Emergency Treatment Options for Pediatric Traumatic Brain Injury

J Exo; C Smith; R Smith; MJ Bell

Disclosures

Pediatr Health. 2009;3(6):533-541. 

In This Article

Mechanical Therapies

Head position is an extremely important aspect in the care of children with TBI, as elevation of the child's head can aid in draining venous blood to minimize intracranial volumes and ICP; and second, maintenance of cervical spine precautions is essential unless a critical neck injury has been excluded. This maneuver is relatively understudied, but has been a part of clinical care for years. In one telling paper, Meixensberger and colleagues found that ICP was significantly decreased in patients that had the head of their bed elevated to 30° compared with those who remained supine.[15] In this study, the authors also found that their maneuver did not appear to affect PbO2.

Surgical evacuation of hematomas and other pathological masses has been a mainstay of treatment for TBI for years, thereby treating two aspects of the Monro–Kellie doctrine: removal of the pathological mass and expansion of the intracranial cavity volume. More recently, decompressive craniectomy (removal of a portion of the skull and opening of the dura) has been advocated as a direct therapy for intractable ICP without focal mass lesion. Anecdotal reports from recent military conflicts have advocated for this practice and small case series have emerged demonstrating efficacy. Specifically, in a single-center, case-controlled study, 35 adults with TBI who underwent bifrontal craniectomy had improved neurological outcome when compared with historical controls, with young age and early operation most strongly associated with improved outcome.[16] However, in a prospective, randomized, controlled trial involving 27 children with severe TBI, early decompressive craniectomy resulted in decreased ICP for the first 48 h after surgery (average decrease in ICP of 9 mmHg), but no definitive improvement in outcome was proven.[17] While it appears very challenging, it is likely that a large, randomized, controlled trial of early decompression surgery will probably be necessary to fully define the utility of this provocative technique.

Cerebrospinal Fluid Drainage

Drainage of CSF is most often accomplished by placement of an externalized ventricular drain in the lateral ventricles of the brain. Occasionally, lumbar drainage of CSF is also instituted, but this must be performed with great care to prevent differential pressures within the cranial vault and potential uncal herniation. The therapeutic rationale for implementing CSF drainage for TBI is reasonably obvious – drainage of CSF from the cranial vault will decrease intracranial volumes and therefore decrease ICP. Some of the most compelling evidence linking CSF drainage to ICP, and presumably improved neurological outcome, was developed by Shapiro and Marmarou.[18] This study was developed to assess the pressure–volume index (PVI), where a given volume of fluid was instilled into the cerebral ventricle to determine the extent of ICP increase after this maneuver. Children with increased PVI (and consequent decreased cerebral compliance) were at highest risk for intracranial hypertension.

Like many of the treatment modalities of therapeutic maneuvers in TBI, definitive outcome studies are lacking, although strong suggestive evidence is present for the use of this modality. James and colleagues demonstrated that intermittent drainage of CSF from an extraventricular drain (EVD) resulted in immediate decreases in ICP in 32 patients ranging in age from 1 to 73 years.[19] However, this therapy alone was insufficient to control ICP secondary to severe swelling and small ventricle size after several days. Similarly, Fortune and colleagues found that CSF drainage for intracranial hypertension was the most effective therapy in 22 adults and adolescents.[20] Importantly, they also found that this therapy maintained CBF despite the large decreases in ICP, while other therapies had greater effects on cerebral hemodynamics. A more recent study by Jagannathan and colleagues demonstrated that CSF drainage via ventriculostomy improved intractable intracranial hypertension in children, and improved quality of life, despite an alarming incidence of meningitis associated with placement of the catheter (22%).[21]

As stated above, lumbar drainage is less frequently employed to treat intracranial hypertension after TBI in children. Levy and colleagues have published the largest series, where they instituted lumbar drainage of CSF in children with intractable ICP. In this series of 16 children who failed EVD-based CSF drainage, hyperventilation, furosemide, mannitol and barbiturates, lumbar drainage was safe and led to a survival rate of 88%.[22] Nevertheless, scrupulous attention to detail when utilizing this therapy should be practiced to avoid cerebral herniation.

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