Early clinical signs and prognosis in children with brain injuries

The outcome of 76 brain-injured children treated at the Department of Neurosurgery, Kuopio University Central Hospital, Kuopio, Finland, during 1980-83 was analyzed to determine the prognostic value of early clinical signs and investigations. Five (8%) of the children died. The coma level (Glasgow Coma Score, GCS) was below 9 in 24 children, four (17%) of whom died. Three of these deaths occurred very early, during or soon after the computerized tomography (CT) study and in these cases aggressive treatment was withheld. There were actually no deaths in children with GCS of 6-8 and one death due to severe intra-abdominal injury in 52 children with GCS of 9-14. Seventeen (22%) of the children had multiple injuries. Fourteen children had significant intracranial hematoma or depressed skull fracture requiring surgical treatment, and all of these children did well. The intraventricular pressure was measured in 11 children with GCS of 3-5, all under controlled respiration. Six children had increased intracranial pressure (ICP), above 20 mmHg. In one child the pressure could not be managed, and she died. CT gave very important prognostic information. All children who died of early uncontrollable ICP already had marked hemorrhagic lesions in the basal cisterns, hypodense areas in the brain stem or brain stem compression. Early and repeated CT to show the complications and aggressive intensive care with intracranial pressure recording in children with GCS of 3-5 can keep the mortality associated with severe brain injury below 20% with an acceptable level of survival.