Abstract
Background : Raised intracranial pressure (ICP) in non-traumatic coma (NTC) is common in children and requires urgent, protocol based management and multimodal monitoring. Initial tiers of raised ICP management are based on evidence based guidelines. However, treatment for refractory raised ICP is limited to medical measures like barbiturate coma, targeted therapeutic hypothermia or a neurosurgical procedure like decompressive craniectomy (DC). Evidence regarding the role of DC in refractory raised ICP due to NTC in children is lacking. Therefore, we planned to study the clinical profile and outcome of these patients undergoing DC. Methods : All patients aged 1 month to 12 years, admitted to a tertiary care pediatric ICU over a period of 5 years (2012 to 2017) and underwent DC for non-traumatic refractory raised ICP were retrospectively analysed. Clinical profile, course and neurological outcomes were studied. Primary outcome measures were survival to hospital discharge and neurological outcome after 3 months using Glasgow Outcome Scale (GOS). GOS of 1 & 2 were classified as good and 3 to 5 as poor. Statistical analysis was done using SPSS version 21 software. Descriptive data were summarized as mean ± SD or median (IQR). Predictors of good outcome were analysed using Chi Square test and multivariate logistic regression. Results : A total of 30 children with median age of 6.5 months (IQR 2, 50) were included. 26 (86.7%) were males. Common presenting symptoms were seizures (n=25; 83%), altered sensorium (n=19; 63%) and fever (n=12; 40%). Common clinical signs were pallor (n=20; 66.6%), asymmetric pupils (n = 15; 50%), bulging anterior fontanelle (n=12; 40%), focal deficits (n=6; 20%) and skin bleeds (n=4; 13%). Median (IQR) Glasgow Coma Score (GCS) at admission was 9 (6,11). Commonest etiology was intracranial bleed in 24 (80%) and infarct in 6 (20%). Location of bleed was parenchymal in 10 (33.3%), subdural 8 (26.7%), extradural 1 (3.3%) and multi-site in 5 (16.7%). All had a midline shift of >5mm on neuroimaging. Median (IQR) time to DC was 24 (24,72) hours of hospital admission. Twenty-six (86.7%) were ventilated for a median (IQR) duration of 96 (48, 144) hours and one patient required tracheostomy. Two patients died (6.6%) during hospital stay. Median (IQR) length of PICU and hospital stay was 5.5 (3, 10) and 17 (12, 27) days respectively. Twenty-one patients were examined at median (IQR) follow-up duration of 12 (5, 54) months. Six more patients died and one lost to follow-up. Good neurological outcome was seen in 15/29 (51.7%) patients. On univariate analysis, skin bleed (p-0.042), pupillary asymmetry (p-0.002) and focal deficit (p-0.011) at admission were significant predictors of poor outcome. On regression analysis, pupillary asymmetry at admission was predictive of poor neurological outcome [p-0.003]. Conclusion : Evidence on management of refractory raised ICP in NTC is still evolving. Timely DC can be considered as an effective treatment modality with good survival and neurological outcome.
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