Extraventricular Drainage as First-Tier Management of Raised Intracranial Pressure After Severe Pediatric Trauma Brain Injury

Objective - To present the most efficatious management of raised intracranial pressure after severe trauma brain injury in a pediatric patient. Case report - A 5-year-old Caucasian presented to the emergency room due to head injury caused by falling down stairs. At the time of admission the patient was comatose with pediatric Glasgow Coma Score 6 (V-1, E-1, M-4) and signs of recent posterior head trauma. Computed tomography (CT) scan showed a multifragmented fracture of the occipital bone above the “sinus lake” causing an epidural mass, contusion in the right cerebellar hemisphere, a skull base fracture without signs of midline shifting. Six hours later, during monitoring in the intensive care unit, the patient became cardiorespiratory unstable with signs of uncal brain herniation and Cushing’s triad. Control CT revealed previously verified posttraumatic changes with new signs of decompensating internal hydrocephalus. Considering that evacuation of the epidural collection and decompression of impaired bone fragments in the area of the “sinus lake” would be too risky, extraventricular drainage as the first tier management was properly selected as the option of treatment. Taking into account the hazard / benefit ratio it was shown to be the most effective form of treatment, which was confirmed after six-month follow-up without any form of neurocognitive impairment. Conclusion – Treatment of traumatic brain injury (TBI) in the pediatric population requires a multidisciplinary approach. Different mechanisms of pediatric TBI injury vary widely by age groups and its impact on the development of primary and secondary brain lesions differs. Although many general principles of managing pediatric TBI are similar to adults, cerebral plasticity is one of the features which ultimately always leaves space for a better final outcome of treatment.