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Clinicoradiological and therapeutic considerations in severe diffuse traumatic brain injury in children
E P Sganzerla1, G Tomei, P Guerra
1Istituto di Neurochirurgia, Università degli Studi di Milano, Italy.
Insights
Severe head injuries in children can lead to diffuse brain swelling (DBS) or diffuse axonal injury (DAI). DBS correlates with high mortality due to increased intracranial pressure (ICP), while DAI has a better prognosis.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Neuroradiology
Background:
- Severe head injuries in children present complex challenges in diagnosis and management.
- Distinguishing between different types of diffuse brain lesions is crucial for predicting outcomes.
Purpose of the Study:
- To analyze the correlation between specific intracranial lesion patterns on CT scans and patient outcomes in children with traumatic coma.
- To determine the role of intracranial pressure (ICP) monitoring in managing severe head injuries.
Main Methods:
- Retrospective study of 41 children with severe head injuries and diffuse brain lesions from a series of 62 children in traumatic coma.
- Classification of intracranial lesions into diffuse axonal injury (DAI) and diffuse brain swelling (DBS) based on CT findings.
- Correlation of CT patterns, ICP levels, and clinical outcomes, including mortality.
Main Results:
- High mortality was associated with severe diffuse brain swelling (DBS), absence of perimesencephalic cisterns, and obliterated ventricles, often due to secondary increases in intracranial pressure (ICP).
- Children with normal CT scans or diffuse axonal injury (DAI) showed favorable outcomes, with no mortality if ICP was not elevated.
- The presence of subarachnoid hemorrhage, respiratory, or circulatory failure exacerbated poor outcomes in DBS cases.
Conclusions:
- Routine ICP monitoring may not be necessary for children with pure diffuse axonal injury (DAI).
- Early ICP monitoring and aggressive management are recommended for comatose children with diffuse brain swelling (DBS), particularly when complicated by other factors.
- CT findings are critical in stratifying risk and guiding management decisions for pediatric head injuries.
Abstract:
Forty-one children with severe head injuries and diffuse brain lesions were selected from a consecutive series of 62 children in traumatic coma (21 focal mass lesions) and studied. According to the CT pattern, two main types of intracranial lesions were considered: diffuse axonal injury (DAI) and diffuse brain swelling (DBS). High mortality, due to secondary increases of intracranial pressure (ICP), correlated well with the patterns of severe DBS, absence of perimesencephalic cisterns, and obliteration of the ventricles. However, children with normal CTs, and/or obvious shearing injuries indicative of DAI, had favorable outcomes; there was no mortality if increased ICP was not present. We conclude that although there does not seem to be any routine indications for ICP monitoring in children with pure DAI, early ICP monitoring and aggressive management of increasing ICP should be considered in comatose children with DBS, especially when associated with subarachnoid hemorrhage and respiratory or circulatory failure.