Traumatismo craneoencefálico grave en el paciente pediátrico. Evaluación de la neuroimagen y monitorización de la presión intracraneal como factores pronóstico

Severe head injury among children: computed tomography evaluation as a prognostic factor

BACKGROUND

The value of neuroimaging in predicting unfavorable events in the outcome of pediatric patients has not been established. Our objectives were to determine clinical characteristics and outcome of severely head-injured children admitted to the pediatric intensive care unit (PICU) of a pediatric third-level university hospital and to evaluate the use of neuroimaging as a prognostic factor of morbimortality in these patients.

METHODS

We performed a 9-year retrospective review. We included all patients with severe head injury admitted to the pediatric intensive care unit of our hospital from January 1995 to December 2003 requiring invasive intracranial pressure monitoring. Clinical summaries and imaging studies were reviewed.

RESULTS

Data for 156 pediatric patients, aged 1 to 18 years, were collected. We reclassified neuroimaging patterns into 2 groups: those with few imaging findings and those with important lesions. These 2 groups were significantly correlated with initial Glasgow Coma Scale (P < .05). We classified patients into favorable evolution, moderate disability, and unfavorable evolution. Poorer evolution correlated with poorer initial neuroimaging patterns, and these differences were statistically significant (P < .05).

CONCLUSIONS

In our group of patients, initial Glasgow Coma Scale was related with the initial neuroimaging pattern, and this relation was statistically significant. Findings in the first and second neuroimaging were useful as prognostic factors in our series.

Intracranial pressure and cerebral perfusion pressure as risk factors in children with traumatic brain injuries

OBJECT

The authors evaluated the initial intracranial pressure (ICP) and cerebral perfusion pressure (CPP) as prognostic factors in severe head injury in children and tried to determine the optimal CPP range.

METHODS

The authors performed a 9-year retrospective review of all patients with severe traumatic brain injuries (TBIs) who required invasive ICP monitoring and were admitted to the pediatric intensive care unit at their institution between January 1995 and December 2003. These patients had Glasgow Coma Scale scores lower than 8 and/or required ICP monitoring due to worsening neurological status or neuroimaging results suggestive of cerebral hypertension. Clinical summaries and imaging studies were reviewed. Data for 156 pediatric patients who ranged in age from 1 to 18 years were obtained. Half of these patients presented with normal initial ICPs (< 20 mm Hg), and a good outcome was achieved in 80% of these children. An unfavorable outcome was observed in more than 60% of patients with an initial CPP lower than 40 mm Hg. The proportion of patients with an unfavorable outcome decreased to 10% with initial CPPs higher than 60 mm Hg, but patients with initial CPPs higher than 70 mm Hg did not improve.

CONCLUSIONS

Initial ICP and CPP measurements were useful as prognostic factors in pediatric patients with severe TBIs: patients with initial CPPs between 40 and 70 mm Hg were found to have a better neurological prognosis than those with CPPs either higher or lower than that range.