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Severe traumatic coma in infancy and childhood: results after surgery and resuscitation
Insights
Severe traumatic coma in young patients (4 months-19 years) shows a 31% overall mortality. Surgical intervention for space-occupying lesions had higher mortality than resuscitation alone, with extradural hematomas and open head injuries having the lowest rates.
Area of Science:
- Neurology
- Pediatric Surgery
- Trauma Surgery
Background:
- Severe traumatic coma in pediatric and adolescent populations presents unique challenges in management and prognosis.
- Understanding outcomes based on injury type and treatment is crucial for improving patient care.
Purpose of the Study:
- To analyze recovery and mortality rates in 390 cases of severe traumatic coma in individuals aged 4 months to 19 years.
- To correlate outcomes with specific pathological lesions and clinical presentation, including duration and severity of coma.
Main Methods:
- Retrospective analysis of 390 patients with severe traumatic coma (unconsciousness > 24-48 hours).
- Categorization of patients based on surgical intervention (e.g., extradural hematoma, acute subdural hematoma, brain laceration, open head injury) versus resuscitation treatment alone.
- Evaluation of outcomes including recovery, mortality, and the development of the apallic syndrome.
Main Results:
- Overall mortality rate was 31%.
- Operated patients had a higher mortality (36.6%) compared to those receiving only resuscitation (28%).
- Extradural hematoma (25.4%) and open head injury (23%) showed the lowest mortality rates. Decerebrated coma had the highest mortality.
- 31 patients developed the apallic syndrome, with 23 recovering, 10 remarkably and 13 severely disabled.
Conclusions:
- Treatment strategies for severe traumatic coma in young individuals should consider the specific pathology.
- While surgery for space-occupying lesions can be life-saving, non-operative management with resuscitation may yield better outcomes in certain cases.
- Complete recovery is possible even after prolonged decerebration, but significant disability, including the apallic syndrome, remains a concern.
Abstract:
This study deals with 390 cases of severe traumatic coma in infancy, childhood and youth, aged between 4 months and 19 years. Cases in which unconsciousness lasted less than 24-48 hours have not been considered here. 161 patients were operated upon for intracranial space-occupying lesions or for open head injury: extradural haematomas 60; extradural haematomas + brain lacerations and/or subdural haematomas 16; acute subdural haematomas 18; brain laceration 36; open head injuries 17; decompressive operations, hydromas and contusions 14. 102 patients recovered and 59 died. 229 subjects were given only to resuscitation treatment. 164 recovered and 65 died. Recovery and mortality rate are discussed in relation to the pathologicial lesions and to the clinical picture (severity, evolution and duration of coma). Overall mortality rate was 31%. Mortality was higher in operated patients (36.6%) and lower in patients in whom space-occupying lesions were not demonstrated by angiography and who underwent only resuscitation treatment (28%). The lowest rate was observed in cases of extradural haematoma (25.4%) and open head injury (23%). Highest mortality rate have been observed in cases of decerebrated coma (with or without signs of low brain stem impairment). Complete recovery can be achieved even after prolonged decerebration. 31 patients showed the typical picture of the "apallic syndrome": in 28 cases after prolonged decerebrated coma, in 3 cases after coma without decerebration. Of our 31 cases, 4 died, 4 are still in a chronic apallic state and 23 recovered. Of these, 10 patients had a remarkable recovery and 13 remained severely disabled.