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Intracranial pressure in children and adolescents with severe head injuries
Insights
Severe head injuries in children and adolescents often lead to poor outcomes, even with intensive care. Early, sustained high intracranial pressure (ICP) is particularly fatal, though delayed peaks may allow survival.
Area of Science:
- Pediatric Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Severe head injuries in pediatric populations present unique challenges in management.
- Intracranial pressure (ICP) monitoring is crucial for assessing and managing traumatic brain injuries (TBIs).
- Understanding the relationship between ICP dynamics and outcomes in children is vital for improving therapeutic strategies.
Purpose of the Study:
- To investigate the long-term outcomes of severe head injuries in children and adolescents based on ICP monitoring.
- To determine the correlation between ICP levels, timing of hypertension, and patient survival and recovery.
- To evaluate the effectiveness of intensive care unit (ICU) therapy in managing intracranial hypertension in this demographic.
Main Methods:
- Long-term ICP monitoring in 53 pediatric patients with severe head injuries.
- Classification of ICP levels (e.g., <10 mmHg, 11-20 mmHg, 21-50 mmHg, >50 mmHg).
- Assessment of neurological signs (e.g., decerebrate posturing, pupil responsiveness) and patient outcomes (survival, disability, recovery).
Main Results:
- Fifteen patients experienced sustained intracranial hypertension over 50 mmHg; 6 died from fulminating hypertension, and 21 died later.
- Early hypertension exceeding 50 mmHg was universally fatal.
- Seven patients with the highest ICP degrees survived, but only when ICP peaked >72 hours post-injury; delayed hypertension may be better tolerated.
- Four patients with mild hypertension but high elastance also died.
Conclusions:
- Pediatric patients may tolerate higher ICP levels than adults, but outcomes remain poor in deep coma despite aggressive ICU care.
- The timing of intracranial hypertension is a critical determinant of survival, with early, sustained elevations being particularly ominous.
- Aggressive ICP management strategies are necessary, but outcomes are significantly influenced by the injury severity and the patient's physiological response.
Abstract:
Long-term ICP monitoring was carried out in 53 children and adolescents with severe head injuries. 36 of them exhibited bilateral decerebrate posturing and 13 bilateral pupil unresponsiveness. The highest ICP levels never exceeded 10 mmHg in 3 patients, ranged between 11 and 20 mmHg in 12 and between 21 and 50 in 16. Fifteen patients showed sustained intracranial hypertension over 50 mmHg. Six patients died from fulminating intracranial hypertension and 21 died later (average survival 10.1 days). Five patients remained severely disabled and 21 satisfactorily recovered. Seven patients with the highest degrees of intracranial hypertension survived, in all of them ICP reached its peak more than 72 hours after injury. Early hypertension exceeding 50 mmHg always proved fatal. Four patients with mild hypertension but with very high elastance on P/V tests died. Although children and adolescents may withstand higher degrees of intracranial hypertension than adults, outcome remains poor despite active therapy in ICU patients with deep stabilised coma.