Severe head injury in children: Impact of risk factors on outcome

Background: Outcome after severe head injury has been shown in some studies to be more favorable in children than in adults. Mortality rates reported range between 20% and 40% for children. Only contradicting data are available regarding the impact of trauma modalities on long-term outcome, or the relative influence of head fractures, intracranial hemorrhages, and brain edema on survival or neurologic sequelae in children. Methods: A retrospective study in a tertiary care facility of long-term outcome of children after severe head injury, and analysis of risk factors for poor outcome. All children up to 16 years of age with severe head injury (Glasgow Coma Scale [GCS] score less than or equal to 8), which have been treated in the pediatric intensive care unit from 1977 until 1994 in a single institution. Results: A total of 150 children with severe head injury (GCS score less than or equal to 8) were treated, 92 of them (61.3%) had traffic-related injuries, The median age was 6.6 years (SD +/- 3.6), There were 96 boys (64%) and 54 girls (36%), Sixty-five children (43.3%) had skull fractures, 87 patients (58.0%) developed an intracranial hemorrhage, and 79 patients (52.7%) developed a diffuse brain swelling/edema visible in computed tomographic scans within 72 hours after trauma. Of 150 children treated, 33 died (22%), In most cases, death was related to the development of secondary brain edema. Fifty-nine children (39.3%) had severe neurologic impairments at the time of discharge, The most significant risk factors for adverse outcome, shown by multivariate analysis, were primary areflexia and secondary brain edema. The risk for development of brain edema and poor prognosis was well predicted by the GCS score. Conclusion: The overall death rate in this study of children with severe head injury was low (22%) compared with other studies, However, the incidence of severe neurologic impairment at discharge remained high. The major risks for death or neurologic impairment were primary areflexia and the development of secondary brain swelling/edema, indicated by a low GCS score.