Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure

Clinical article

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Object

The management strategies and outcomes in pediatric patients with elevated intracranial pressure (ICP) following severe traumatic brain injury (TBI) are examined in this study.

Methods

This study was a retrospective review of a prospectively acquired pediatric trauma database. More than 750 pediatric patients with brain injury were seen over a 10-year period. Records were retrospectively reviewed to determine interventions for correcting ICP, and surviving patients were contacted prospectively to determine functional status and quality of life. Only patients with 2 years of follow-up were included in the study.

Results

Ninety-six pediatric patients (age range 3–18 years) were identified with a Glasgow Coma Scale score < 8 and elevated ICP > 20 mm Hg on presentation. The mean injury severity score was 65 (range 30–100). All patients were treated using a standardized head injury protocol. The mean time course until peak ICP was 69 hours postinjury (range 2–196 hours). Intracranial pressure control was achieved in 82 patients (85%). Methods employed to achieve ICP control included maximal medical therapy (sedation, hyperosmolar therapy, and paralysis) in 34 patients (35%), ventriculostomy in 23 patients (24%), and surgery in 39 patients (41%). Fourteen patients (15%) had refractory ICP despite all interventions, and all of these patients died. Seventy-two patients (75%) were discharged from the hospital, whereas 24 (25%) died during hospitalization. Univariate and multivariate analysis revealed that the presence of vascular injury, refractory ICP, and cisternal effacement at presentation had the highest correlation with subsequent death (p < 0.05). Mean follow-up was 53 months (range 11–126 months). Three patients died during the follow-up period (2 due to infections and 1 committed suicide). The mean 2-year Glasgow Outcome Scale score was 4 (median 4, range 1–5). The mean patient competency rating at follow-up was 4.13 out of 5 (median 4.5, range 1–4.8). Univariate analysis revealed that the extent of intracranial and systemic injuries had the highest correlation with long-term quality of life (p < 0.05).

Conclusions

Controlling elevated ICP is an important factor in patient survival following severe pediatric TBI. The modality used for ICP control appears to be less important. Long-term follow-up is essential to determine neurocognitive sequelae associated with TBI.

Abbreviations used in this paper: CPP = cerebral perfusion pressure; CSF = cerebrospinal fluid; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; IVH = intraventricular hemorrhage; PCRS = patient competency rating scale; QOL = quality of life; TBI = traumatic brain injury.

Article Information

Address correspondence to: John A. Jane Jr., M.D., Department of Neurosurgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, Virginia 22908. email: jaj2k@virginia.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flow chart summarizing the management strategies and outcomes in the study population.

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    Histogram demonstrating the relationship between injury severity scores and the time to operative decompression in patients who underwent operative treatment for elevated ICP. The mean injury severity scores (bars) were higher in patients who underwent later operative decompression. Patients who died (black circles) had higher injury severity scores than survivors (open circles).

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    Graph showing that postoperative neurological deficit was lowest in patients who had medical treatment alone when compared with those who underwent surgery or ventriculostomy. Data points represent the percentage of patients in each treatment group who had neurological deficits at follow-up.

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    Histogram showing the relationship between the presenting GCS score and the 2-year GOS score. The median 2-year GOS scores (bars) were higher in patients with a GCS score > 4 at presentation (mean 4.7, median 5) compared with patients whose presenting GCS score was ≤ 4 (mean 4.2, median 5). More deaths occurred in patients with lower GCS scores at presentation as well.

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    Graph showing the results of neurocognitive assessment revealing that patients who underwent medical management (black circles) had higher neurocognitive outcomes when compared with patients who underwent surgery (grey circles) or a ventriculostomy (open circles). The differences in ratings for daily living and cognition were statistically significant between the medical and nonmedical groups. Data points represent the average PCRS score for each treatment group according to the neurocognitive area tested.

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