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Tamara C. Valovich McLeod, PhD, ATC, CSCS, provided conception and design; analysis and interpretation of the data; and drafting, critical revision, and final approval of the manuscript.
Reference: Dunning J, Batchelor J, Stratford-Smith P, et al. A meta-analysis of variables that predict significant intracranial injury in minor head trauma. Arch Dis Child. 2004;89:653–659.
Clinical Question: Which clinical signs or symptoms of minor head trauma are predictive of intracranial hemorrhage in children and adolescents?
Data Sources: Investigations were identified by MEDLINE and EMBASE searches from 1990 through 2002 by a search of the grey literature and by contacting experts for additional papers. The search terms were selected to find all studies reporting intracranial hemorrhage (ICH) or complications after head trauma.
Study Selection: A full systematic review was conducted, and all cohort or nested cohort studies that presented data on minor head injuries in children less than 18 years old, with or without ICH, were identified. Studies were then judged for inclusion based on the presentation of a series of at least 100 patients and a documented reliable standard for the detection of ICH for all patients in the study. The use of computed tomography (CT) and medical follow-up was considered an acceptable gold standard. Intracranial hemorrhage was defined as any abnormality detected on the CT scan due to the traumatic presence of extravascular blood. Minor head trauma was defined as patients presenting with a Glasgow Coma Scale (GCS) score of 13–15.
Data Extraction: Seven clinical correlates were used for data extraction, including skull fracture, headache, vomiting, focal neurology, seizure, loss of consciousness, and a GCS score of less than 15. Data were analyzed using a pooled estimate of the relative risk ratio with a random-effects model.
Main Results: The searches identified a total of 2134 studies for the initial review. After an abstract review by 2 independent examiners, 98 studies were identified for a full-paper review. Each study was graded on a 4-point scale according to the level of evidence provided, using scales consistent with the Oxford Centre for Evidence-Based Medicine and the National Institute for Clinical Excellence. Thirty-four of these articles were of adequate quality for inclusion; however, many did not include data that could be separated into a specific data set for children, had too small a sample size, or lacked enough data on individual correlates to head trauma. Nineteen studies provided data on children, but 3 of these were excluded due to poor quality or lack of a reported CT scan, leaving a total of 16 studies for the meta-analysis.
The analysis included a total of 22420 patients ranging between 0 and 18 years of age. The meta-analysis showed a significant increased relative risk of ICH for patients sustaining loss of consciousness (2.23), GCS <15 (5.51), skull fracture (6.13), and focal neurology (9.43). No significant increases in risk for headache (1.02), vomiting (0.878), or seizure (2.82) were noted; however, heterogeneity was significant for this last correlate. The prevalence of ICH ranged from 1.3 to 36%, supporting the notion of a large amount of heterogeneity or variability in the inclusion criteria among the studies.
Conclusions: These findings demonstrate that loss of consciousness, decreased level of consciousness (GCS <15), skull fracture, and focal neurology are risk factors for ICH in the pediatric population. However, these findings are not definitive enough to establish pediatric head-injury guidelines regarding CT scanning or admission to hospital after minor head trauma.
Although intracranial hemorrhage (ICH) after mild head injury is a rare occurrence in athletes, certified athletic trainers (ATCs) must be aware of the signs and symptoms of all severities of head trauma, including ICH. The initial role of the ATC when there is a suspected head injury is the detection of focal traumatic brain injury (TBI), including epidural hematoma, subdural hematoma, cerebral contusion, and intracerebral hemorrhage and hematoma.1,2 To successfully recognize these potentially life-threatening head injuries, the ATC must understand the various presentations of athletes with head injuries and the signs and symptoms that often accompany them, such as loss of consciousness (LOC), cranial nerve deficits, decreasing mental status, and worsening symptoms.1
Dunning et al3 presented a meta-analysis that has direct relevance to the practice of athletic training and the management of minor head injuries. Understanding the potential risk factors for ICH is an important step in ensuring adequate referral to medical professionals and a quick diagnosis of possible ICH. Often, the ATC must decide whether an athlete should be referred to the emergency room once he or she has sustained a mild head injury and, once at the emergency room, physicians need to decide on a course of diagnostics. This is even more of a concern in the pediatric athlete because of the potential for both short-term and long-term complications in the still-developing brain.4–7 As a general rule, failure of an athlete's mental status to clear rapidly should lead to a referral for neuroimaging.8 With the suspicion of focal TBI, CT scans have been recommended as the neuroimaging modality of choice because they can easily detect acute blood collection and skull fracture.8
It is important to note that differences exist between sport-related minor head trauma and minor head trauma from additional mechanisms, such as motor vehicle accidents, falls, and other accidents. None of the studies used by Dunning et al3 were investigations of sport-related minor head injury. Minor head injuries that produce ICH or any of the clinical correlates found to be significant predictors of ICH (LOC, focal neurology, Glasgow Coma Scale [GCS] <15, or skull fracture) are rare in athletes.2 In fact, recent authors have reported that only 6.3 to 8.9% of collegiate athletes experienced LOC after a concussion.9–11 Regardless of the rarity of focal TBI and injuries that result in ICH during athletics, it is imperative that these injuries be ruled out by the ATC.
Based on this meta-analysis, the correlates identified as predictors of ICH included LOC, a GCS score of <15, focal neurology, and a skull fracture. Fortunately, the presence of these clinical signs and symptoms in an athlete would warrant physician referral based on the recommendations made in the National Athletic Trainers' Association position statement on sport-related concussion and other recommendations for on-field management of head trauma.1,2,8 Even though headache and vomiting were not predictive of ICH, documenting these and other signs and symptoms of mild head trauma should be part of the ATC's assessment protocol.1,12,13 By quantifying the number of signs and symptoms present as well as the frequency and/or duration of these signs and symptoms, the ATC can track the recovery of the athlete and use the information for referral if the athlete does not demonstrate improvement. In addition, the ATC should use age-appropriate adjunct assessments, including neurocognitive testing7,14–18 (traditional pen-and-paper neuropsychological tests, ImPACT [Immediate Postconcussion Assessment and Cognitive Testing, University of Pittsburgh Medical Center, Pittsburgh, PA], ANAM [Automated Neuropsychological Assessment Metrics, National Rehabilitation Hospital Assistive Technology and Neuroscience Center, Washington, DC], Concussion Resolution Index [HeadMinder Inc, New York, NY], Standardized Assessment of Concussion [CNS Inc, Waukesha, WI]) and postural stability testing18 to aid in the decision-making process.
The findings of Dunning et al3 provide insight into specific risk factors the ATC should look for when evaluating minor head trauma in children and adolescents. The presence of any of the significant predictors should warrant immediate referral. The authors also acknowledge that other signs and symptoms (eg, dizziness, drowsiness, confusion) could be predictive of ICH; however, these factors had not been adequately investigated in the pediatric literature identified for this meta-analysis and therefore were not included. This factor, along with the variability in the inclusion criteria, timing of CT scans, and differences in the ICH definitions in the individual studies are limitations of this meta-analysis. Another potential limitation regarding the predictive value of the headache variable to ICH stems from a lack of information regarding the severity of the headaches reported in the individual studies. Some evidence suggests a relationship between severe headaches and ICH19; therefore, headache severity should also be questioned during the clinical examination. Several other limitations of this meta-analysis include no listing of specific medical subject headings terms used to search the databases, not describing the duration of LOC from the various studies used, and not adequately describing or defining the specific types of focal neurology used as a correlate. However, other authors have described focal neurologic changes as including posturing and dilating pupils.2
Although this meta-analysis offers medical professionals working with children and adolescents one interpretation of the evidence regarding clinical risk factors predictive of ICH, it does not provide strong enough evidence to alter the current head-injury management and CT scanning protocols for children.20 Future studies should address the limitations outlined by Dunning et al3 to better determine the predictive value of various clinical signs and symptoms of minor head trauma in the pediatric population.