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Pathophysiology, treatment and outcome following severe head injury in children
Insights
Severe head injuries in children often show acute brain swelling, not edema, leading to increased cerebral blood flow. Aggressive management of intracranial pressure (ICP) resulted in good recovery for most patients.
Area of Science:
- Pediatric Neurology
- Neurocritical Care
- Neuroradiology
Background:
- Severe head injuries in children present unique pathophysiological challenges.
- Acute brain swelling is a common finding on initial CT scans.
- Understanding the underlying mechanisms of swelling is crucial for effective management.
Purpose of the Study:
- To present the pathophysiology and outcomes of severe head injury in pediatric patients.
- To investigate the relationship between CT findings, cerebral blood flow (CBF), and clinical presentation.
- To evaluate the effectiveness of aggressive intracranial pressure (ICP) management.
Main Methods:
- Retrospective analysis of 85 children with severe head injury.
- Computed Tomography (CT) scans for diagnosis of brain swelling and mass lesions.
- Cerebral blood flow (CBF) measurements in a subset of patients.
- Intracranial pressure (ICP) monitoring and therapeutic interventions.
Main Results:
- Acute brain swelling, characterized by increased white matter density on CT, was the most common diagnosis.
- CBF measurements indicated hyperemia despite decreased cerebral metabolic rate of oxygen (CMRO2) and coma.
- Elevated ICP (>20 Torr) was frequent in comatose children, particularly those with decerebrate or flaccid posturing.
- Aggressive ICP management, including barbiturates, was successful in 80% of patients.
Conclusions:
- The observed CT pattern suggests cerebrovascular congestion and hyperemia, not cerebral edema.
- Controlled hyperventilation was part of the initial management strategy.
- Effective ICP control is associated with favorable outcomes, with 87.5% achieving useful recovery.
Abstract:
The pathophysiology and outcome following severe head injury in 85 children are presented. The commonest initial CT diagnosis was of acute brain swelling. This swelling was associated with an increased white matter density on the CT scan which decreased to normal concomitant with recovery and increased ventricular size. CBF measurements in 6 of these patients revealed an increased blood flow despite a decreased CMRO2 and clinical coma. This CT pattern of diffuse swelling is believed to be due to acute cerebrovascular congestion and hyperemia and not to edema. Because of this, all children were treated with endotracheal intubation and controlled hyperventilation as part of the initial management. Mass lesions were uncommon, 20%. ICP was monitored in 40 children. The ICP rose above 20 Torr despite therapy in 80% of children with decerebrate or flaccid coma and in only 20% of children with spontaneous motor function. The ICP was at its highest between the second and fifth day. Aggressive therapy to control the ICP, with barbiturates if necessary, was successful in 80% of the patients. The overall results were useful recovery in 87.5% of the children, 3.5% were left vegetative or severely disabled and 9% died.