Thakul Oearsakul, Thara Tunthanathip

Department of Surgery, Division of Neurosurgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand

Keywords: Brain injury, clinical prediction rules, nomogram, Traumatic brain injury


OBJECTIVES: Traumatic brain injury (TBI) in children has become the major cause of mortality and morbidity in Thailand that has had an impact with economic consequences. This study aimed to develop and internally validate a nomogram for a 6-month follow-up outcome prediction in moderate or severe pediatric TBI.

METHODS: This retrospective cohort study involved 104 children with moderate or severe TBI. Various clinical variables were reviewed. The functional outcome was assessed at the hospital discharge and at a 6-month follow-up based on the King's Outcome Scale for Childhood Head Injury classification. Predictors associated with the 6-month follow-up outcome were developed from the predictive model using multivariable binary logistic regression to estimate the performance and internal validation. A nomogram was developed and presented as a predictive model.

RESULTS: The mean age of the samples was 99.75 months (standard deviation 59.65). Road traffic accidents were the highest injury mechanism at 84.6%. The predictive model comprised Glasgow Coma Scale of 3–8 (odds ratio [OR]: 16.07; 95% confidence interval [CI]: 1.27–202.42), pupillary response in one eye (OR 7.74; 95% CI 1.26–47.29), pupillary nonresponse in both eyes (OR: 57.74; 95% CI: 2.28–145.81), hypotension (OR: 19.54; 95%: CI 3.23–117.96), and subarachnoid hemorrhage (OR: 9.01, 95% CI: 1.33–60.80). The concordance statistic index (C-index) of the model's discrimination was 0.931, while the C-index following the bootstrapping and 5-cross validation were 0.920 and 0.924, respectively.

CONCLUSIONS: The performance of a clinical nomogram for predicting 6-month follow-up outcomes in pediatric TBI patients was assessed at an excellent level. However, further external validation would be required for the confirmation of the tool's performance.

Ethics Committee Approval

All procedures performed in the study that involved studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee or both and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
The study was approved by the Human Research Ethics Committee of the Faculty of Medicine, Prince of Songkla University (REC.63 373 10 1, Date: 29.09.2020).

Author Contributions

TE: Review and editing (equal), Conceptualization (supporting). TT: Conceptualization (lead); Methodology (lead); writing – original draft (lead); formal analysis (lead).

Conflict of Interest

None Declared.

Financial Disclosure



The authors would like to offer their special thanks to Professor. Nakornchai Phuenpathom and Associate professor. Sakchai Sae heng for their advice about manuscript preparation.