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Adequate control of intracranial pressure best predicts survival in pediatric traumatic brain injury, research suggests

Tuesday, October 07 2008 | Comments

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What's This? In pediatric patients with severe traumatic brain injury (TBI), patient survival appears to depend on controlling elevated intracranial pressure (ICP), irrespective of the means of achieving control, based on the findings of a recently published review.

Researchers analyzed data for 96 patients aged 3 to 18 years (mean age, 15.1 years; 74% male) who had sustained a TBI and were admitted to a single hospital between 1995 and 2006. Each of the patients had an abnormal computed tomography (CT) scan at presentation and refractory raised ICP (sustained elevation >20 mm Hg during the first hour after placement of an ICP monitor). The mean preintervention Marshall grade for these patients was 4 (range, 2-4).

Subarachnoid hemorrhage was present in 65 of the initial CT scans (68%), and diffuse axonal injury was observed on 48 (50%). Forty-four of the patients (46%) presented with contusions and 44 had skull fractures. Subdural hemorrhage was present in 22 of the patients (23%) and epidural hematoma was seen in 5 patients (5%). Presenting CT scans showed evidence of midline shift in 40 patients (42%), cisternal effacement in 25 (26%), and infarction in 4 (4%). Presenting scans demonstrated that 84 of the patients (88%) had >=2 radiographic abnormalities, 70 (73%) had >=3 abnormalities, and 11 (11%) had only 1 abnormality.

Forty-six of the patients (48%) had >=3 systemic injuries, 73 (76%) had >=2, and 2 (2%) had only one. Eighteen patients (19%) required emergency noncranial operations. The mean injury severity score was 65 (range, 30-100).

The mean time course until peak ICP was 69 hours postinjury (range, 2-196 hours). Control of ICP was achieved in 82 of the patients (85%). Medical management alone, including sedation, hyperosmolar therapy, and paralysis, was sufficient to control ICP in 34 of the patients (35%). Of the remaining patients, 23 (24%) required placement of a ventricular drain and 40 (42%) needed operative decompression, including 39 patients who failed to respond to medical management alone and 1 with an unsuccessful ventriculostomy.

Univariate and multivariate analyses indicated that severity of presenting injury, treatment modality, and peak ICP were not related to control of ICP or ultimate survival.

A total of 24 patients (25%) died during hospitalization. Fourteen of these were directly related to elevated ICP that was refractory to treatment. The patients who presented with vascular injury, refractory ICP, and cisternal effacement were the most likely to die (P<.05).

The mean follow-up period was 53 months (range, 11-126 months). During this period, 2 patients died from sepsis and 1 patient committed suicide.

The mean Glasgow Outcome Scale score at 2 years was 4 (median, 4; range, 1-5), and the mean competency rating was 4.13 out of 5 (median, 4.5; range, 1-4.8). A univariate analysis demonstrated that the extent of intracranial and systemic injuries had the best correlation with long-term quality of life (P<.05).

"Controlling elevated ICP is an important factor in patient survival following severe pediatric TBI," the study authors concluded, noting that, in their experience, refractory ICP despite medical management or surgery is almost always associated with death.

They recommended tailoring the method for controlling ICP to the individual patient, adding that long-term follow-up is necessary to determine the neurocognitive sequelae of TBI. (Jagannathan J, et al. J Neurosurg Pediatrics 2008;2:240-249.)

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