Non-traumatic Coma Research Articles

Aetiology and outcome of non-traumatic coma in African children: protocol for a systematic review and meta-analysis

BackgroundNon-traumatic coma is a common acute childhood presentation to healthcare facilities in Africa and is associated with high morbidity and mortality. Historically, the majority of cases were attributed to cerebral malaria (CM). With the recent drastic reduction in malaria incidence, non-malarial coma is becoming a larger proportion of cases and determining the aetiology is diagnostically challenging, particularly in resource-limited settings. The purpose of this study will be to evaluate the aetiology and prognosis of non-traumatic coma in African children.MethodsWith no date restrictions, systematic searches of MEDLINE, Embase, and Scopus will identify prospective and retrospective studies (including randomised controlled trials, cluster randomised trials, cohort studies, cross-sectional, and case-control studies) recruiting children (1 month–16 years) with non-traumatic coma (defined by Blantyre Coma Score ≤ 2 or comparable alternative) from any African country. Disease-specific studies will be included if coma is associated and reported. The primary outcome is to determine the aetiology (infectious and non-infectious) of non-traumatic coma in African children, with pooled prevalence estimates of causes (e.g., malaria). Secondary outcomes are to determine overall estimates of morbidity and mortality of all-cause non-traumatic coma and disease-specific states of non-traumatic coma, where available. Random effects meta-analysis will summarise aetiology data and in-hospital and post-discharge mortality. Heterogeneity will be quantified with τ2, I2, and Cochran’s Q test.DiscussionThis systematic review will provide a summary of the best available evidence on the aetiology and outcome of non-traumatic coma in African children.Systematic review registrationPROSPERO CRD42020141937

STUDY OF NON TRAUMATIC COMA IN CHILDREN AT TERTIARY HOSPITAL.

Introduction: Non-traumatic coma can have varied etiology and clinical characteristics. These may determine the management and outcome of the patients. We aimed to study the etiology and outcomes of children diagnosed and treated for non-traumatic coma in our hospital. Methodology: Medical records of children aged 2 months to 18 years, diagnosed with non-traumatic coma from January 2020 till December 2020 were reviewed retrospectively. The nal outcome was determined by patient's death or neurological condition at the time of discharge. Results: In the present study, out of 45 patients of NTC, 44% of the patients were in the age group 2 months to 5 years, 31% in 6 years to 12 years and 24% in 13 years to 18 years and 42% were Males & 57% were Females. In etiology, Infectious and Non-infectious causes contributed equally. Among the infectious causes, the most common ones were acute encephalitis (22%), acute pyogenic meningitis (9%), TBM (9%) and remaining infectious causes contributed to 9%. Among the non-infectious causes, diabetic ketoacidotic coma (22%), epileptic encephalopathy and metabolic encephalopathy contributed to 7% each. In outcome of the sample of 45 patients, 39 (87%) were discharged home and mortality was observed in 6 (13%). Among the total patients discharged (87%), 53% were neurologically normal, 7% had mild disability, 9% had moderate disability and 18% had severe disability. In our study, mortality was 3% in children with moderate brain injury, 33% mortality in children with severe brain injury (p value < 0.01). Conclusions: In our study, mortality rate was high with severe brain injury as compared to mild and moderate brain injury as assessed by GCS at admission.

A Prospective Cohort Study on Serum Sodium and Clinical Outcome in Pediatric Nontraumatic Coma.

To study the serum sodium level and clinical outcome in pediatric nontraumatic coma. A prospective cohort study was conducted in a tertiary care pediatric intensive care unit (PICU) from September 2015 to June 2016. Children aged < 13 y with nontraumatic coma [modified-Glasgow Coma Scale (m-GCS) score ≤ 8 or fall of ≥ 3 from baseline within 24h of admission] were included. Children who received intravenous fluids for > 24h, those with developmental delay, or died within 24h of admission were excluded. The serum sodium profile (mEq/L) in the first 72h and clinical outcome [mortality, length of stay in mechanical ventilation, PICU, and hospital] were studied. Eighty patients [Died n = 26 and Survived n = 54] were enrolled. Median [interquartile range (IQR)] age and m-GCS were 21 (4-78) mo and 9 (7-11), respectively. The mean [standard deviation (SD)] Pediatric Risk of Mortality-III (PRISM-III) was 17.7 (4). The most common etiology was acute central nervous system (CNS) infections (30%, n = 24) followed by an intracranial bleed (11.3%, n = 9). Mean (Standard error, SE) sodium levels and fluctuation of serum sodium from baseline up to 72h were similar between nonsurvivors and survivors [140.8 (1.3) vs. 139.6 (0.8), p = 0.421] and [1.2 (0.3) vs. 0.8 (0.2), p = 0.307], respectively. On multivariate analysis, the need for vasoactive therapy was an independent predictor of mortality [adjusted odds ratio = 20.78, 95% CI 4.24-101.85, p = < 0.001, R2 = 0.62]. Mean serum sodium within normal range and fluctuation of serum sodium of 0.8 to 1.2mEq/L over 72h was not associated with poor outcomes in pediatric nontraumatic coma. Vasoactive therapy was an independent predictor of mortality.

The diagnostic value of the neurological examination in coma of unknown etiology

BackgroundIdentifying the cause of non-traumatic coma in the emergency department is challenging. The clinical neurological examination is the most readily available tool to detect focal neurological deficits as indicators for cerebral causes of coma. Previously proposed clinical pathways have granted the interpretation of clinical findings a pivotal role in the diagnostic work-up. We aimed to identify the actual diagnostic reliability of the neurological examination with regard to identifying acute brain damage.MethodsEight hundred and fifty-three patients with coma of unknown etiology (CUE) were examined neurologically in the emergency department following a predefined routine. Coma-explaining pathologies were identified retrospectively and grouped into primary brain pathology with proof of acute brain damage and other causes without proof of acute structural pathology. Sensitivity, specificity and percentage of correct predictions of different examination protocols were calculated using contingency tables and binary logistic regression models.ResultsThe full neurological examination was 74% sensitive and 60% specific to detect acute structural brain damage underlying CUE. Sensitivity and specificity were higher in non-sedated patients (87/61%) compared to sedated patients (64%/59%). A shortened four-item examination protocol focusing on pupils, gaze and pyramidal tract signs was only slightly less sensitive (67%) and more specific (65%).ConclusionsDue to limited diagnostic reliability of the physical examination, the absence of focal neurological signs in acutely comatose patients should not defer from a complete work-up including brain imaging. In an emergency, a concise neurological examination should thus serve as one part of a multimodal diagnostic approach to CUE.

P0020 / #1115: ASPIRATION THROMBECTOMY IN AN ADOLESCENT MALE PRESENTING WITH BILATERAL CEREBRAL VENOUS THROMBOSIS: CASE REPORT AND REVIEW OF LITERATURE FROM AN LOWER MIDDLE INCOME COUNTRY

Aims & Objectives: Bilateral Cerebral Venous Thrombosis (CVT) is a rare clinical presentation in the adolescent population and therefore offers a diagnostic challenge. The purpose of reporting this case is that the novel use of EMT in an adolescent with bilateral CVT has not been reported before and should be considered in as an emergent therapeutic adjunct in a similar case presentation. Methods: We present the case of a 17 year old boy who presented as non-traumatic coma and was found to have bilateral CVT on MRI. He subsequently underwent endovacular mechanical thrombectomy (EMT) Results: Case Presentation: We report a case of a 17 year old boy who presented as non-traumatic coma. Further imaging revealed extensive cerebral venous sinus thrombosis with hemorrhagic venous infarction in bilateral parietal lobes. Examination revealed a drowsy child. Hemodynamics were within the normal range. However, a detailed neurological examination revealed anisocoric pupils, increased tone in all four extremities and upgoing planters; He was started on Enoxaprin (1mg/kg SC Q12hourly); This was not an easy decision since the patient also had a hemorrhagic conversion in the infarct. There was no significant clinical improvement despite initiation of anticoagulation. A multidisciplinary decision led by neurology, hematology, and critical care decided on an emergent endovascular mechanical thrombectomy. Aspiration thrombectomy in the Superior sagittal sinus was performed and the enoxaparin was later switched to rivoroxaban. The patient showed dramatic clinical improvement. He regained consciousness with restoration of motor function.Conclusions: Endovascular mechanical thrombectomy is a safe therapeutic consideration of failed medical management for bilateral CVT.

Nontraumatic coma in the pediatric intensive care unit: etiology, clinical characteristics and outcome

Background/aimThe purpose of this study was to evaluate the etiology, clinical characteristics, and outcome of nontraumatic coma (NTC) among children admitted to a pediatric intensive care unit (PICU). Materials and methodsA total of 159 children with NTC were included in the study. The modified Glasgow coma scale (GCS) was used to assess consciousness. Patients were classified with regard to etiology. For each patient, demographic and clinical characteristics, survival and degree of disability at PICU discharge were recorded. ResultsMedian age was 55 months (IQR: 17.0 - 109.0). The most common cause of NTC was neuroinfection (31.4%) followed by toxic-metabolic conditions (25.8%) and epileptic disorder (15.1%). There was no significant relationship between the level of encephalopathy at admission and NTC etiology. A total of 13 patients died (8.2%). Among the survivors, 61.6% were discharged without any neurologic deficit, 2.8% had severe neurologic disability, and 3.4% were in a vegetative state. Complete neurological recovery was significantly more common in patients with toxic metabolic disease, whereas neurological deficits were more frequent in patients with tuberculous meningo-encephalitis (P = 0.01 and P = 0.04, respectively). Higher pediatric risk of mortality III (PRISM III) score at PICU admission (Odds ratio: 1.51, 95% CI: 1.19 - 1.92; P < 0.001) was the only variable that was independently associated with mortality. The length of stay (LOS) at hospital (Odds ratio: 0.73, 95% CI: 0.58-0.91; P = 0.006) was associated with improved odds of survival.ConclusionsAlthough results obtained from this single-center study cannot be generalized to the pediatric population, the contribution to the literature in terms of the relationships between NTC etiology, and outcome can be crucial for clinical decision-making. We report neuroinfection as the most common cause of NTC, and the only factor that was closely associated with mortality was PRISM III score. Length of hospital stay was inversely correlated to patient mortality.

Value of coma scale in prediction of mortality in non-traumatic coma in 1-12 years old children

Background: Acute non-traumatic coma is a common problem in pediatric practice accounting for 10-15% of all hospital admissions and is associated with significant mortality. Assessment of the severity of coma is essential to comment on the likelihood of survival in comatose children. In the last three decades, various scores have been used to assess the severity of coma and to predict its outcome. Glasgow Coma Scale (MGCS) in spite of its various drawbacks has been widely used for assessing pediatric coma, though only few studies are available to support its use in pediatric coma as a whole. Hence the study was undertaken to evaluate the usefulness of coma scale in prediction of mortality in children between 1-12 years old admitted with coma of non-traumatic origin. Methods: A prospective study was conducted at Inpatient services of intensive medical care unit and general medical wards of Institute of child Health and Hospital for children, Egmore, Chennai, between October 2018 to November 2019. A Study Population consisting of children in the age group 1-12 years admitted in intensive care unit and medical wards with alteration in sensorium as one of the predominant complaints and admitted within 7 days of onset of coma were included. Sample size was 148. Chi-square test was used to study the association between the scores at Various times points and outcome. Results: It was observed that when the scores were between 3‐ 5 mortality rate was 67.0%, it was 17% when the minimal observed score was between 6-8. The group in which the minimal score never decreased be1ow 9 had no mortality. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa. This type of association has been observed at different time points (Initial, 24 hrs, 48 hrs and 72 hrs). The significance of this association increases with the progression of time since admission. P value for the degree of association at various time points are: At presentation P &lt; 0.00001, 24hrs - P &lt; 0.000001, 48 hrs - P &lt; 0.000001 and 72 hrs P &lt; 0.00000001. Conclusion: There is highly statistically significant association between the GSC score levels and outcome. As the score increases the proportion of death decreases and the proportion having good recovery increases and vice versa.

Value of coma scale in prediction of mortality in non-traumatic coma in 1-12 years old children

Value of coma scale in prediction of mortality in non-traumatic coma in 1-12 years old children

Value of coma scale in prediction of outcome in non-traumatic coma in 1-12 years old children

Value of coma scale in prediction of outcome in non-traumatic coma in 1-12 years old children

Pediatrik non-travmatik koma prognozunu öngörmede klinik, elektroensefalografik ve nöroradyolojik parametrelerin rolü

Objective: To investigate early outcome of non-traumatic coma (NTC) in pediatric critical care in relation to prognostic role of clinical, electroencephalographic and neuro-radiological factors. Methods: A total of 77 children (mean(SD) age: 70.5±68.7 months, 55.8% were boys) with acute encephalopathy and NTC were included in this retrospective cross-sectional study. Data on patient demographics (age, gender, etiology of NTC) and four prognostic factors [Glasgow coma scores (GCS), pupillary light reflex (PLR), EEG and cranial MRI findings] and neurological outcome (ICU period and post-discharge 3rd month) were recorded in each patient. Results: Hypoxic-ischemic encephalopathy (35.1%) and CNS infection (22.1%) were the most common etiologies in the cohort. Favorable and unfavorable neurological outcome were noted in 57% and 43% of patients, respectively. Lack of PLR (OR 3.09, 95% CI: 2.17 to 4.40, p<0.001), GCS ≤5 (OR 7.85, 95% CI: 2.77 to 22.37, p<0.001), poor prognostic pattern in EEG (OR 13.76, 95% CI: 1.62 to 116.54, p=0.004) and presence of MRI lesions (OR 4.04, 95% CI: 1.15 to 14.19, p=0.029) were significant determinants of unfavorable neurological outcome. Conclusion: In conclusion, our findings emphasize that combined used of clinical, EEG and MRG patterns might provide more accurate estimation of neurological outcome in pediatric NTC.

English

English

Ophthalmological Findings in Paediatric Non-Traumatic Coma in Enugu State University Teaching Hospital, Parklane, Enugu, Nigeria

The ophthalmological examination is a vital aspect of the central nervous system examination in comatose children. Several authors have documented different findings with disparities in their recommendations about making ophthalmological examination a routine in the management of the unconscious child. This study sought to evaluate the relevance of routine ophthalmological examination in the management of unconscious children admitted into the paediatric emergency room of Enugu State University Teaching Hospital, Parklane, Enugu, Nigeria. This was a prospective longitudinal study conducted from April 2018 to March 2019. Unconscious patients whose caregivers gave consent were recruited into the study. Traumatic causes of coma were excluded. Demographic features of the patients were obtained. The ophthalmologic examination and diagnoses were made by an ophthalmologist, while the emergency room pediatrician made clinical assessment and diagnoses. Sixteen unconscious children had ophthalmologic examinations done. The Glasgow coma scale scores ranged from 3 to 11, with a mean of 6.6±2.2. Thirteen (81.3%) of the children were classified as severe unconsciousness while the rest were moderate. The degree of unconsciousness was significantly associated with the outcome (?2 =16.0, P = 0.03). A total of six (37.5%) ophthalmologic diagnoses were made, which included cerebral malaria, degenerative myopia, orbital cellulitis, and exposure keratopathy. The presence of an abnormal ophthalmologic finding was not significantly associated with outcome (?2 =0.36, P = 0.55). Routine ophthalmologic examination may not be justified as a management protocol in unconscious children but may be considered in selected cases.

Clinical profile of children presenting with nontraumatic coma

Clinical profile of children presenting with nontraumatic coma

Correlation of risk factors with Glasgow coma scale to predict the severity and outcome of children with non-traumatic coma

Background: Non-traumatic coma is the problem of pediatric group, accounts 10-15% in hospital admissions. Assessment of the severity of coma is useful to speculate the survival. The aim was to assess outcome in pediatric non-traumatic coma with role of Glasgow coma scale and modified Glasgow coma scale.Methods: Total of 80 cases of non-traumatic coma between 1 month to 12 years, coma severity was assessed by using Glasgow coma scale. A score of less than 8 and more than 8 were used for analysis of outcome.Results: The maximum number of patents with non-traumatic coma were in the age group of 1 month-5 years, 40 children (50%). On neurological examination 42 (52.5%) children has GCS score of &gt;8, 38 cases (47.5%) has GCS &lt;8, 20 children had meningeal signs, 7 children had cranial nerve deficit (7th nerve), 9 children had decebrate posture. Out of 80 cases, 8 cases expired (10%), 4 cases were discharged against medical advice (4%), 68 cases were improved and discharged (85%), among these, 8 cases were discharged with complication (11.7%). Overall mortality was (10%) (8/80), males outnumbered females in frequency with ratio of 1.28:1. CNS infection accounted for almost about 66%.Conclusions: Children with GCS and MGCS scores of less than 8 have poor prognosis and a very high probability of death. Those with GCS score of more than 8 have good prognosis. Identification of these cases at the outset can help prepare the treating physician to plan critical care referral and to give a preliminary assessment of outcome to the family.

Identification of Plasmodium falciparum and host factors associated with cerebral malaria: description of the protocol for a prospective, case-control study in Benin (NeuroCM)

IntroductionIn 2016, an estimated 216 million cases and 445 000 deaths of malaria occurred worldwide, in 91 countries. In Benin, malaria causes 26.8% of consultation and hospitalisation motif in the...

Study on clinical profile and etiology of acute febrile encephalopathy in children aged between 2 months to 14 years attending to a tertiary care hospital, Eluru, Andhra Pradesh, India

Background: Acute febrile encephalopathy (AFE) is a common conditionleading to hospitalization of children in India. CNS infections are commonest cause of non-traumatic coma in children. Although AFE is one of the major causes of hospital admissions of children and adults in India, only a few studies have been done on it so far.So this study was conducted to study the clinical profile and etiology of AFE in children. Methods: This prospective study was carried out on 84 children between 2 months to 14 years, with fever duration of<14 days, GCS ≤12 at the time of admission and altered sensorium in the pediatric intensive care unit over a period of 12 months from August 2017 to August 2018. Clinical profile and etiology were evaluated. Results: Thepresent study, has identified viral encephalitis (38%) and pyogenic meningitis (34.5%) as the major causes of Acute febrile encephalopathy in the study population. Most common symptoms apart from fever and altered sensorium were vomiting (58.3%), convulsions (45.2%), headache (35.7%), jaundice (8.3%), and most common presenting clinical signs apart from fever and GCS< 12 were neck stiffness (52.4%), signs of raised ICT (47.6%), positive Kernig’s sign (39.2%), and motor tone abnormalities (34.5%). Conclusion: In this study, we observed that CNS infections are the most common cause of febrile encephalopathy in children. Early recognition of the clinical signs and immediate and appropriate treatment will combat the problem and improve the survival rate.

S23. Mortality prediction with the status epilepticus severity score

Status epilepticus (SE) as a cause of impaired level of consciousness in intensive care unit (ICU) is reported in the international literature between 5% and 49%, probably underdiagnosed. The many different forms and stages of SE (Refractory SE, RSE and Super-Refractory SE, SRSE) are associated with neuronal injury and require optimal treatment. The Status Epilepticus Severity Score (STESS) was recently developed to predict outcome of SE. AIM: To determine the association between STESS scale and mortality in patients with epileptic status assisted in the ICU of a public hospital. Analytical, observational and retrospective study of cases of nontraumatic coma with clinical or electroencephalography criteria of SE (classified according to the International League Against Epilepsy, ILAE) admitted to the ICU in a tertiary care hospital in Buenos Aires, Argentina, over a three year period (2014–2017). The STESS scale was used. EEG was recorded using 21 electrodes placed according to the International 10–20 System, at least 60 min of artifact-free recording. We excluded cases with extra-axial brain compression lesions. The cohort consisted of 15 subjects who presented some type of SE, mean age was 49 years (± 18 years), 46% were women, time from ICU admission to first EEG: 2.5 days (±1.7 days). A total of 53% of patients had tonic-clonic SE, SRSE (40%) and RSE in the rest of the population. In-hospital mortality rate was 26%. The 86% presented acute brain injury (included stroke, hypoxic-ischemic encephalopathy, metabolic causes, autoimmune encephalitis and infectious encephalitis) and 13% was progressive causes (two patients with brain tumor). A total number of 13 cases (86%), presented with new onset SE without a history of epilepsy and 13% patients had active epilepsy on treatment. STESS scores were significantly higher in non-survivors compared to survivors (P-value = 0.0035). No statistically significant association was found between STESS scores and injury. Patients with STESS scores ⩽3 were found to survive. Follow-up with EEG was useful in 73% patients with SE who recover consciousness once the seizure has been aborted. Despite of the small sample size used in this study, the STESS scale at the admission could predict the evolution of SE. The STESS scores were found to be good predictor of mortality in UCI patients with SE. SE is a very heterogeneous condition in terms of clinical presentation and causes, the application of this scale can help to design better therapeutic regimens for the SE.

Proving cortical death after vascular coma: Evoked potentials, EEG and neuroimaging

ObjectivesSeveral studies have shown that bilateral abolition of somatosensory evoked potentials after a nontraumatic coma has 100% specificity for nonawakening with ethical consequences for active care withdrawal. We propose to evaluate the prognostic value of bilateral abolished cortical components of SEPs in severe vascular coma. MethodsA total of 144 comatose patients after subarachnoid haemorrhage were evaluated by multimodal evoked potentials (EPs); 7 patients presented a bilateral abolition of somatosensory and auditory EPs. Their prognosis value was interpreted with respect to brainstem auditory EPs, EEG, and structural imaging. ResultsOne patient emerged from vegetative state during follow-up; 6 patients did not return to consciousness. The main neurophysiological difference was a cortical reactivity to pain preserved in the patient who returned to consciousness. This patient had focal sub-cortical lesions, which could explain the abolition of primary cortical components by a bilateral deafferentation of somatosensory and auditory pathways. ConclusionsThis is the first report of a favourable outcome after a multimodal abolition of primary cortex EPs in vascular coma. For the 3 cases of vascular coma with preserved brainstem function, EEG reactivity and cortical EPs were abolished by a diffuse ischaemia close to cerebral anoxia. SignificanceThe complementarity of EPs, EEG, and imaging must be emphasised if therapeutic limitations are considered to avoid over-interpretation of the prognosis value of EPs.

Clinical profile and the outcome of children admitted to a tertiary care hospital with non-traumatic coma

Objective: To study the clinical profile, the outcome and to determine clinical signs predictive of the outcome in pediatric patients admitted with non-traumatic coma. Methods: This prospective study was conducted over a period of two years on 150 children between age group 2 months and 14 years admitted with non-traumatic coma to the PICU of a tertiary care state government run hospital of eastern India. Clinical parameters at admission and at 48 hours were analysed. Relevant laboratory investigations and radiological studies were documented. Outcomes were analysed at the time of discharge or death. Results: CNS infection was the leading cause of coma in 57.3 % of the cases, out of which acute bacterial meningitis in 38.4% cases, encephalitis in 33.7% cases, cerebral malaria in 18.6% cases and tuberculous meningitis in 9.3% cases. The toxic-metabolic conditions (21.3%) were overall second followed by status epilepticus (7.4%), intracranial haemorrhage (4%), and others (10%). Among the 99 (66%) children survived, 59(39.3%) were normal, 17(11.3%) had mild, 17(11.3%) had moderate and 6(4%) had severe disability. Survival was highest in ischemic stroke patients (100%) followed by patients with CNS infection (71%). Poor pulse volume, abnormal blood pressure, respiratory pattern, poor GCS and abnormal brain stem reflexes at admission or at 48 hours showed significant correlation with mortality. The abnormal heart rate, abnormal motor pattern, the presence of papilledema and convulsion if present at 48 hrs were poor predictors of survival. Conclusion: CNS infection was the commonest aetiology and clinical signs at 48 hrs of admission were important predictors of mortality.

Clinical profile and predictors of outcome in children with Non-traumatic Coma undergoing decompressive Craniectomy : A tertiary center experience

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.