Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults

Abstract

Objective The evidence to guide therapy in pediatric TBI is lacking, including insight into the ICP/CPP thresholds in abusive head trauma (AHT). We examined ICP/CPP thresholds and indices of ICP and CPP burden in relationship to outcome in severe TBI and in accidental and AHT cohorts. Design A prospective observational study. Setting PICU in a tertiary children’s hospital. Patients Children <18y admitted to PICU with severe TBI and had ICP monitoring. Measurements and Main Results A pediatric TBI database was interrogated with 85 patients (18 AHT) enrolled. Hourly ICP and CPP (in mm Hg) were collated and compared to various thresholds. C-statistics for ICP and CPP data in the entire population were determined. Intracranial hypertension and cerebral hypoperfusion indices were formulated based on number of hours with ICP>20 and CPP<50, respectively. A secondary analysis was performed on accidental and AHT cohorts. All of these were compared with dichotomized 6 month GOS scores. The models with the number of hours with ICP>20 (C=0.641, 95% confidence interval: 0.523, 0.762) and CPP<45 (C=0.702, 95% confidence interval: 0.586, 0.805) had the best fits to discriminate outcome. Two factors were independently associated with a poor outcome, number of hours ICP>20 and AHT (OR=5.101, 95% CI: 1.571, 16.563). As the number of hours with ICP>20 increase by 1, the odds of a poor outcome increased by 4.6% (OR=1.046, 95% CI: 1.012, 1.082). Thresholds did not differ between accidental vs. AHT. The intracranial hypertension and cerebral hypoperfusion indices were both associated with outcome. Conclusion The duration of hours of ICP>20 and CPP<45 best discriminated poor outcome. As the number of hours ICP>20 increase by 1, the odds of a poor outcome increased by 4.6%. Although AHT was strongly associated with unfavorable outcome, ICP/CPP thresholds did not differ between accidental and AHT.

Abusive Head Trauma and Mortality–An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury

“…This is a novel and potentially important finding particularly given the well-known paucity of ICP monitoring in young children (some presumed to have AHT) reported by Bennett and colleagues (44). Our finding certainly suggests that victims of AHT have increased ICP and could likely benefit from ICP monitoring and ICP-directed therapy as others have suggested (45). …”

Monitoring and Measurement of Intracranial Pressure in Pediatric Head Trauma

“…Treatment threshold for ICP in the pediatric patient is based on 12 retrospective and prospective studies examining target values for lowering ICP to improve clinical outcome (10). Most studies applied an ICP threshold of 20 mmHg and reported lower ICP values in patients with a favorable outcome compared to those with an unfavorable outcome (64)(65)(66)(67)(68)(69)(70). Few studies examined if different threshold values resulted in different outcome [respectively 14/20/30 mmHg (69) and 15/20 mmHg (71)].…”

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

“…In a study evaluating adherence to the 2003 Pediatric TBI guidelines in children with severe TBI who survived past 48 hours of admission, for every 1% increase in adherence there was a 1% decrease in the chance of a poor outcome at discharge (42). Multiple predictors of unfavorable neurologic outcome following pediatric TBI have been described, including elevated intracranial pressure and decreased cerebral perfusion pressures (37,42,101), low Glasgow Coma Scale (GCS) on admission (40,41,44,46), subarachnoid hemorrhage and abnormal basal cisterns (35,44), and cerebral edema (35,41,46) on neuroimaging. However, several randomized controlled trials in pediatric TBI investigating therapies such as hypothermia (102), decompressive craniectomy (103), or immune-enhancing diet (104), have failed to improve patient outcomes.…”