title: Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure.
abstract: OBJECTIVE
  The management strategies and outcomes in pediatric patients with elevated intracranial pressure (ICP) following severe traumatic brain injury (TBI) are examined in this study.
  
  
  METHODS
  This study was a retrospective review of a prospectively acquired pediatric trauma database. More than 750 pediatric patients with brain injury were seen over a 10-year period. Records were retrospectively reviewed to determine interventions for correcting ICP, and surviving patients were contacted prospectively to determine functional status and quality of life. Only patients with 2 years of follow-up were included in the study.
  
  
  RESULTS
  Ninety-six pediatric patients (age range 3-18 years) were identified with a Glasgow Coma Scale score<8 and elevated ICP>20 mm Hg on presentation. The mean injury severity score was 65 (range 30-100). All patients were treated using a standardized head injury protocol. The mean time course until peak ICP was 69 hours postinjury (range 2-196 hours). Intracranial pressure control was achieved in 82 patients (85%). Methods employed to achieve ICP control included maximal medical therapy (sedation, hyperosmolar therapy, and paralysis) in 34 patients (35%), ventriculostomy in 23 patients (24%), and surgery in 39 patients (41%). Fourteen patients (15%) had refractory ICP despite all interventions, and all of these patients died. Seventy-two patients (75%) were discharged from the hospital, whereas 24 (25%) died during hospitalization. Univariate and multivariate analysis revealed that the presence of vascular injury, refractory ICP, and cisternal effacement at presentation had the highest correlation with subsequent death (p<0.05). Mean follow-up was 53 months (range 11-126 months). Three patients died during the follow-up period (2 due to infections and 1 committed suicide). The mean 2-year Glasgow Outcome Scale score was 4 (median 4, range 1-5). The mean patient competency rating at follow-up was 4.13 out of 5 (median 4.5, range 1-4.8). Univariate analysis revealed that the extent of intracranial and systemic injuries had the highest correlation with long-term quality of life (p<0.05).
  
  
  CONCLUSIONS
  Controlling elevated ICP is an important factor in patient survival following severe pediatric TBI. The modality used for ICP control appears to be less important. Long-term follow-up is essential to determine neurocognitive sequelae associated with TBI.
authors.affiliation: Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
authors.forename: Jay
authors.initials: J
authors.lastname: Jagannathan
authors.forename: David O
authors.initials: DO
authors.lastname: Okonkwo
authors.forename: Hian Kwang
authors.initials: HK
authors.lastname: Yeoh
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
authors.forename: Dwight
authors.initials: D
authors.lastname: Saulle
authors.forename: Julie
authors.initials: J
authors.lastname: Haizlip
authors.forename: Jeffrey T
authors.initials: JT
authors.lastname: Barth
authors.forename: John A
authors.initials: JA
authors.lastname: Jane
authors.forename: John A
authors.initials: JA
authors.lastname: Jane
mesh_terms: D000293:Adolescent; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy; D002648:Child; D002675:Child, Preschool; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019586:Intracranial Hypertension / Q000628:therapy; D007427:Intracranial Pressure / Q000502:physiology*; D008297:Male; D011379:Prognosis; D011788:Quality of Life; D011859:Radiography; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014696:Ventriculostomy