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Published on: August 16, 2019
Clinical Characteristics and Outcomes of Children with Acute Catastrophic Brain Injury: A 13-Year Retrospective
Kerri L LaRovere1, Bradley J De Souza2, Eliza Szuch3
1Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA. kerri.larovere@childrens.harvard.edu.
Insights
Most children with acute catastrophic brain injury (CBI) die within a month. Traumatic brain injury etiology improved survival, while higher organ dysfunction scores increased mortality risk. Some survivors regained function without technology dependence.
Area of Science:
- Pediatric Critical Care Medicine
- Pediatric Neurology
- Neurocritical Care
Background:
- Acute catastrophic brain injury (CBI) in children presents significant mortality and morbidity.
- Understanding clinical characteristics and outcomes is crucial for improving care.
Purpose of the Study:
- To describe and analyze clinical characteristics and outcomes in pediatric patients with acute catastrophic brain injury (CBI).
Main Methods:
- Retrospective cohort study of 106 children in pediatric and cardiac intensive care units over 13 years (2008-2020).
- CBI defined by acute neurologic injury, need for life-sustaining therapies, and poor Glasgow Coma Scale score at discharge.
- Multivariable Cox proportional hazard models analyzed factors associated with death.
Main Results:
- 81% of children with CBI died, with withdrawal of life-sustaining therapies being the most common cause.
- Increased pediatric sequential organ failure assessment (pSOFA) score on admission correlated with a higher hazard of death.
- Traumatic brain injury etiology was associated with greater survival compared to other causes of CBI.
Conclusions:
- Most pediatric CBI cases result in death within one month; traumatic brain injury is a favorable prognostic factor.
- Higher admission pSOFA scores predict increased mortality risk in pediatric CBI.
- Survivors may achieve significant functional and cognitive recovery, highlighting the need for further research into long-term outcomes and predictive factors.
Background:
The purpose of this study was to describe and analyze clinical characteristics and outcomes in children with acute catastrophic brain injury (CBI).
Methods:
This was a single-center, 13-year (2008-2020) retrospective cohort study of children in the pediatric and cardiac intensive care units with CBI, defined as (1) acute neurologic injury based on clinical and/or imaging findings, (2) the need for life-sustaining intensive care unit therapies, and (3) death or survival with a Glasgow Coma Scale score < 13 at discharge. Patients were excluded if they were discharged directly to home < 14 days from admission or had a chronic neurologic condition with a baseline Glasgow Coma Scale score < 13. The association between the primary outcome of death and clinical variables was analyzed by using Kaplan-Meier estimates and multivariable Cox proportional hazard models. Outcomes assessed after discharge were technology dependence, neurologic deficits, and Functional Status Score. Improved functional status was defined as a change in total Functional Status Score [Formula: see text] 2.
Results:
Of 106 patients (58% boys, median age 3.9 years) with CBI, 86 (81%) died. Withdrawal of life-sustaining therapies was the most common cause of death (60 of 86, 70%). In our multivariable analysis, each unit increase in admission pediatric sequential organ failure assessment score was associated with 10% greater hazard of death (hazard ratio 1.10, 95% confidence interval 1.04-1.17, p < .01). After controlling for admission pediatric sequential organ failure assessment scores, compared with those of patients with traumatic brain injury, all other etiologies of CBI were associated with a greater hazard of death (p = .02; hazard ratio 3.76-10). The median survival time for the cohort was 22 days (95% confidence interval 14-37 days). Of 23 survivors to hospital discharge, 20 were still alive after a median of 2 years (interquartile range 1-3 years), 6 of 20 (30%) did not have any technology dependence, 12 of 20 (60%) regained normal levels of alertness and responsiveness, and 15 of 20 (75%) had improved functional status.
Conclusions:
Most children with acute CBI died within 1 month of hospitalization. Having traumatic brain injury as the etiology of CBI was associated with greater survival, whereas increased organ dysfunction score on admission was associated with a higher hazard of mortality. Of the survivors, some recovered consciousness and functional status and did not require permanent technology dependence. Larger prospective studies are needed to improve prediction of CBI among critically ill children, understand factors guiding clinician and family decisions on the continuation or withdrawal of life-sustaining treatments, and characterize the natural history and long-term outcomes among CBI survivors.
