Update in Pediatric Neurotrauma
Update in Pediatric Neurotrauma
Sarah Murphy 0
Ann-Christine Duhaime 0
0 Wang Ambulatory Care Center, Suite 331, Neurosurgical Service, Massachusetts General Hospital , Fruit Street, Boston, MA 02114 , USA
Purpose of Review Globally, the incidence of traumatic brain injury (TBI) is increasing with significant costs and consequences to society. Recent Findings Despite a tremendous research effort, however, there have been few clear, specific advances in the care of patients with severe TBI over the last 25 years. Multicenter randomized controlled trials (RCTs) have been conducted to investigate promising potential neuroprotective therapies in TBI, notably for hypothermia and progesterone among others, but none have demonstrated a clear therapeutic benefit. Because of the heterogeneity in age, injury type, and other factors, large-scale, appropriately powered studies are notoriously difficult to undertake in pediatric head injury. There remain few high-level evidence-based treatment recommendations for children with TBI. Summary The increased use of MRI and other advanced imaging modalities may help direct pathoanatomic classification and individualized treatment of head injury in children.
Traumatic brain injury; TBI; Pediatrics; Injured child; Head injury; Neurotrauma
* Sarah Murphy
Traumatic brain injury (TBI) has been called Bthe most
complex disease in the most complex organ^  and is
characterized by tremendous heterogeneity in mechanism, pathology,
and severity. TBI is a leading cause of death and life-long
disability in children [2–5]. Data from the CDC indicate that
more than 1.7 million people and more than 500,000 children
sustain a TBI in the USA each year. More than 2000 US
children die from their acute TBI and many more will survive
with life-long repercussions [3, 6]. The CDC estimates that
145,000 children and adolescents are living with substantial
limitations in social, behavioral, physical, or cognitive
functioning following a TBI . These numbers may
underestimate the true burden of injury, given the likely under-reporting
of mild TBI (mTBI), concussion, and abusive head trauma .
The potential physical, cognitive, and behavioral sequela of
TBI include neurologic complications such as motor
weakness and spasticity, epilepsy, hydrocephalus, headache
syndromes, and autonomic disturbances, as well as cognitive
impairments such as deficits or impairments in attention,
memory, executive function, and processing speeds [9 , 10, 11 ].
The impact of TBI on a child’s social development is less well
understood but may be one of the most disabling and
longlasting consequences of injury . Investigators have linked
pediatric TBI to aggressive and maladaptive behavior and
poor social adjustment and engagement. A longitudinal study
of pediatric patients showed that recovery profiles differed as
a function of injury severity. Children with severe TBI had
significant social problems that were continuing to evolve
between 12 and 24 months post-injury when compared with
uninjured controls and children with only mild or moderate
TBI. In contrast, children with mild and moderate injuries
showed only few social problems at 12 months post-injury
and little change over time . It has been hypothesized that
the susceptibility of the frontotemporal lobes to injury,
situated above boney surfaces where brain tissue can be easily
impacted by force, may be responsible for the cognitive and
behavioral symptoms commonly seen after a TBI  (CDC
report 2015). How TBI disrupts developing, widespread
neural networks in pediatric patients is poorly understood, a
subject of intense research, and undoubtedly consequential [11 ].
Worldwide, there is a global pandemic of TBI, with
significant societal cost and consequence [14 ]. The incidence of
TBI in developing countries is increasing, particularly in
middle and low-income countries with increasing use of motor
vehicles, and TBI is expected to surpass many other diseases
as a major cause of death and disability by 2020 according to
the World Health Organization [15, 16]. In the USA, the
Nationwide Emergency Department Sample database
(NEDS), representing a patient sample from 950 participating
hospitals, suggests that emergency department (ED) visits for
TBI have increased 29.1 % between 2006 and 2010, which is
8× the percent increase in total ED visits . The majority of
these are coded as concussion or Bhead injury other.^ Patients
at the extremes of age, adults >60 years and children <3 years,
had the greatest increase in injuries over this time period,
perhaps reflecting that these populations are least impacted
by public health efforts such as traffic safety laws and
concussion prevention measures .
More than half of the TBI among children 0 to 14 years was
caused by falls (55 %) (CDC website). Unintentional blunt
trauma (e.g., being hit by an object) accounted for close to a
quarter (24 %) of all TBIs in children, and motor vehicle
crashes were the third overall leading cause of TBI (14 %)
but are responsible for a disproportionate portion of mortality.
Motor vehicle crashes were the leading cause of TBI-related
death for children and young adults aged 5–24 years while
assault is the leading cause of TBI-related death for children
aged 0–4 years. With over 7000 pediatric deaths reported in
the USA in 2005, TBI is a leading killer of children in the
USA and is estimated to cost more than $2 billion dollars each
year for acute care alone. The societal costs, including lifetime
costs of disability, lost life years, and lost productivity, are
high [14 , 18, 19].
Despite a tremendous research effort, there have been few
clear, specific advances in the care of patients with severe TBI
over the last 25 years. Multiple multicenter randomized
controlled trials (RCTs) have been conducted to investigate
promising potential neuroprotective therapies in TBI, but none have
demonstrated a clear therapeutic benefit, and some
metaanalyses have shown that improvements in mortality and
morbidity rates for people with severe TBI have stalled .
Neuroprotective therapies that have been investigated over
the last 25 years include therapeutic hypothermia,
progesterone, decompressive craniectomy, and intracranial pressure
(ICP) monitoring. Of these, only hypothermia has been
studied in an RCT in a pediatric population. Though the initial trial
of therapeutic hypothermia to 33 °C for 48 h in adults with
severe TBI (NABISH)  did not demonstrate a benefit in
terms of mortality or outcome, subgroup analysis suggested
the possibility of a modest benefit in a subgroup of younger
TBI patients (<45 years). This effect, however, was not borne
out in the follow-up study by the same investigators 
targeting a younger adult population (<45 years) with earlier
cooling. In subsequent years, the Canadian Critical Care Trials
Group study BHypothermia after TBI in children^ [23 ] and
the multinational CoolKids study [24 ] both failed to find a
benefit to cooling to 32–33 °C for 24 or 48–72 h, respectively,
in pediatric patients with severe TBI. In the Hutchison trial,
children treated with hypothermia had a trend toward higher
mortality and an increased risk of developing hypotension
during rewarming. The CoolKids trial was terminated for
futility after interim analysis failed to demonstrate a benefit. In a
detailed feasibility analysis conducted in a third study of
hypothermia following pediatric sTBI (phase II pilot), Beca et al.
noted that given the low randomization rates in pediatric
hypothermia trials (ranging from 4.2 to 15 %), between 3000 and
10,000 patients would need to be screened in order to enroll
enough patients to detect a 10 % absolute reduction in poor
outcome , making the completion of such a trial
Over the same period, multicenter RCTs in adults have
failed to find clinical crossover of the preclinical benefits seen
from progesterone therapy in TBI [26, 27] or to find evidence
of efficacy from bifrontal cranial decompression (discussed in
detail below). The routine use of ICP monitoring, a
fundamental tenet of acute care in severe TBI management for nearly
30 years, was found to provide no outcome or mortality
benefit in a recent international RCT conducted in Ecuador and
Bolivia compared to careful serial examination and serial
imaging. In this study involving 324 patients aged 13 years or
older, guideline-based management, guided by
ICP-monitoring, did not result in better outcomes than those that could be
achieved through aggressive treatment based on clinical
examination and head imaging alone [28 ].
In 1995, the Brain Trauma Foundation first published
guidelines for the care of adults with severe TBI that included
a recommendation for intracranial pressure monitoring and
stepwise treatment of ICP above a threshold of 20–
25 mmHg. Pediatric guidelines followed in 2003 and were
most recently revised in 2012; these had disappointingly little
new grade I or II evidence to incorporate into best practice. In
fact, best practices for most aspects of TBI care in children
have not been established [14 , 29]. The most recent pediatric
guidelines include no level I and only a handful of level II
recommendations, including recommendations about
hypothermia that are at variance with the results of the most recent
trial results) . Other grade II recommendations include lack
of evidence for an immune-modulating diet to improve
outcome and lack of benefit of corticosteroids to improve
outcomes or reduce edema. The remaining recommendations,
including those regarding ICP monitoring and treatment,
minimum cerebral perfusion pressure (CPP) goals, use of
analgesics and sedatives, and others, are level III
recommendationexpert opinions  .
Because of the heterogeneity in injury type, age, and other
factors, large-scale, appropriately powered studies on which to
base high-level-evidence standards are notoriously difficult to
undertake in pediatric head injury, and for this reason, much
treatment is individualized. This is particularly true with
increased use of MRI and other imaging modalities that can help
with pathoanatomic classification rather than treatments based
solely on Glasgow Coma Scale (GCS) . In light of the fact
that guidelines documents contain many options based on
weak evidence and few high-quality evidence-based
standards, it may not be surprising that the extent to which centers
adhere to currently published guidelines documents is variable
[30–32]. Additionally, how Bcompliance^ is measured in
studies of this type is variable, since many of the recommendations
are only at the Boption^ level, making interpretation of
adherence problematic. In a recent US survey of 245 adult trauma
center directors, 83.3 % reported that the guidelines were
completely followed at their center in less than 75 % of severe
TBI cases and 32.2 % reported that the guidelines are followed
in less than 50 % of adult patients presenting with severe TBI
. This is consistent with previous reports of large variance
in percent compliance with guidelines within and across
centers. As in other studies [32, 33], ICP monitoring and also the
use of hypertonic saline were the most contentious
recommendations with the lowest rate of reported compliance. A
majority of directors (61.2 %) stated that ICP policies were
implemented in less than 60 % of sTBI cases, and 60.1 % of
directors reported the hypertonic saline is used in compliance with
the guideline recommendations less than 60 % of the time
. To improve clinical practice and consistency in care in
TBI, there has been an emphasis on improving guideline
adherence in adult trauma patients in the USA and a trend toward
better overall compliance since their inception in 1995 .
But, the evidence regarding whether consistency with the
guidelines actually improves outcomes is mixed. Though
some single-center studies have suggested improvement in
mortality and outcome with higher guideline adherence [32,
35, 36], more recent investigations had found little or no
association between complete/high levels of guideline
compliance  or compliance with specific recommended measures
(ICP monitoring, craniotomy) and risk-adjusted outcomes of
adult patients with severe TBI [33, 37]. However, there is a
well-documented Bhalo^ effect seen as improved outcomes in
both treatment and control groups in clinical trials (mostly in
adults), suggesting that attention to detail and protocol-driven
management may have major benefits .
Despite the lack of supporting evidence, the idea of having
pediatric guidelines available, with review of currently
available evidence, has been generally well received . As
might be expected from the variable strength of evidence,
adherence to published recommendations is variable both
between and within centers. This has been most well studied in
regard to the issue of ICP monitoring. In a recent US National
Trauma Database review of pediatric patients with severe TBI
from 2001 to 2006, only 7.7 % of patients meeting the criteria
underwent ICP monitoring. Notably, ICP monitoring in this
study was associated with decreased mortality only when the
GCS was 3 but was associated with longer ICU stay, longer
hospitalization, and more days on the ventilator, potentially
reflecting the population most likely to be chosen to undergo
monitoring . In the past decade, reported rates of ICP
monitoring in the pediatric population have ranged from 7.7 to 59 %
[39–43]. It has been shown that infants less than 1 year are less
likely to undergo ICP monitoring [41, 42] than are older
children. Additionally, children hospitalized at adult-only trauma
centers are more likely to have ICP monitors placed than are
pediatric patients cared for at pediatric trauma centers . The
reasons for variable compliance with guideline
recommendations likely include, in addition to factors related to
implementation, dissemination, culture and communication, meaningful
questions about guideline credibility, and the applicability of
specific recommendations for an individual patient [42, 44].
In one study, rapid early improvement in GCS, decision to
pursue clinical surveillance, and moribund status, for example,
were the most common reasons found for why ICP monitoring
was not implemented. In addition, in this study, radiologic (CT
or MRI) features were also noted to be an important factor in the
decision whether or not to place an ICP monitor—a factor not
included in the current guidelines. All of the patients who
underwent clinical surveillance in this study had Rotterdam
CT scores of 1, 2, or 3 (most often 1–2) .
Vavilala et al. studied attainment of 34 clinical care
indicators derived from the 2003 guideline recommendations in 5
high-volume level I pediatric trauma centers through a
retrospective review of cases from 2007 to 2011 . Overall
compliance with the clinical indicators defined by the study
was 73 % and ranged from 68 to 78 %, comparable to Brain
Trauma Foundation guideline compliance rates reported in
adults. A 6 % lower hazard of death and a 1 % decrease in
the chance of poor (vegetative or major impairment)
functional outcome was found for every percentage point increase in
adherence with the indicators. After controlling for
confounders, mortality and outcome were found to be associated
each with three different clinical indicators. The indicators
associated with reduced mortality included absence (but not
treatment) of prehospital hypoxia, early ICU nutrition (<72 h),
and no hyperventilation in the absence of evidence of
herniation. The specific indicators associated with improved
outcome in survivors were a CPP maintained >40 mmHg in the
OR and ICU, respectively, and absence of a surgical
intervention. This study provides indirect support of the goals of care
put forth in head injury management recommendations,
finding an association between related clinical indicators and
outcome. However, the argument can be made that this reflects
that patients in whom parameters cannot be controlled because
of severe injury burden, such as patients in whom ICP or CPP
cannot be maintained in a Btarget range,^ simply have worse
outcomes on that basis, rather than providing evidence that
specific interventions alter outcome. Single-center studies
have demonstrated improvement in outcome after the
adoption of local care processes consistent with guideline
recommendations [46, 47]. Perhaps the most notable direct evidence
for a pediatric guideline recommendation was provided in a
study published in Pediatrics in 2009 . In this retrospective
study of pediatric patients presenting to a level I trauma center
ED with severe TBI, hypoxia (44 %) and hypotension (39 %)
were detected frequently in the ED. Non-treatment of
hypotension (but not of hypoxia) was associated with a 3.4
increased odds of death and a 3.7 increased odds of disability.
This is consistent with general principles of maintenance of
physiologic stability and avoidance of so-called secondary
insults to add to the injury burden.
There persist wide discrepancies in outcome even between
Bexperienced^ TBI centers that may impede the accurate
assessment of neuroprotective therapies and strategies in
multicenter, randomized controlled trials . The adult
International Mission on Prognosis and Clinical Trial design
in Traumatic Brain Injury (IMPACT) trial analyzed individual
patient data from over 9500 adult patients with moderate and
severe traumatic brain injury enrolled in 10 randomized
controlled trials and 3 observational studies [50 ]. A
randomeffects logistic regression model was used to estimate the
between-center differences in unfavorable outcome (dead,
vegetative state, or severe disability measured with the
Glasgow Outcome Scale) at 6 months adjusted for differences
in patient characteristics. A 3.3-fold difference in the odds of
having an unfavorable outcome was found between centers, a
difference which was not explained by random variation or
patient characteristics [50 ]. In fact, adjusting for patient
characteristics increased between center differences. In this study,
as in others, outcomes adjusted for patient characteristics did
not improve over the study period (1984–2004), during which
time guidelines were disseminated.
There is significant variability in pediatric TBI-related
outcomes by state. A retrospective cohort study using Healthcare
Cost and Utilization Project data found nearly a 2-fold
difference between states in inpatient mortality after pediatric TBI
. Regional differences have also been shown in the
outcome of patients with severe TBI even after adjusting for
known facility and patient variables including trauma level,
facility size and teaching status, age of patient, patient
insurance status, measures of TBI severity, presence of
hypotension, heart rate, age, transfer status, GCS, AIS, and other
factors [51, 52]. These results are in agreement with CDC
estimates of TBI-related mortality in children, which have
been lowest in the northeast (2.4 per 100,000), compared with
the west (3.2 per 100,000), Midwest (3.9 per 100,000), and
south (4.3 per 100,000) (CDC website). Disparities in
outcomes have also been shown with minority and impoverished
children having a higher incidence of TBI, worse severity of
injury, and higher mortality rates related to their TBI [53, 54].
Such differences in outcome might be explained by
differences in data collection and reporting, process and trauma
system factors, differences in injuries or in the population, or
differences in treatment and practice . In 2013, Bell et al.
published results of a survey that asked participants from 32
pediatric TBI centers from across the USA and Europe about
their treatment goals for pediatric patients with severe TBI
. There were wide differences reported in stated medical
goals, including differences in intracranial hypertension
management; use of cerebrospinal fluid diversion; use of
multimodal, brain tissue oxygenation monitoring; and initiation of
nutritional support, among other areas.
For all these reasons, there remain many questions about
current best practice in the management of sTBI in children.
The current state of knowledge and the somewhat
controversial results of recent trials including BEST-TRIP and others
[28 , 56, 57] challenge some of the historic management
recommendations for adults and children with sTBI. The next
evolution in TBI care may be toward adding more
sophisticated management algorithms into the care of patients, based
on individual patients’ unique pathophysiology of injury. This
care might be guided by the use of advanced imaging and
monitoring techniques that might allow targeted treatment
and individualized treatment thresholds .
Recent focus in clinical TBI research has turned to
leveraging the differences in care practices and medical treatment
goals that currently exist. An international initiative including
the National Institutes of Health (NIH) and the European
Commission (EC) has sought to establish collaboration in
TBI research by establishing common shared definitions and
standards such as those described by the common data
elements (CDE) for TBI. By using agreed-upon definitions and
standards, large-scale shared databases of TBI patients can be
created and studied. Through this collaboration, comparative
effectiveness trials including Approaches and Decisions in
Acute Pediatric TBI (ADAPT), Transforming Research and
Clinical Knowledge in Traumatic Brain Injury
(TRACKTBI), and the Collaborative European NeuroTrauma
Effectiveness Research in Traumatic Brain Injury
(CENTER-TBI) studies all aim to compare the relative
benefits and harms of alternative treatments and strategies
currently used in the care of patients with severe TBI through
prospective data collection of highly granular clinical,
neuroimaging, biomarker, and outcome data [14 ]. ADAPT aims to
evaluate TBI therapies specifically in children with severe
TBI, including the use of intracranial hypertension strategies,
use of prophylactic hyperventilation and brain tissue oxygen
monitoring, and nutritional support.
The main goal of surgery is to relieve dangerous tissue shifts
and, less commonly, to decrease globally increased
intracranial pressure. Most instances of potentially preventable death
and disability from traumatic brain injury in the hospital
setting occur as a result of tissue shifts which cause progressive
compromise of otherwise relatively spared areas of the brain.
These areas can become secondarily ischemic, resulting in
swelling and extension of the volume of compromised tissue.
This can occur before intracranial pressure causes failure of
global brain blood flow. Thus, prompt removal of mass
lesions and creating Broom^ for contused tissue to swell away
from undamaged tissue are the most common scenarios
requiring surgical intervention.
Extraaxial and Intraparenchymal Hematomas
Patients presenting with extraaxial hemorrhages—epidural
and subdural hematomas—are evaluated via the initial
assessment algorithm (Fig. 1). It should be kept in mind that epidural
hematomas in infants and young children most often occur
from low-height falls, and that they may progress rapidly or,
in the case of venous hemorrhages, more slowly . Mass
lesions causing immediate or potential compromise are best
evacuated before irreversible injury occurs to adjacent tissue
. Mass lesions close to sites in which tissue shifts are more
likely to cause compromise of vessels or of critical tissue—
such as those in the temporal region near the tentorial incisura
and brainstem, those near the falx which can cause subfalcine
herniation and compromise of the anterior circulation, and
those in the posterior fossa which can cause brainstem
compression or compromise of the posterior arterial circulation via
herniation through the foramen magnum—are all managed
with a high index of suspicion for potential deterioration.
Additionally, extraaxial lesions which are not causing
immediate compromise but are associated with contused
parenchyma that can be predicted to swell as the injury evolves also
decrease the surgeon’s threshold for operative intervention.
These lesion scenarios may prompt prophylactic surgical
intervention to decrease the chance of sudden irreversible
decline even before herniation is imminent.
Conversely, some mass lesions that do not compromise
uninjured tissue and that can be predicted to have a high
likelihood of stability can be treated conservatively initially but
always with close observation in case unexpected worsening,
clinically or radiographically, occurs. This is why the timing
of the scan relative to the injury event can be so useful; a
small, stable venous epidural hematoma associated with a
simple fracture located far from structures associated with
herniation in a well-appearing child may be well tolerated
and may be managed non-operatively initially. Subdural
bleeding in the setting of preexisting encephalomalacia falls
into a similar category of lesion which has a lower risk of
causing dangerous tissue shifts; this situation is more common
in adults than in children. In borderline cases, such as a
moderate epidural hematoma with persistent headache and
vomiting but without major herniation risk, it is worth keeping
in mind that symptomatic patients typically recover more
quickly and leave the hospital sooner if surgery is performed
early, rather than having patients undergo many days of
observation and repeated scans, especially if imaging is
performed with CT and its attendant radiation exposure .
Follow-up imaging of small, asymptomatic or minimally
symptomatic epidural collections, especially if the first scan
was obtained within hours of injury, is another context in
which rapid MRI may have utility compared to CT.
Other mass lesions follow similar principles but can require
more judgment. Intraparenchymal hemorrhages with mass
effect also can compromise adjacent tissue, but surgery carries
the additional risk of compromise of the surrounding brain
which may have the potential to recover. This is particularly
true in eloquent cortex, such as the temporal and frontal lobes,
common locations of traumatic contusions which may include
significant solid hemorrhage. While frontal contusions have
been thought to be amenable to surgical intervention with little
obvious consequence in the past, more recent recognition of the
role of the frontal lobes in decision-making and executive
functions, reward processing, and social interaction has made
preservation of these areas more compelling. This may be
particularly true in light of the fact that deficits from injury in this area
may not be apparent until later in maturation for many children.
Thus, surgical decision-making of significant traumatic
hemorrhages in this area involves weighing goals of short- and
longterm risks against immediate benefits of reduction of
intracranial pressure and melioration of local mass effect.
Similar decision-making occurs regarding traumatic
hemorrhages in the temporal lobe. This is why knowing the child’s
handedness may be very useful early in the course of care.
While younger children may exhibit language plasticity, older
children may exhibit expressive or receptive language deficits
after surgical evacuation of parenchymal hematomas in the
dominant temporal lobe and perisylvian region. However,
because the temporal lobe is close to the brainstem, mid- or
posterior-temporal hemorrhages carry significant risk, and
judicious surgical evacuation may be prudent.
Deep hemorrhages, such as those in the basal ganglia,
internal capsule, and thalamus, occur most commonly in the
setting of high-speed rotational events, such as trauma
- Via standardized tool (GCS, motor, pupils, other)
"Pure" diffuse axonal injury
Isolated focal lesion not near
Chronic subdural hematoma
Fig. 1 Head injury: initial assessment and management for neurosurgical consultants. **Unoperated epidural hemtaoma, significant contusion, others at
discretion of the treating physician. Adapted from 
including motor vehicles, often in concert with diffuse axonal
injury. When life-threatening, these can be evacuated but carry
risk of damage to surrounding tissue which requires some
degree of disruption to remove the deep collection of blood.
Careful planning of a trajectory to the hematoma that
minimizes collateral risk is important, and the use of intraoperative
ultrasound or image guidance, even under conditions of
urgent surgery, can be extremely helpful in this circumstance.
Mechanical trauma along brain surfaces can result in tissue
contusions, most often in the frontal or temporal lobes, but
these can occur in any area, including the posterior fossa.
Contusions represent zones of damaged interspersed with
potentially salvageable tissue, and in general, caution is used
when evacuating these in order to preserve as much function
as possible. However, as per the principles outlined above,
when contused tissue swells to the point of progressive
compromise of adjacent uninjured tissue or herniation, creating
room for swelling via decompression and/or evacuation
becomes important. It should be kept in mind that the majority of
contusions swell over the first few days after injury, and
minimizing this is the goal of many medical management of TBI.
Intracranial Pressure Monitoring and Ventriculostomy
The goal of intracranial pressure monitoring is to supplement
the continuous evaluation of the head-injured patient beyond
what serial neurologic exams and serial imaging can provide.
In some instances, neither serial exams nor serial imaging can
be performed or have high risk—for instance, when children
have polytrauma requiring extracranial surgery, have painful
injuries requiring sedating analgesics, have pulmonary
function compromise requiring ventilation parameters only
II. Initial management algorithm
Is there a mass lesion causing symptoms or significant tissue shift now or with
Is there a swelling-prone injury (see list above) with significant risk of increased ICP or
dangerous tissue shift during the acute course?
no (see above for list)
Can patient be examined
(follows commands, localizes)
Exam or symptoms worsening/failing to improve?
Check Na, EEG, imaging
possible with deep sedation or muscle paralysis, or have
decreased level of consciousness related to the brain injury.
While serial neurologic examination is a pillar of
management and should always be the goal whenever possible, as it
provides information about level of consciousness, new
focal findings, pain management adequacy, as well as signs of
recovery that can lead to de-escalation of care, intracranial
pressure monitoring can provide supplementary
information. In particular, trends to increases in intracranial
pressure may be of great importance during many phases of
management, including those mentioned above. While
tissue shift and frank herniation can occur even without major
increases in intracranial pressure, elevations can be a
harbinger of delayed mass lesions, progressive swelling,
ischemia, agitation, and other trends potentially requiring
changes in management. Thus, intracranial pressure monitoring is
generally instituted in all patients in whom it will add to the
information available which may help prevent potentially
avoidable deterioration. This includes children who are
unconscious, who cannot undergo serial clinical examination
with an interpretable exam (usually, one is which they can
reliably follow command), or whose exam and findings are
unreliable due to other needed medical interventions.
Ventriculostomy requires placement of a catheter into
the ventricle and thus has a slightly higher risk of
intraparenchymal hemorrhage as well as infection
compared to intraparenchymal ICP monitors. However,
ventriculostomy allows for continuous or intermittent
drainage of CSF, which can be extremely useful in
patients with brain swelling. Because children and
adolescents often have little Bextra^ subarachnoid space
compared to older adults, even relatively small volumes of
swollen tissue can lead to dangerous tissue shifts and
elevations of intracranial pressure. Thus, removal of even a
few milliliters of CSF per hour in the setting in which the
intracranial pressure can be elevated significantly by small
increases in volume can add considerable safety to
management. Thus, placement of ventriculostomy should be
considered early in the setting of anticipated brain
swelling that does not require more major forms of
decompression, such as those discussed below. For lesions that do
not fall into the Bswelling-prone^ category, such as
isolated diffuse or traumatic axonal injury without
contusion or superimposed hypoxic-ischemic injury,
parenchymal ICP monitors offer a reliable method of monitoring
changes in pressure, along with serial neurologic exams
and serial imaging as clinically indicated. They also can
be used to supplement ventriculostomy readings when
continuous CSF drainage is chosen for management, to
take advantage of their capacity for reliable, continuous
ICP measurement; the authors typically use a fiberoptic
parenchymal monitor in children requiring continuous
ventriculostomy drainage as an extra means of following
pressures. While these are general principles, the exact
efficacy of these approaches in children awaits further
prospective study .
Brain Swelling and Decompressive Craniectomy
While some contused tissue is best removed by surgical
evacuation, other contusions can be handled by
decompressive surgery, leaving the tissue largely intact. If an
entire hemisphere or bifrontal region can be expected to
swell, either because of prior evacuation of a subdural
hematoma—a lesion often associated with hemispheric
brain swelling—or because of large contusions,
decompressive craniectomy can be performed. This has been
employed with increasing frequency in the past decade
and sometimes enables preservation of parenchyma
during the period of maximal swelling while minimizing the
risk of progressive compromise of adjacent tissue.
Multiple studies have demonstrated that decompressive
craniectomy, either bifrontal or, more often, unilateral, is
associated with best outcomes if performed early in the
course of predicted swelling [62–65]. Similar
decompression can be accomplished in the setting of cerebellar
contusions as well as large penetrating lesions such as some
gunshot wounds in which significant tissue sparing may
be anticipated. However, when physiologic damage
results from hypoxic-ischemic injury or other diffuse
metabolic insult, or when herniation infarcts have already
occurred, decompression may be life-saving but with poor
neurologic outcome . Additionally, late complications,
including shunt-dependent hydrocephalus and bone
resorption, occur with high frequency after decompressive
craniectomy. Thus, families need to be informed that
multiple surgeries may be needed during what can be a long
and intervention-laden recovery [62, 66].
Despite these cautions, decompressive craniectomy has
come to be used more frequently in both adults and children
and is considered a justified option in circumstances of
swelling-prone lesions that can be anticipated to cause
progressive compromise of potentially salvageable tissue that
might be avoided by this surgical maneuver .
For pediatric patients, there is significant concern about
the long-term effects of radiation exposure—both
increased risk of malignancy and the potential for cognitive
injury have been reported from CT scans in children [68 ,
69–71]. For initial imaging, reduced radiation head and
extracranial CT protocols exist, and these typically are
sufficient for initial assessment and triage. For further
assessment of significant brain or spine injuries, MRI
has more sensitivity and specificity for parenchymal
assessment and can often give additional information about
acute injury as well as evolving pathophysiology of injury
that might be used to direct further management. New,
rapid MRI sequences can often be performed safely,
limiting the amount of time that the patient is in the imaging
suite. Some newer sequences, such as half-Fourier
acquisition single-shot turbo spin-echo (HASTE), can scan the
entire brain in 30 s and have the added advantage of being
relatively resistant to motion artifact. MRI is used
increasingly both in the acute setting (emergency department)
and as the follow-up imaging modality of choice in
pediatrics . The National Institutes of Health, along with
other government agencies, sponsored the creation of
common data elements for traumatic brain injury, with
CT and MRI parameters for children, which can be used
to guide imaging decisions, protocols, and interpretation
There remain few high-level, evidence-based
recommendations for the acute care of children with severe TBI. The
increased use of advanced MRI imaging modalities may allow
for more tailored, pathoanatomic management of head injury
in children. Large-scale databases of TBI patients promise to
advance our care of patients with severe TBI. Comparative
effectiveness trials include Approaches and Decisions in
Acute Pediatric TBI (ADAPT), Transforming Research and
Clinical Knowledge in Traumatic Brain Injury
(TRACKTBI), and the Collaborative European Neurotrauma
Effectiveness Research in Traumatic Brain Injury
(CENTER-TBI) and will compare the relative benefits and
harms of alternative treatments and strategies currently used.
Compliance with Ethical Standard
Conflict of Interest Drs. Duhaime and Murphy declare no conflicts of
interest relevant to this manuscript.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
Papers of particular interest, published recently, have been
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