrolled in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study. The TRACK-TBI investigators are prospectively collecting preinjury, injury-related, biomarker and imaging data for patients presenting to Level 1 trauma centers throughout the U.S.

For purposes of this analysis, the inclusion criteria were:

  • Enrolled between March 2014 and March 2017
  • Age three to 16 years at the time of injury
  • Had at least one of the following: loss of consciousness, loss of memory for events, alteration in mental state at the time of the accident or focal neurologic deficits
  • Enrolled within 24 hours of injury
  • Underwent computerized tomography (CT) or magnetic resonance imaging (MRI) within 24 hours of injury
  • Had at least one follow-up MRI within the first two weeks of injury
  • A parent completed the Health and Behavior Inventory (HBI) two weeks and/or three months after injury

The research team's intention was to focus the study on pediatric patients who might have an array of imaging findings but were likely to regain normal mental status within the first 24 hours and be discharged to home. Therefore, patients were excluded if they had a major preinjury neurologic or psychiatric diagnosis, a spinal cord injury of grade C or worse, severe extracranial injuries, neurosurgery or intracranial pressure monitoring.

Characteristics of the Cohort

  • Twenty-three of the 45 subjects (51%) had a loss of consciousness
  • The median worst unsedated Glasgow Coma Score (GCS) in the emergency department was 15 (range, 4–15)
  • Fifteen children had at least one pre-existing neurobehavioral condition: nine had attention-deficit/hyperactivity disorder, five had a learning disability and four had anxiety, depression or a history of psychotherapy
  • Twenty-three subjects had no lesions on neuroimaging. Seven had extra-axial lesions only, seven had intra-axial lesions only and eight had both intra- and extra-axial lesions. Most of these were relatively small surface lesions. No subject had a significant brainstem injury
  • Cognitive symptom scores on the HBI were significantly increased two weeks postinjury, compared with the preinjury scores as recalled by parents (median 16 vs. 11, P = .004). They returned to baseline levels by three months after injury
  • Somatic symptom scores on the HBI were significantly increased two weeks postinjury compared with baseline (median 5 vs. 1, P < .001) and remained elevated at three months (3 vs. 1, P = .03)

Predictors of Symptom Severity at Two Weeks

Multivariable models were adjusted for age, sex, socioeconomic status and preinjury symptoms. The potential predictors tested were loss of consciousness, worst GCS, brain lesion category (intra-axial or extra-axial lesion present or absent), extracranial injuries, neurobehavioral history and race.

Loss of consciousness proved to be the only significant predictor of worse cognitive symptom scores two weeks postinjury. It was also a significant predictor of worse somatic symptom scores.

Predictors of Symptom Severity at Three Months

A history of a neurobehavioral condition was the only significant predictor of worse cognitive symptom scores three months postinjury, and it also predicted worse somatic symptom scores.

The presence of extra-axial injuries on imaging predicted less severe cognitive symptoms.

Clinical Implications

This study adds to the growing evidence that preinjury factors may play a significant role in the persistence of TBI-related symptoms. When a child or adolescent who has a history of a neurobehavioral condition presents with even noncritical TBI, clinicians should consider close follow-up, regardless of imaging findings.

It's worth noting that the worst GCS in the emergency department did not predict the severity of symptoms at either two weeks or three months. This confirms the recent consensus that GCS has limited sensitivity at differentiating injury severity at the milder end of the injury spectrum.

Learn more about the Pediatric Neurosurgery service at Mass General

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