Delayed Intracranial Hypertension and Cerebral Edema in Severe Pediatric Head Injury: Risk Factor Analysis

Abstract

Introduction: Diffuse brain edema has been described as a major cause of intracranial hypertension (IH) following traumatic brain injury (TBI), and several studies suggest that it may be more frequent in children than in adults. While most cases of IH following TBI are present from the beginning, several studies have described a subgroup of patients with delayed elevations in intracranial pressure (ICP). Methods: Retrospective review of severe pediatric TBI cases admitted to a single institution during a 6-year period. Patients were classified into three groups, based on the temporal evolution of ICP: patients who evolved without IH, patients who had IH at admission and patients with delayed IH. A risk factor analysis was performed to find differences between these groups. Results: 31 cases of severe pediatric TBI were analyzed. 13 patients were female and 18 male, with an average age of 8.9 years. 4 patients met the described criteria for delayed IH; the only significant risk factor was presence of edema at the initial brain CT (p = 0.008). 3 additional patients presented clinical deterioration after 48 h and signs of brain edema in the CT, after ICP monitoring had been discontinued. Conclusions: Late-onset IH is a relatively common clinical condition in the pediatric population with severe TBI (present in 13% of the cases in our series), and the presence of a Marshall III CT scan at admission is a significant risk factor for this condition. Pediatric patients may benefit from a more prolonged period of ICP monitoring than adults, and the lack of amelioration of brain edema at follow-up brain CT (even with normal ICP values) may be an indication that more prolonged monitoring is needed.