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Table of Contents    
CORRESPONDENCE
Year : 2016  |  Volume : 64  |  Issue : 6  |  Page : 1419-1421

Role of ICP monitoring in children with head injuries: Some thoughts


Department of Neurosurgery, Park Clinic, 4 Gorky Terrace, Kolkata - 700 017, West Bengal, India

Date of Web Publication11-Nov-2016

Correspondence Address:
Sandip Chatterjee
Department of Neurosurgery, Park Clinic, 4 Gorky Terrace, Kolkata - 700 017, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.193790

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How to cite this article:
Chatterjee S. Role of ICP monitoring in children with head injuries: Some thoughts. Neurol India 2016;64:1419-21

How to cite this URL:
Chatterjee S. Role of ICP monitoring in children with head injuries: Some thoughts. Neurol India [serial online] 2016 [cited 2019 Aug 20];64:1419-21. Available from: http://www.neurologyindia.com/text.asp?2016/64/6/1419/193790


Sir,

Head injuries are the leading cause of mortality in the pediatric age group. It has been established by previous reports that a sudden rise in intracranial pressure (ICP) is the cause of severe morbidity or mortality and that sustained elevation of intracranial pressure above 20 mmHg for more than 5 minutes may have disastrous consequences.[1],[2] It has been proposed [3] to monitor treatment in head injuries in the pediatric age group using ICP or the cerebral perfusion pressure (CPP) as the endpoint. The target for maintaining ICP below 20 mmHg is based on studies done in adults. Studies on pediatric patients have documented that variations in ICP from 15 mmHg to 30 mmHg are regarded as optimum pressures to ensure that adequate CPP is maintained.[4],[5] However, extrapolating from adult studies, one may assume that 20 mmHg represents the optimal level at which ICP should be maintained in children as well. On the question of which children with head injuries require ICP monitoring, there is no Class I evidence at all, although those with Glasgow Coma Scale (GCS) score between 3 and 8 are considered as appropriate candidates.

At what level should CPP be maintained in children? The answer from adults should be 50-70 mmHg. However, we know this is not true, and in children, maintaining CPP between 40 and 60 mmHg may be adequate. It is well known that CPP below 40 mmHg is associated with a poor prognosis.[6]

All efforts in the treatment of head injuries lie in controlling secondary injury- that which is caused by inadequate perfusion of the surviving brain tissue. It is here that ICP monitoring plays a major role. Determining the exact role that ICP monitoring in children has played in influencing the overall outcome would be difficult as there are many confounding factors which have not been individually evaluated – e.g., protocol driven intensive trauma unit care, tracheal intubation, aggressive treatment of hypotension and hypovolaemia, etc. Yet, a number of studies have documented a definitely higher incidence of reduced CPP in children with head injuries.[7],[8],[9] It does appear from available studies that in a child with a moderate-to-major head injury, the chance of developing a compromised CPP is higher than in adults.

Does this mean we have proof that ICP monitoring is necessary or helpful in children? Seventeen studies up to date involving some 970 children have demonstrated an association between ICP greater than 20 mmHg and a poor neurological outcome. Two of the studies [9],[10] have demonstrated a definite relationship between aggressive intervention to keep the ICP down and the ultimate outcome. The first of these studies prospectively looked at 100 children with severe TBI treated with combinations of hyperventilation, cerebrospinal fluid drainage, sedation and pharmacological paralysis. It reported a better one year outcome in children whose intracranial pressure had been successfully lowered compared to those in whom it was uncontrollable. The second was a retrospective study that sought to establish almost the same thing. Both these studies like a lot of the others, however, represent Class III evidence at best.

Two issues have never been adequately addressed. First, does aggressive medical management, in the absence of ICP monitoring, have a worse prognosis in children? Second, is there a subgroup stratification in children with severe head injuries to determine the subjects who would definitely benefit from recording the value of ICP level? The answer to both these questions are not yet available. Neither is there a randomized study to compare children with and without monitoring during treatment, nor is there a randomized stratification to identify the specific group where the ICP may rise suddenly and preclude an early intervention. Whether this intervention should be in the nature of hyperventilation, decompressive craniectomy or other measures is an issue which also has been debated at length but never settled. In fact a recent study [11] has felt that brain tissue oxygen tension (PbtO2), which is an important indicator of outcome after head injury, correlates poorly with ICP and CPP recordings in children. Perhaps this means that the role of ICP monitoring has less predictive value in children than in adults. A recent randomised study [12] of adults with head injury, who were either treated on the basis of head injury monitoring or clinico-radiological parameters, found no significant difference in the primary outcome measures between the two groups. Perhaps the time has come to plan for a similar study in children! A recent study treating paediatric head injuries with intracranial pressure targeted therapy, based on the so-called Lund Principle, found a favourable outcome when this protocol was followed.[13] However, the trial had few patients and was a retrospective two centre study. ICP monitoring is mandatory in the Lund concept. The threshold for intracranial hypertension defined by the authors in this study was 20 mmHg, which is in agreement with the paediatric guidelines.[14]

In summary, therefore, there is an urgent need to design a randomised prospective trial comparing the two groups of children with moderate-to-severe head injuries: Those with and without ICP monitorings. To do so, of course, one would need to define a clear set of endpoints as well.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McLaughlin MR, Marion DW. Cerebral blood flow and vasoresponsivity within and around cerebral contusions. J Neurosurg 1996;85:871-6.  Back to cited text no. 1
    
2.
Marmarou A. Increased intracranial pressure in head injury and influence of blood volume. J Neurotrauma 1992;9(Suppl 1):S327-32.  Back to cited text no. 2
    
3.
Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents – Second edition. Pediatr Crit Care Med 2012;13(Suppl 1):S1-82.  Back to cited text no. 3
    
4.
Roumeliotis N, Pettersen G, Crevier L, Émeriaud G. ICP monitoring in children: Why are we not adhering to guidelines? Childs Nerv Sys 2015;31:2011-4.  Back to cited text no. 4
    
5.
Adelson PD, Ragheb J, Kanev P, Brockmeyer D, Beers SR, Brown SD, et al. Phase II clinical trial of moderate hypothermia after severe traumatic brain injury in children. Neurosurgery 2005;56:740-54.  Back to cited text no. 5
    
6.
Elias-Jones AC, Punt JA, Turnbull AE, Jaspan T. Management and outcome of severe head injuries in the Trent region 1985-90. Arch Dis Child 1992;67:1430-5.  Back to cited text no. 6
    
7.
Downard C, Hulka F, Mullins RJ, Piatt J, Chesnut R, Quint P, et al. Relationship of cerebral perfusion pressure and survival in pediatric brain-injured patients. J Trauma. 2000;49:654-8.  Back to cited text no. 7
    
8.
Downard C, Hulka F, Mullins RJ, Piatt J, Chesnut R, Quint P, et al. Relationship of cerebral perfusion pressure and survival in pediatric brain-injured patients. J Trauma. 2000;49:654-8.  Back to cited text no. 8
    
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Alberico AM, Ward JD, Choi SC. Outcome after severe head injury. Relationship to mass lesions, diffuse injury and ICP course in pediatric and adult patients. J Neurosurg 1987;67:648-56.  Back to cited text no. 9
    
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Jagannathan J, Okonkwo DO, Yeoh HK, Dumont AS, Saulle D, Haizlip J, et al. Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure. J Neurosurg Pediatr 2008;2:240-9.  Back to cited text no. 10
    
11.
Figaji AA, Zwane E, Thompson C, Fieggen AG, Argent AC, Le Roux PD, et al. Brain tissue oxygen tension monitoring in pediatric severe traumatic brain injury. Part 2: Relationship with clinical, physiological, and treatment factors. Childs Nerv Syst 2009;25:1335-43.  Back to cited text no. 11
    
12.
Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, et al. Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367:2471-81.  Back to cited text no. 12
    
13.
Wahlstrom MR, Olivecrona M, Koskinen LD, Rydenhag B, Naredi S. Severe traumatic brain injury in pediatric patients: Treatment and outcome using an intracranial pressure targeted therapy- the Lund concept. Intensive Care Med 2005;31:832-9.  Back to cited text no. 13
    
14.
Carney NA, Chesnut R, Kochanek PM. Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Crit Care Med 2003; 31:417-91.  Back to cited text no. 14
    




 

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