During the study period, 987 cases of TBI were admitted at the emergency department of GHD, 103 cases were children giving a prevalence of 10.43% for PTBI. The PTBI patients comprised 75 boys and 28 girls, sex ratio, 2.67. Figure 1 gives the age distribution of the patients. The mean age was 7.42 ± 5.028 years (median, 6 years, and range, 1 to 15 years).

Table 3 summarizes the general features of the study population. The first mode of injury was the RTA in 44.66% of the cases. The transport from injury site to the hospital was done by non-medical means in most cases. The loss of consciousness at the time of injury was the most frequent clinical manifestation

To obtain the GCS score, eye opening, verbal and motor responses points are added to each other. Minimum = 3; maximum = 15. ^§: conversation is possible, but signs of mental confusion are noticed. *: comprehensible words, but conversation is not possible. ^#: incomprehensible sounds such as grunting.

in 48.54%. Figure 2 is a clinical example of an 11 years old boy who sustained a moderate TBI with a massive depressed skull fracture with sagittal and lambdoid sutures dislocation.

All patients but one had a brain CT scan (99%), five, a skull and two a cervical spine X-ray. Table 3 shows the lesions found on CT. The most radiological finding was post-traumatic cerebral edema.

The management (Table 3) has consisted in medical treatment in all cases and surgery in 28. Paracetamol was administered to all but one patients (99%), 3^rd generation cephalosporin (mainly ceftriaxone) to 83 (80.60%), and Mannitol infusion to 52 (50.50%).

The overall mortality was 3.88% with 4 deaths. Ninety-three (90.28%) patients recovered fully and six (5.82%) had mild to moderate disability. The persisting

GCS: Glasgow coma scale. *: time interval between trauma and admission. ^§: for removal of intracranial hematomas or depressed skull fractures. ^#: hemiparesis, one case; chronic headaches, five cases. TBI: traumatic brain injury.

disability consisted in hemiparesis in one case and chronic headaches in four. It is only the GCS score at admission which significantly influenced the outcome (Table 4). The time interval between trauma and arrival at the hospital, gender, age, and the treatment modality did not have an impact on the outcome.

The age distribution of children who sustained TBI varies amongst series. In the present series, children aged between 0 and 5 years were the most involved, followed by those between 11 and 15 years of age. This finding is similar to data reported by other authors [1] [4] [7] [17] [18].

The male predominance for TBI even in children is unanimously reported from the literature suggesting that males and hence boys, are more exposed to activities at risk for TBI [1] [6] [7] [10] [12] [13] [14] [17] [18]. In the present series, boys represented 73% of children who sustained a TBI.

The falls are the 1^st mode of injury for pediatric TBI, mainly before six years of age, followed by road traffic accidents [1] [6] [10] [12] [17] [18]. In this series, the RTA was the first mechanism of injury accounting for 44.7% of PTBI and falls were second with 40.8%. The motorcycles were involved in most of the RTA because motorcycles are the main mean of transport in the Douala city area.

Most TBI are mild both in children and adults. This is consistent with findings from this series in which 61.20% of PTBI were mild (GCS 13 to 15). The predominance of mild and moderate TBI in children can be explain by many factors: in children up to two years of age, the skull is deformable and can absorb shock better than adult skull; most accidents occur at home and are therefore low-energy injuries; parents may be more worried even in cases of light blow and may be more prone to bring children to the hospital [16].

Concerning the clinical findings, the initial loss of consciousness was the most common symptom observed in 50 (48.50%) children, and this finding was consistent with reported data [12] [13] [14]. Vomiting was observed in 36.90% of cases from this series. Vomiting is frequent in pediatric TBI but, in the presence of consciousness alteration, it can cause inhalation and lead to inhalation pneumonia which can worsen the prognosis. Seizures’ frequency (27.20%) in this series was higher compared to data from other authors. Headaches are common in TBI and can persist long after the injury and spoil the child life. Its frequency varies from 9% to 72% according to [5] [18] [19]. Headaches were found in 31 (30.10%) of our children and four of them were disabled by chronic persisting headaches. The scalp wounds are also frequent in TBI. They can range from pin-point wound to huge scalp avulsions. Their frequency varies amongst series. Forty-three (41.70%) children of this series had a wound of the scalp. The time interval between the TBI and admission at the emergency department of GHD was more than 48 hours in 47.6% (48) of the cases. This reflects the fact that the General Hospital, Douala is a tertiary referral health institution and therefore, children were transported primarily to other health facilities. This was corroborated by the fact that 83.5% of children of this series were referred to GHD in second intention. But, this did not have a significant impact on the outcome.

The CT scanning of the head is the imaging tool of 1^st intention for patients with TBI [5] [10] [12] [13] [14]. The CT scanning of the head was done in 99% (102/103) of the cases in this series. The most common findings were cerebral edema, linear and depressed skull fractures, and the acute subdural hematomas.

In this series, 22 patients (21.36%) needed a craniotomy for intracranial hematomas or depressed skull fractures and six had sutured scalp wounds. Therefore, the prevalence for post-traumatic intracranial lesions requiring surgery was 13.59% (14 children). In the series from O’Lynnger et al. 20 to 32% of children with severe TBI needed a neurosurgical operation [11]. In 2009, Kuppermann et al. [20] have found that, for 42,412 children admitted in hospitals in the USA, 0.9% had significant post-traumatic intracranial lesions and only 0.1% were operated. This discrepancy with our results can be explained by a selection bias from our series since its study population was withdrawn from head trauma patients and not from global pediatric admissions.

TBI can be detrimental on a developing brain with a negative impact on school performance and family functioning with a high economic cost, and this is particularly true for severe TBI in which mortality can reach 20% with 50% unfavorable outcome at six-month [6]. Long-term neurocognitive assessment of children who sustained a TBI has shown cognitive, emotional and behavioral impairment in a significant number [5] [8] [9] [15] [16] [21]. Nevertheless, most children who have sustained a TBI will recover fully (Table 4). This was consistent with this series where 90.28% of children recovered fully. One child was moderated disabled (hemiparesis) and four complained of chronic headaches. The mortality was also low and consistent with data from the literature [1] [6] [8] [9] [10] [15] [16] [19] [21]. Age, gender, treatment modality (surgery or not), and time interval between trauma and admission to the hospital did not influence the outcome, but the admission GCS score (trauma severity) did. In the present series, the mortality and persisting disabilities were significantly higher in children with severe TBI than those with mild or moderate TBI. The mortality for mild and moderate TBI was 2.06% (2 deaths out of 97 children), while that of severe TBI was 33.33% (2 deaths out of 6 patients); the prevalence of persisting disability was 5.26% in the survivors with mild and moderate TBI (5/95), and 25% in survivors with severe TBI (1/4), p value = 0.001. But it is established that the time elapsed from trauma to treatment favors secondary brain insults and influence the outcome, but this was not the case in this pediatric series. The good prognosis in this series can also be explain by the high proportion of mild and moderate PTBI (97; 94.17%) compared to severe ones (6; 05.82%).