Predicting persistent postconcussion symptoms with a clinical risk score

1. In children presenting to an emergency department within 48 hours of an acute head injury, persistent postconcussion symptoms (PPCS) were present in 31% of patients.

2. A clinical risk score with 9 variables had modest discrimination to stratify PPCS risk at 28 days, with an area under the curve of 0.71.

Evidence Rating Level: 2 (Good)

Study Rundown: Concussion is a rising public health concern among children presenting to emergency departments. While many children stop experiencing symptoms within 2 weeks of a concussion, about a third of children have ongoing symptoms. Specifically, those symptoms persisting beyond 28 days are referred to as PPCS. The purpose of this study was to derive and validate a clinical risk score in children to stratify PPCS risk after a concussion. Among more than 2500 children who presented within 48 hours of an acute head injury and completed follow-up at 28 days, 801 (31%) had PPCS. During initial presentation, several variables were identified that were associated with an increased risk of developing PPCS, including female sex, age 13 years or older, fatigue, sensitivity to noise, headache, physician-diagnosed migraines, prior concussion with symptoms lasting longer than a week, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. Each patient could score a total of 12 points in the model. Low risk patients (<3 points) had a negative likelihood ratio of 0.36, and high risk patients (>9 points) had a positive likelihood ratio of 3, leading to an area under of the curve of 0.68.

In aggregate, the clinical risk score provided modest discrimination in stratifying PPCS risk at 28 days, thus allowing higher risk individuals to be identified and treated as early as possible. This study allows for generalizability given that participants had a wide age range and spectrum of injuries. However, there may have been selection bias in this study as children with concussions warranting emergency department care may be more likely to develop PPCS as compared to children with more mild concussions who did not present to a hospital.

Click to read the study in JAMA

Relevant Reading: Emergency department visits for concussion in young child athletes.

In-Depth [prospective cohort]: This prospective, multicenter cohort study recruited children ages 5 to 18 from 9 pediatric emergency departments within Canada between 2013 and 2015. In total, 2584 patients who presented within 48 hours of an acute head injury and who followed-up 28 days later were enrolled in both a derivation and validation cohort. There were 510 participants (30%) meeting criteria for PPCS in the derivation cohort, and 291 patients (33%) meeting criteria in the validation cohort. The variables included in the PPCS risk score model included female sex, age 13 years or older, fatigue, sensitivity to noise, headache, physician-diagnosed migraines, prior concussion with symptoms lasting longer than a week, answering questions slowly, and 4 or more errors on the Balance Error Scoring System tandem stance. The clinical risk score had modest discrimination to stratify PPCS risk at 28 days, with an area under the curve of 0.71 (95%CI 0.69-0.74) for the derivation cohort and 0.68 (95%CI 0.65-0.72) for the validation cohort.

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