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Prognostic Factors for Pediatric Acute Encephalopathy Associated with Severe Brain Edema
Goichiro Tamura1, Takayuki Inagaki1
1Division of Pediatric Neurosurgery, Ibaraki Children's Hospital, Mito, Japan.
Insights
Cytokine storms and diffuse brain edema are key risk factors for poor outcomes in pediatric acute encephalopathy. Decompressive craniectomy (DC) may help severe cases, but its role requires further study.
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Pediatric Critical Care
Background:
- Acute encephalopathy is a severe pediatric brain dysfunction often following infection, characterized by diffuse brain edema.
- The predictive risk factors for clinical deterioration and the efficacy of decompressive craniectomy (DC) in pediatric acute encephalopathy remain unclear.
Purpose of the Study:
- To identify risk factors for clinical deterioration in pediatric acute encephalopathy.
- To evaluate the utility of a new syndromic classification and the role of DC in managing this condition.
Main Methods:
- A retrospective study analyzed pediatric patients with acute encephalopathy from 2015-2019.
- Patients were classified by preceding pathogens, a novel syndromic classification (Groups 1-3), and brain edema extent.
- Outcomes were assessed using the Glasgow Outcome Scale (GOS), with DC reserved for severe cases.
Main Results:
- Of 19 patients, 42.1% had unfavorable outcomes (GOS 1-3).
- Unfavorable outcomes were significantly higher in Group 1 (cytokine storm) (87.5%) compared to Group 2 (14.3%) and Group 3 (0%).
- Diffuse brain edema (72.7%) and cytokine storms were associated with unfavorable outcomes; DC was performed in 2 critical cases.
Conclusions:
- Cytokine storms and diffuse brain edema are significant risk factors for poor outcomes in pediatric acute encephalopathy.
- The new syndromic classification effectively stratifies patient risk.
- The role of decompressive craniectomy in pediatric acute encephalopathy warrants further investigation on a case-by-case basis.
Background And Objective:
Acute encephalopathy is a life-threatening brain dysfunction in children, often associated with a preceding infection and diffuse noninflammatory brain edema. At present, the role of decompressive craniectomy (DC) over the swollen area of the brain is unclear. The risk factors for predicting clinical deterioration also need clarification.
Methods:
A retrospective study of pediatric patients admitted between 2015 and 2019 with acute cerebral encephalopathy was carried out. Patients were classified according to: (1) the preceding pathogens, (2) the syndromic classification, and (3) the extent of brain edema. The syndromic classification is a relatively new classification of acute encephalopathy proposed in 2016 and divides patients into 3 groups: those with systemic inflammatory reactions or "cytokine storms" (group 1), those with status epilepticus but no cytokine storm (group 2), and others (group 3). Glasgow Outcome Scale (GOS) scores of 1-3 were defined as unfavorable, while a GOS score of 4 or 5 was defined as a favorable outcome in this study. DC was performed for select patients with life-threatening signs of brainstem compression.
Results:
Nineteen patients (mean age: 23.3 months) were included in the study, 8 (42.1%) of whom had an unfavorable outcome. There was no significant correlation between the types of pathogens and outcome. Unfavorable outcomes were observed in significantly more patients in group 1 (87.5%) than group 2 (14.3%) and group 3 (0%). There was a significant association between diffuse brain edema and unfavorable outcomes (72.7%). Neurosurgical DC was performed in 2 patients to alleviate life-threatening brainstem compression: one with a cytokine storm and diffuse bilateral brain edema, and the other with prolonged status epilepticus causing diffuse right-sided brain edema. The GOS score was 3 and 4, respectively.
Conclusion:
The risk factors for clinical deterioration in pediatric acute encephalopathy were evaluated based on a variety of classifications, including the new syndromic classification. Laboratory features of cytokine storms and radiological evidence of diffuse brain edema were associated with unfavorable outcomes. The role of surgical decompression is still controversial and should be assessed on a case-by-case basis.
