Edited by: Anthony A. Figaji, University of Cape Town, South Africa
Reviewed by: Ahmed Negida, Zagazig University, Egypt; Ursula Rohlwink, University of Cape Town, South Africa
This article was submitted to Neurotrauma, a section of the journal Frontiers in Neurology
†CENTER-TBI Investigators and Participants are listed in the
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Traumatic brain injury (TBI) is considered to be the leading cause of death and disability in children (
For the present analysis, data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study and the CENTER-TBI registry were used. The CENTER-TBI core study is a multi-center prospective longitudinal and observational cohort study conducted in Europe and Israel. Eligibility criteria for this study were a clinical diagnosis of TBI, presentation within 24 h of injury, an indication for brain CT scanning, and informed consent (see below) (
Flow-Diagram of patient selection within the CENTER-TBI core study (separate from the CENTER-TBI registry).
Our study was primarily conducted with the CENTER-TBI core dataset because it provides more variables and especially outcome-related data such as GOSE ratings in comparison to the CENTER-TBI registry. Where possible, we compared key results from the core dataset with the registry dataset to confirm findings in an even larger patient cohort. The following variables regarding patient demographics and injury causes were collected from the core dataset: age, sex, injury type, place, area, cause, and intention. To assess injury severity and clinical status at admission, the AVPU (Alert, Verbal, Pain, Unresponsive) status, Glasgow Coma Scale (GCS), GCS—motor score, pupillary response, total Injury Severity Score (ISS), and Abbreviated Injury Scale (AIS) for brain injury, head/neck, cervical/thoracic/lumbar spine, thorax, abdomen/pelvis, upper and lower extremities, and skin were retrieved. Radiological injury characteristics (e.g., presence of midline shift, epidural hematoma, acute or subacute subdural hematoma, subarachnoidal hemorrhage, intraventricular hemorrhage, contusion, traumatic axonal injury, cisternal compression, subdural collections/mixed density hematoma, mass lesion, skull fracture) as well as the Marshall and Rotterdam CT scores were obtained from initial brain CT scans. In terms of clinical care, the performance of surgical interventions (intra- and extracranial) was recorded. Secondary injury insults during the pre-hospital and emergency room phase were evaluated and included hypoxia (PaO2 <60 mmHg and/or SaO2 <90% or suspected by clinical signs such as cyanosis), hypotension (systolic blood pressure <90 mmHg, patients reported to be in shock and/or absent brachial pulse not related to extremity injury), hypothermia (documented core temperature <35°C), seizures (partial, generalized, status epilepticus), or cardiac arrest. The imputed six month Glasgow Outcome Scale Extended (GOSE) variable provided in the Neurobot database which includes both, observed ratings and imputed values was used to assess outcome. Values were only imputed if at least one GOSE rating from another time point was available per patient. Unfavorable outcome was defined as a GOSE score from 1 to 4 and a favorable outcome as a GOSE score from 5 to 8. From the registry dataset, the variables age, sex, injury type, place, cause, total ISS, AIS Brain Injury, GCS motor/verbal/eyes, and presence of abnormality on brain CT were obtained. All variables were retrieved from the CENTER-TBI Neurobot database (CENTER core version 2.0 and registry version 2.0).
Patient demographics, injury, and imaging characteristics as well as clinical data were summarized using descriptive statistics. Results are given as median + interquartile range (IQR) unless stated otherwise. For group comparisons, the Mann-Whitney
In total, 227 TBI patients younger than 18 years from the CENTER-TBI core dataset were included in this study. Pediatric patients had been enrolled in 33 of the 59 participating centers. 95 (42%) of them were admitted to the hospital ward (admission stratum) while 132 (58%) patients required critical care and were admitted to the ICU (ICU stratum). The median age of the entire cohort was 14 (IQR 8–16, range 0–17) years and 64% of patients (
Injury causes- and details of pediatric TBI patients in the admission and ICU stratum of the CENTER-TBI core study.
Number of patients | 227 | 95 (42%) | 132 (58%) | - |
Age (IQR) | 14 (8-16) | 13 (9-16) | 14 (8-16) | 0.583 |
Sex | 0.695 | |||
- Female | 81 (36%) | 32 (34%) | 49 (37%) | |
- Male | 146 (64%) | 63 (66%) | 83 (63%) | |
Injury area | 0.072 | |||
- Urban | 153 (67%) | 72 (76%) | 81 (61%) | |
- Rural | 65 (29%) | 20 (21%) | 45 (34%) | |
- Unknown | 9 (4%) | 3 (3%) | 6 (5%) | |
Injury intention | 0.805 | |||
- Intentional | 6 (3%) | 3 (3%) | 3 (2%) | |
- Unintentional | 212 (93%) | 94%) | 123 (93%) | |
- Undetermined | 9 (4%) | 3 (3%) | 6 (5%) | |
Injury cause | ||||
- Road traffic incident | 110 (48%) | 33 (35%) | 77 (58%) | |
- Incidental fall | 78 (34%) | 41 (43%) | 37 (28%) | |
- Other non-intentional injury | 22 (10%) | 11 (12%) | 11 (8%) | |
- Violence | 5 (2%) | 4 (4%) | 1 (1%) | |
- Other | 11 (5%) | 5 (5%) | 0 (0%) | |
- Unknown | 1 (0%) | 1 (1%) | 6 (5%) | |
Injury road incidents | 0.069 | |||
- Motor vehicle occupant | 21 (19%) | 3 (9%) | 18 (23%) | |
- Pedestrian | 37 (34%) | 11 (33%) | 26 (34%) | |
- Cyclist | 27 (25%) | 11 (33%) | 16 (21%) | |
- Scooter | 13 (12%) | 7 (21%) | 6 (8%) | |
- Motor Bike | 10 (9%) | 1 (3%) | 9 (12%) | |
- Other | 2 (2%) | 1 (3%) | 2 (3%) | |
Injury place | ||||
- Street/Highway | 118 (52%) | 38 (40%) | 80 (61%) | |
- Home | 40 (18%) | 19 (20%) | 21 (16%) | |
- School | 14 (6%) | 7 (7%) | 7 (5%) | |
- Sport/Recreation | 40 (18%) | 21 (22%) | 19 (14%) | |
- Public location | 11 (5%) | 8 (8%) | 3 (2%) | |
- Other | 2 (1%) | 0 (0%) | 2 (2%) | |
- Unknown | 2 (1%) | 2 (2%) | 0 (0%) | |
Total ISS (IQR) | 18 (10-32) | 10 (9-17) | 26 (17-41) | |
AIS Brain Injury | 4 (3-4) | 3 (3-3) | 4 (4-5) | |
Face injury | 68 (30%) | 28 (29%) | 40 (30%) | 1 |
Head/ Neck injury | 104 (46%) | 44 (46%) | 59 (45%) | 1 |
Cervical spine injury | 12 (5%) | 5 (5%) | 7 (5%) | 1 |
Thoracic spine injury | 7 (3%) | 3 (3%) | 4 (3%) | 1 |
Lumbar spine injury | 4 (2%) | 1 (1%) | 3 (2%) | 0.859 |
Thorax injury | 55 (24%) | 5 (5%) | 50 (38%) | |
Abdominal injury | 16 (7%) | 2 (2%) | 14 (11%) | |
Pelvic injury | 15 (7%) | 3 (3%) | 12 (9%) | 0.133 |
Upper extremity injury | 40 (18%) | 18 (19%) | 22 (17%) | 0.788 |
Lower extremity injury | 37 (16%) | 10 (11%) | 27 (20%) | 0.069 |
Skin injury | 31 (14%) | 8 (8%) | 23 (17%) | 0.080 |
The most common places of injury overall were streets and highways (52%), especially in the ICU stratum where more than 60% of injuries occurred in that setting (
Injury places
Twenty two percent of pediatric patients in our cohort presented with mild TBI (GCS 13-15) while moderate (GCS 9-12) and severe TBI (GCS 3-8) occurred in 12 and 61%, respectively. Brain injury was considered serious to severe in the majority of patients (AIS 3 (3–4),
Presenting symptoms of pediatric patients with TBI. PTA: Post-traumatic amnesia.
In pediatric TBI patients within the core dataset, an intracranial abnormality was detected in more than 60% of all patients in the initial brain CT scan (
Details of initial brain CT imaging.
Contusion | 58 (27%) | 9 (10%) | 49 (39%) | |
Traumatic axonal injury | 28 (13%) | 6 (7%) | 22 (18%) | |
Acute subdural hematoma | 40 (19%) | 8 (9 %) | 32 (26%) | |
Subacute or chronic subdural hematoma | 0 (0%) | 0 (0%) | 0 (0%) | - |
Traumatic subarachnoid hemorrhage | 62 (29%) | 9 (10%) | 53(42%) | |
Epidural hematoma | 32 (15%) | 8 (9%) | 24 (19%) | 0.053 |
Intraventricular hemorrhage | 21 (10%) | 1 (1%) | 20 (16%) | |
Skull Fracture | 103 (48%) | 30 (33%) | 73 (58%) | |
Subdural collection density | 0 (0%) | 0 (0%) | 0 (0%) | - |
Mass lesion | 9 (4%) | 0 (0%) | 9 (7%) | |
Cisternal compression | 21 (10%) | 1 (1%) | 20 (16%) | |
Midline shift | 7 (3%) | 0 (0%) | 7 (6%) | 0.057 |
Any intracranial abnormality | 133 (62%) | 33 (36%) | 100 (80%) | |
Marshall CT Score (IQR) | 2 (1-2) | 1 (1-2) | 2 (2-2) | |
Rotterdam CT Score (IQR) | 2 (2-3) | 2 (2-2) | 2 (2-3) |
The median length of stay for pediatric TBI patients was 2 (IQR 1-4) days in the admission stratum and 10 (IQR 5-24) days in the ICU stratum. An emergency intracranial surgery was performed in 15% of ICU patients while 18% underwent emergency extracranial surgery. One-third of all ICU patients required emergency or non-emergency intracranial surgery during their entire hospital stay (this included placement of intracranial pressure monitoring devices). This differed significantly from patients in the admission stratum where no emergency intracranial surgery (
Clinical status, hospital course, and outcome of pediatric TBI patients in the admission and ICU stratum of the CENTER-TBI core study.
AVPU | ||||
- Alert | 115 (51%) | 80 (84%) | 35 (27%) | |
- Verbal | 23 (10%) | 12 (13%) | 11 (8%) | |
- Pain | 20 (8%) | 1 (1%) | 19 (14%) | |
- Unresponsive | 60 (26%) | 1 (1%) | 59 (45%) | |
- Unknown | 9 (4%) | 1 (1%) | 8 (6%) | |
GCS (IQR) | 14 (10-15) | 15 (15-15) | 11 (6-14) | |
GCS – motor (IQR) | 6 (5-6) | 6 (6-6) | 5 (1-6) | |
Pupillary response | ||||
- Both reactive | 205 (92%) | 92 (100%) | 113 (86%) | |
- One reactive | 5 (2%) | 0 (0%) | 5 (4%) | |
- Both unreactive | 13 (6%) | 0 (0%) | 13 (10%) | |
Vomiting | 28 (14%) | 17 (21%) | 11 (10%) | |
Signs of facial fractures | 16 (8%) | 2 (3%) | 14 (12%) | |
Facial contusion | 19 (10%) | 6 (8%) | 13 (11%) | 0.512 |
Signs of head/skull trauma | 61 (31%) | 14 (18%) | 47 (41%) | |
Signs of skull base trauma | 21 (11%) | 2 (3%) | 19 (17%) | |
Alteration of Consciousness | 35 (18%) | 10 (13%) | 25 (22%) | 0.136 |
Loss of consciousness | 76 (39%) | 36 (45%) | 40 (35%) | 0.214 |
Seizures | 6 (3%) | 1 (1%) | 5 (4%) | 0.412 |
Post-traumatic amnesia <4 h | 3 (2%) | 3 (4%) | 0 (0%) | 0.136 |
Headaches | 26(13%) | 20 (25%) | 6 (5%) | |
Neurological deficit | 16 (8%) | 2 (3%) | 14 (12%) | |
Length of stay | 5 (2-13) | 2 (1-4) | 10 (5-24) | |
Emergency intracranial surgery | 20 (10%) | 0 (0%) | 20 (15%) | |
Emergency extracranial surgery | 25 (11%) | 2 (2%) | 23 (18%) | |
Intracranial surgery | 47 (21%) | 3 (3%) | 44 (33%) | |
Extracranial surgery | 45 (20%) | 7 (7%) | 38 (28%) | |
GOSE at six months (IQR) | 7 (6-8) | 8 (7-8) | 6 (5-8) | |
Mortality | 6 (3%) | 0 (0%) | 6 (5%) | 0.099 |
Unfavorable outcome (GOSE 1-4) at 6 months | 20 (10%) | 1 (1%) | 19 (16%) |
Multivariate logistic regression analysis to unfavorable outcome (GOSE 1-4) in pediatric TBI patients in the admission and ICU stratum of the CENTER-TBI core study.
Age | 0.030 | 0.738 | 0.543 (0.020-11.529) |
Gender | −0.884 | 0.248 | 1.030 (0.871-1.241) |
RTI | 0.472 | 0.599 | 0.413 (0.086-1.851) |
GCS | −0.378 | <0.001 | 0.686 (0.535-0.833) |
Total ISS | 0.014 | 0.625 | 1.014 (0.958-1.075) |
Secondary insult | 3.081 | <0.001 | 21.782 (4.137-160.287) |
Notably, 50 patients with mild TBI (GCS 13–15) were admitted to the ICU. Accidents in those patients were more commonly set in streets/highways when compared to patients with mild TBI in the admission stratum (58 vs. 39%;
Severe TBI (GCS 3–8) occurred in 46 patients all of whom were subsequently admitted to the ICU. An unfavorable outcome was reported in 13 of 43 patients (30%) with severe TBI and available GOSE at 6 months (
Comparison of pediatric severe TBI patients with favorable or unfavorable outcome in the CENTER-TBI core study.
Age (IQR) | 15 (9-16) | 15 (8-16) | 15 (10-17) | 0.717 |
Sex | 0.108 | |||
- Female | 17 (37%) | 7 (23%) | 7 (54%) | |
- Male | 29 (63%) | 23 (77%) | 6 (46%) | |
Injury cause | 0.056 | |||
- Road traffic incident | 28 (61%) | 16 (53%) | 9 (69%) | |
- Incidental fall | 10 (22%) | 10 (33%) | 0 (0%) | |
- Other non-intentional injury | 7 (15%) | 4 (13%) | 3 (23%) | |
- Violence | 0 (0%) | 0 (0%) | 0 (0%) | |
- Other/Unknown | 1 (2%) | 0 (0%) | 1 (8%) | |
Injury road incident | 0.930 | |||
- Motor vehicle occupant | 7 (25%) | 4 (25%) | 2 (22%) | |
- Pedestrian | 7 (25%) | 3 (19%) | 3 (33%) | |
- Cyclist | 6 (21%) | 3 (19%) | 2 (22%) | |
- Scooter | 3 (11%) | 2 (13%) | 1 (11%) | |
- Motor Bike | 4 (14%) | 3 (19%) | 1 (11%) | |
- Other | 1 (4%) | 1 (6%) | 0 (0%) | |
Safety helmet (cyclist, scooter, motor bikers) | 0.301 | |||
- Yes | 6 (46%) | 4 (50%) | 2 (50%) | |
- No | 6 (46%) | 4 (50%) | 1 (50%) | |
- Unknown | 1 (8%) | 9 (0%) | 1 (25%) | |
Total ISS (IQR) | 34 (25-48) | 29 (21-49) | 41 (34-57) | |
GCS (IQR) | 5 (3-7) | 6 (3-7) | 4 (3-6) | 0.157 |
GCS motor (IQR) | 2 (1-4) | 3 (1-5) | 2 (1-4) | 0.694 |
Pupillary response | 0.342 | |||
- Both reactive | 36 (78%) | 25 (83%) | 9 (69%) | |
- One reactive | 2 (4%) | 1 (3%) | ||
- Both unreactive | 8 (17%) | 4 (13%) | 4 (31%) | |
Secondary Insult: Hypoxia | 7 (15%) | 0 (0%) | 6 (46%) | |
Secondary Insult: Hypotension | 7 (15%) | 1 (3%) | 6 (46%) | |
Secondary Insult: Cardiac arrest | 3 (7%) | 0 (0%) | 3 (23%) | |
Secondary Insult: Hypothermia | 6 (13%) | 2 (7%) | 4 (31%) | |
Secondary Insult: Seizures | 5 (11%) | 3 (10%) | 2 (15%) | 0.836 |
Length-of-stay (IQR) | 28 (10-43) | 28 (10-42) | 29 (6-59) | 0.814 |
GOSE at 6 months (IQR) | 6 (4-7) | 7 (6-8) | 3 (1-3) |
Secondary insults at admission in patients with favorable (GOSE 5–8) and unfavorable (GOSE 1–4) outcome at six months.
The CENTER-TBI registry was used to compare the 227 pediatric TBI patients in the core dataset with a substantially larger cohort of 687 pediatric TBI patients in the registry dataset and confirm key findings regarding injury causes and severity (
Comparison of patient characteristics between the CENTER-TBI core vs. registry datasets.
Number of patients | 227 | 687 | 95 | 423 | 132 | 264 |
Age (IQR) | 14 (8-16) | 12 (4-16) | 13 (9-16) | 12 (5-16) | 14 (8-16) | 12 (4-16) |
Sex | ||||||
- Female | 81 (36%) | 246 (36%) | 32 (34%) | 147 (35%) | 49 (37%) | 99 (38%) |
- Male | 146 (64%) | 441 (64%) | 63 (66%) | 276 (65%) | 83 (63%) | 165 (62%) |
Injury Place | ||||||
- Street | 118 (52%) | 298 (42%) | 38 (40%) | 169 (38%) | 80 (61%) | 129 (49%) |
- Home | 40 (18%) | 192 (28%) | 19 (20%) | 126 (30%) | 21 (16%) | 66 (25%) |
- Work/School | 14 (6%) | 4 (1%) | 7 (7%) | 3 (1%) | 7 (5%) | 1 (0%) |
- Sport | 40 (18%) | 72 (10%) | 21 (22%) | 56 (13%) | 19 (14%) | 16 (6%) |
- Public | 11 (5%) | 96 (14%) | 8 (8%) | 69 (4%) | 3 (2%) | 36 (14%) |
- Other | 2 (1%) | 31 (5%) | 0 (0%) | 16 (4%) | 2 (2%) | 15 (6%) |
- Unknown | 2 (1%) | 3 (0%) | 2 (2%) | 2 (0%) | 0 (0%) | 1 (0%) |
Injury Cause | ||||||
- RTI | 110 (48%) | 282 (41%) | 33 (35%) | 152 (36%) | 77 (58%) | 130 (49%) |
- Fall | 78 (34%) | 276 (40%) | 41 (43%) | 184 (43%) | 37 (28%) | 92 (35%) |
- Other | 39 (17%) | 129 (19%) | 21 (22%) | 87 (21%) | 18 (14%) | 42 (16%) |
GCS (IQR) | 14 (10-15) | 15 (13-15) | 15 (15-15) | 15 (14-15) | 11 (6-14) | 12 (7-15) |
GCS – motor (IQR) | 6 (5-6) | 6 (6-6) | 6 (6-6) | 6 (6-6) | 5 (1-6) | 6 (4-6) |
AIS Brain Injury (IQR) | 4 (3-4) | 3 (2-4) | 3 (3-3) | 2 (1-3) | 4 (4-5) | 4 (3-5) |
ISS (IQR) | 18 (10-32) | 13 (9-22) | 10 (9-17) | 10 (5-13) | 26 (17-41) | 25 (16-38) |
Pupillary response | ||||||
- Both reactive | 205 (92%) | 619 (94%) | 92 (100%) | 403 (99%) | 113 (86%) | 216 (85%) |
- One reactive | 5 (2%) | 20 (3%) | 0 (0%) | 5 (1%) | 5 (4%) | 15 (6%) |
- Both unreactive | 13 (6%) | 23 (3%) | 0 (0%) | 0 (0%) | 13 (10%) | 23 (9%) |
CT Brain: Any intracranial abnormality | 133 (59%) | 318 (49%) | 33 (35%) | 115 (30%) | 100 (76%) | 203 (77%) |
Traumatic brain injury in children is a very serious condition that can lead to lifelong disability but still presents as a scientific field with a general lack of research and evidence (
Road traffic incidents were the most common injury causes overall (admission and ICU stratum) ahead of incidental falls, which is in line with previous reports (
Brain CT imaging in the young patients in our analysis allowed insights into common pathologies behind pediatric TBI. The most common finding hereby was traumatic subarachnoid hemorrhage which is a relevant diagnosis in children as its complications include hydrocephalus and cerebral vasospasms (
Because TBI patients within the CENTER-TBI study were stratified into different strata upon enrollment, analysis of the data offers the opportunity to directly compare pediatric TBI patients treated in different hospital settings, in particular patients treated on the regular ward vs. the ICU. We found, as expected, considerable differences in injury cause and severity between the admission and ICU stratum. While patients requiring intensive care were more often involved in road-traffic incidents, incidental falls were the most common cause in patients in the admission stratum. Injury severity was in general significantly higher in ICU patients, as indicated by higher ISS and GCS scores, and prevalence of concurrent injuries in other body regions, especially thorax and abdomen, was greater. Notably, more than three quarters of patients also suffered from other body injuries, emphasizing the importance of a general and extensive clinical examination in pediatric TBI patients. A total of 61% of pediatric patients in our cohort were classified as mild TBI. Interestingly, 36% of them were admitted to the ICU. While this finding corresponds to the number of mild TBI patients admitted to the ICU in the adult CENTER-TBI patient population (36%), discussed reasons such as advanced age, comorbidities or antithrombotic drugs which might increase the risk for lesion progression are not applicable for the pediatric patients assessed in our study (
Severe TBI was present in 22% of all patients in our cohort of pediatric TBI. As expected, all of those patients were treated in the ICU with an injury so grave that emergency intracranial surgery had to be performed in 4 of 46 patients (9%). An unfavorable outcome was reported in 30% of pediatric severe TBI patients in our cohort, showing associations with road traffic incidents, lower GCS at presentation as well as the occurrence of secondary injury insults such as hypotension at admission. The high prevalence of road-traffic incidents in children with severe TBI and an unfavorable outcome emphasizes the need and potential for more preventive efforts.
Considering the overall outcome in our cohort of pediatric TBI patients, a GOSE score of 7 or 8 could be observed in 64% of cases. However, an unfavorable outcome (GOSE 1-4) was still present in 10% of pediatric TBI patients which is comparable to numbers from single-center studies reported from India (10%) and the United States (16%) (
Despite a relatively high injury severity, mortality was still rather low in the overall pediatric CENTER-TBI cohort assessed in our study (3%) as well as in the group of pediatric severe TBI patients (9%) and thus lower than in the overall CENTER-TBI cohort that includes predominately adult patients (14.9% for patients admitted to the regular ward or ICU) (
Nevertheless, alarming numbers have very recently been published concerning age-adjusted TBI mortality for patients aged 0–19 years in the US: Despite an initial decline from 1999 to 2012, pediatric TBI mortality has been raising again since 2013 (
With the findings in the CENTER-TBI core study and their validation in the CENTER-TBI registry, our analysis displays the most common injury causes of pediatric TBI in Europe at present. Also, it confirms known predictors for an unfavorable outcome after TBI in children. While neurosurgeons, pediatricians, and other health practitioners should be especially aware of the risks associated with secondary insults, legislators are reminded that further preventive efforts such as advertising the use of safety helmets or building safer infrastructure might still be needed to reduce the incidence of severe TBI.
TBI in pediatric patients within the CENTER-TBI study that were admitted to the regular ward or ICU were most commonly caused by road-traffic incidents and incidental falls. Injury severity was serious especially in ICU patients and concurrent injuries in other body parts were common. GCS and the occurrence of secondary insults were identified as predictors for an unfavorable outcome (GOSE 1–4) at six months follow-up. The current analysis suggests, that preventive efforts could still be very effective in decreasing the incidence of TBI.
There are several limitations to this analysis. Recruitment to the CENTER-TBI core study was conducted at the discretion of the participating centers and thus influenced by local logistics and academic interests which might be a potential source of selection bias. Because of data anonymization reasons, no information on the specific countries where the TBI patients were recruited can be obtained from the CENTER-TBI database. The data used for our analyses might, therefore, be derived from only a subset of countries and the results should be generalized with caution. Moreover, although the CENTER-TBI study included pediatric as well as adult patients, the participating centers were mainly general hospitals and not specialized pediatric centers and might thus not have primarily managed pediatric TBI in some regions or countries. Because data on the type of ICU is not available within the CENTER-TBI database, a possible bias from the treatment of pediatric patients in specialized ICUs cannot be ruled out. In addition, not all participating centers enrolled pediatric patients. This might be the reason why pediatric TBI was underrepresented in comparison to adult TBI in the CENTER-TBI study. While we can therefore not comment on the absolute incidence of pediatric TBI in Europe, we still provide a large multi-center pediatric patient cohort that can give important insights into injury causes and patterns. Furthermore, although the data were prospectively collected, missing data was still present especially regarding to long-term outcomes with GOSE ratings being only available for 90% of patients.
The datasets generated for this study are available on request to the corresponding author and with permission of the CENTER-TBI management committee.
The CENTER-TBI study is compliant with all relevant EU- and national laws of recruiting centers in regard to privacy, data protection and ethical standards and in accordance with the Declaration of Helsinki (“Ethical Principles for Medical Research Involving Human Subjects”). Informed consent was obtained from all patients and/or their legal representatives, according to the local legislations, included in this study. Ethical approval was obtained for each recruiting site (see
LR and AY designed the study, conducted the data analysis, interpreted the data, and co-wrote the manuscript. KZ, AU, and AE helped with data interpretation and critically revised the manuscript.
The authors declare that the research was conducted in the absence of any other commercial or financial relationships that could be construed as a potential conflict of interest.
We thank Julia Mattern and Madlen Rädel for their help with the local organization of the CENTER-TBI study at Heidelberg University Hospital.
The Supplementary Material for this article can be found online at: