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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.68 no.3 São Paulo June 2010 



Do children with Glasgow 13/14 could be identified as mild traumatic brain injury?


Pacientes pediátricos com Glasgow 13 ou 14 podem ser identificados como traumatismo craniano leve?



José Roberto Tude MeloI; Laudenor Pereira Lemos-JúniorII; Rodolfo Casimiro ReisII; Alex O. AraújoII; Carlos W. MenezesII; Gustavo P. SantosII; Bruna B. BarretoII; Thomaz MenezesII; Jamary Oliveira-FilhoIII

INeurosurgeon, Master Doctor, PhD student in Medicine (PPgMS-UFBA). Post-Graduation Program in Medicine and Health from Federal University of Bahia (PPgMS-UFBA), Salvador BA, Brazil
IIMedical Students (UFBA). Post-Graduation Program in Medicine and Health from Federal University of Bahia (PPgMS-UFBA), Salvador BA, Brazil
IIINeurologist, PhD in Neurology (University of São Paulo)
. Post-Graduation Program in Medicine and Health from Federal University of Bahia (PPgMS-UFBA), Salvador BA, Brazil





OBJECTIVE: To identify in mild head injured children the major differences between those with a Glasgow Coma Scale (GCS) 15 and GCS 13/14.
METHOD: Cross-sectional study accomplished through information derived from medical records of mild head injured children presented in the emergency room of a Pediatric Trauma Centre level I, between May 2007 and May 2008.
RESULTS: 1888 patients were included. The mean age was 7.6±5.4 years; 93.7% had GCS 15; among children with GCS 13/14, 46.2% (p<0.001) suffered multiple traumas and 52.1% (p<0.001) had abnormal cranial computed tomography (CCT) scan. In those with GCS 13/14, neurosurgery was performed in 6.7% and 9.2% (p=0.001) had neurological disabilities.
CONCLUSION: Those with GCS 13/14 had frequently association with multiple traumas, abnormalities in CCT scan, require of neurosurgical procedure and Intensive Care Unit admission. We must be cautious in classified children with GCS 13/14 as mild head trauma victims.

Key words: adolescents, brain injuries, child, Glasgow Coma Scale, head trauma, prognosis.


OBJETIVO: Identificar as principais diferenças entre os pacientes com Escala de Coma de Glasgow (GCS) 15 e aqueles com escore 13/14.
MÉTODO: Estudo realizado por meio da revisão de prontuários médicos de crianças vítimas de traumatismo craniencefálico leve, admitidas em Centro de Urgências Pediátricas nível I, durante um ano.
RESULTADOS: Incluídas 1888 vítimas; idade média de 7,6±5,4 anos; 93,7% apresentaram pontuação 15 na GCS. Naqueles com pontuação 13/14, 46,2% (p<0,001) sofreram traumas múltiplos e 52,1% (p<0,001) apresentaram alterações na tomografia de crânio. Tratamento neurocirúrgico foi necessário em 6,7% dos pacientes com GCS 13/14 e 9,2% (p=0,001) apresentaram seqüelas neurológicas no momento da alta hospitalar.
CONCLUSÃO: Crianças com escore 13/14 apresentam maior prevalência de traumas múltiplos, alterações na tomografia de crânio, necessidade de tratamento neurocirúrgico e internação em Unidade de Terapia Intensiva. Devemos ser cautelosos ao classificar crianças com pontuação 13/14 na GCS como vítimas de traumatismo craniano leve.

Palavras-chave: adolescente, injúria cerebral, criança, Escala de Coma de Glasgow, traumatismos craniocerebrais, prognóstico.



Head trauma is one of the most relevant public health problems throughout the world, reaching high morbidity and mortality rates. It also represents the leading cause of death and disability in children and young adults, which affects patients' quality of life and sometimes disrupts family environment1-11 , even if they have mild traumatic brain injury (MTBI)12. In Brazil we notice the same problems, and children and adolescents make an important group affected by head trauma3,5,6.

Based on Glasgow Coma Scale (GCS)13, some authors diverge about the classification of MTBI6,13-17. Definition of cut off values to define MTBI varies among different guidelines, but the score 13-15 is the original one13. Comparison among groups and studies as well as development of recommendations and guidelines become particularly difficult when one takes in count all these different concepts regarding MTBI16,18 .

Here we sought to identify the major differences regarding the scores that define MTBI, and try to demonstrate that we must be very cautious in classified children with GCS 13/14 as MTBI.



This is a cross-sectional study developed to access clinical, epidemiological and demographic data of children and adolescents younger than 18 years with MTBI. We reviewed all medical records of patients admitted to the emergency room (ER) of a Pediatric Trauma Centre level I, from Salvador/Bahia, Brazil. Observation was carried through a one-year period, which started on May 2007 and ended on May 2008. Data were collected for age, gender, trauma history, GCS score on admission (including the adjustment for children under 05 years old19,20), modality of treatment (neurosurgical or not), cranial computed tomography (CT) scan results, length of hospital stay (in days), admission in the Pediatric Intensive Care Unit (PICU) and Glasgow Outcome Scale (GOS)21 score at hospital discharge. We considered GOS between 2 and 4 (neurological disabilities) as worse outcomes.

Only patients with GCS score known as 13, 14 or 15 were classified as MTBI13. Here we used the World Health Organization (WHO) definition for pediatric population22.

Patients were classified into two groups for analysis, since hospital admission: Those with GCS score of 15 (GCS 15); Those with GCS score of 13 or 14 (GCS13/14).

The pediatricians who assisted the children in the emergency room defined which radiological exam was necessary. The reports of CT scans were provided by neurologists, neurosurgeons or radiologists.

The study was approved by the Hospital Ethics Committee under registration nº 06/07.

Statistical analysis

For data analysis, all quantitative variables are expressed as mean±SD (standard deviation). Categorical data were analyzed by using chi-square test.



A total of 2593 patients aged from 0 to 18 years with a history of head trauma were available within the one-year study period. A total of 1888 (72.8%) had MTBI. According age group, those between 3 and 6 years-old (28%) were the main victims. Mean age was 7.6±5.4 years. In 93.7% of the cases we observed a GCS 15 at hospital admission. Prevalence of MTBI in male kids (68.2%) was significantly higher than in female ones (31.8%) (p<0.01). Children with GCS 13/14 were older than those with GCS 15. Demographic data are presented in Table 1.



Regarding to possible associations with other lesions, 485 (27.4%) patients with a GCS 15 suffered multiple trauma, against 46.2% of the other group (p<0.001). In reference to imaging studies, 734 patients were submitted to CT scan and 205 (10.9% of all admitted patients) had abnormal findings. In the GCS 15 group, we observed 143 (8.1%) abnormal CT scans, against 62 (52.1%) in the GCS 13/14 group (p<0.001) (Table 2).



Neurosurgical treatment was performed in 6.7% of patients in the GCS 13/14 group and only in 2.3% of patients in the GCS 15 group (p=0.007). Patients in the GCS 13/14 group were admitted to a PICU more often than victims in the GCS 15 group (6.7% and 0.4%; p<0.001). Mean length of hospital stay was 4.2 (±6.7) days among children in the GCS 13/14 group whereas the majority (93%) of children with GCS 15 was discharged from the hospital within the first 24 hours (Table 2).

On hospital discharge, GOS score of 2, 3 or 4 (neurological disabilities) was observed in 9.2% of patients in the GCS 13/14 group, against 0.8% of patients in the GCS 15 group (p=0.001) (Table 2).



Children between 3 and 6 years-old composed the main group in this study, and fall from a height represented the leading cause of head trauma in those patients, probably due to the discovery of new activities such as climbing trees, beds, chairs and walls. Similarly to previous studies, we observed boys as the main victims of MTBI, which is in agreement with the relevant exposure of this group to some traumatic agents6,11,23. We also showed here that children with GCS 13/14 are older than those with a GCS 15, maybe because those are exposed and involved in more severe accidents, such as traffic ones.

In reference to the most important causes of traumatic brain injury, our results are similar to those in previous studies, which define falls and vehicle-pedestrian accidents as the leading mechanisms of injury in children and adolescents6,11,23. These data corroborate the need for new traffic safety education policies in our city. Furthermore it is important to think about these accidents as a consequence of caregivers' possible lack of attention regarding to some children activities in high places and streets.

We verified that children with a GCS 13/14 were more often involved in multiple traumas than those with GCS 15. The same was observed regarding to abnormal findings on CT scans, PICU admission and neurological disabilities at hospital discharge. Perhaps these differences between both groups show the severity of trauma in those with GCS 13/14, the higher risk of brain damage and the possible worse outcome. Some authors propose modifications regard including those with GCS13/14 as MTBI as they have worse evolution and require major attention24.

We agree with previous authors with regard to the need of performing CT scans in multiple trauma victims and in those with GCS score of 13 or 1414,15,18,25,26 who have had more severe mechanisms of injury. Nevertheless, we must keep in mind that some children with GCS 15 must be submitted to CT scans as well, regarding some neurological findings14,15,18,25-27.

We observed here different modalities of treatment among children and adolescents with MTBI in confluence to previous studies14-16,25. Children that needed neurosurgical procedures were composed mainly by the GCS 13/14 group, which shows, once again, the need of reviewing this group as MTBI. As it has already been observed by other authors, MTBI occurred with a much higher frequency than others head traumas, no neurosurgical treatment is generally necessary, and the patient just remains in observation at hospital or, sometimes, at home5,6,8,14,16,28. We noticed that this benign evolution was more frequent among victims with a GCS 15, as verified by others authors17,24,29. All these data point to the main differences among MTBI, and show us that we must be aware when including patients with a GCS 13/14 as MTBI victims. Our results could be corroborate by The Brazilian Society of Neurosurgery15 regarding the importance to take apart victims with MTBI according the risk in developing post traumatic brain lesion.

We noticed that children with MTBI compose a heterogeneous group, with different risk of brain injury and prognosis according to GCS score on admission. We know that it will be very difficult to provide only one appropriate guideline to manage these children but, due to our results in confluence with others references, since they have different characteristics and prognosis, we think that we must be very careful in considering all children with MTBI in the same category as mild trauma.



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José Roberto Tude Melo
Alameda dos Jasmins 200/702 B
40296-200 Salvador BA - Brasil

Received in 29 July 2009
Received in final form 13 September 2009
Accepted 20 October 2009

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