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Severe traumatic brain injury in children--a single center experience regarding therapy and long-term outcome
Ulrich-Wilhelm Thomale1, Daniela Graetz, Peter Vajkoczy
1Pediatric Neurosurgery, Charité, Campus Virchow Klinikum, Universitätsmedizin Berlin, Berlin, Germany.
Insights
Decompressive craniectomy (DC) in pediatric severe traumatic brain injury (TBI) patients may lead to comparable long-term outcomes, even with a worse initial Glasgow Coma Scale (GCS) score. Early DC is suggested for uncontrollable intracranial pressure (ICP) management in children.
Area of Science:
- Neurosurgery
- Pediatric Traumatology
- Critical Care Medicine
Background:
- Severe traumatic brain injury (TBI) in children presents complex management challenges.
- Intracranial pressure (ICP) monitoring and management are critical in pediatric TBI.
- Decompressive craniectomy (DC) is a neurosurgical intervention used to reduce elevated ICP.
Purpose of the Study:
- To examine the impact of ICP, DC, ICP therapy extent, and extracranial complications on long-term outcomes in pediatric TBI patients.
- To evaluate the effectiveness of DC in pediatric severe TBI.
- To determine optimal timing for DC in pediatric TBI management.
Main Methods:
- Retrospective review of a prospectively acquired database of pediatric TBI patients (≤16 years) from April 1996 to March 2007.
- Analysis of neurosurgical interventions, including DC, ICP therapy, and Glasgow Coma Scale (GCS) scores.
- Evaluation of 12-month and long-term outcomes using the Glasgow Outcome Scale (GOS).
Main Results:
- Fifty-three pediatric TBI patients were studied; 14 underwent DC and 39 received conservative treatment.
- The DC group had a lower initial GCS score and a longer ICU stay compared to the conservative group.
- Despite worse initial GCS, 92% of survivors who underwent DC returned to school at long-term follow-up (mean 5.2 years).
Conclusions:
- Pediatric TBI patients undergoing DC showed comparable long-term outcomes to those treated conservatively, despite worse initial GCS scores.
- Early decompressive craniectomy (within 2 days) may be beneficial for managing uncontrollable ICP in children.
- DC is a viable option for severe pediatric TBI, potentially improving long-term functional recovery.
Object:
The impact of intracranial pressure (ICP), decompressive craniectomy (DC), extent of ICP therapy, and extracranial complications on long-term outcome in a single-center pediatric patient population with severe traumatic brain injury (TBI) is examined.
Methods:
Data of pediatric (≤16 years) TBI patients were retrospectively reviewed using a prospectively acquired database on neurosurgical interventions between April 1996 and March 2007 at the Charité Berlin. The patients' records, neuroimages, admission Glasgow Coma Scale (GCS) score, the time to craniectomy for hematoma evacuation/DC, and the extent of ICP therapy were reviewed. Twelve-month and long-term outcome was evaluated (Glasgow Outcome Scale).
Results:
Fifty-three pediatric TBI patients [mean age 8.41 (0-16) years] were studied. Patients were categorized into two groups, with DC (n = 14) and without DC (n = 39). DC was performed 3 ± 3.98 median, quartiles 2 (0-3.75) days post-trauma. In the majority of children (n = 9; 64%), surgical decompression was performed early within 2 days post-trauma. (0.8 ± 0.9 days). The DC group tended to be older (median age 12 vs. 7 years, p = 0.052), had a lower GCS (3 vs. 6.5, p < 0.01), and had a 3-fold longer stay on the ICU (20 vs. 6.5 days, p < 0.03) compared to the conservatively treated group. Mean follow-up duration (n = 30) was 5.2 ± 2.4 years (range 1-10.5). At the most recent follow-up examination, 92% of survivors had returned to school.
Conclusion:
Though initial GCS was worse in pediatric TBI patients who underwent decompressive craniectomy compared to the conservatively treated patients, long-term outcome was comparable. In children, decompressive craniectomy might be favored early in the management of uncontrollable ICP.
