Pediatric Traumatic Brain Injury & Neurocritical Care

What are pediatric traumatic brain injuries?

From a simple “bump on the head” to severe traumatic brain injury requiring ICU care—what do these terms mean in practice?

The term traumatic brain injury (TBI) refers to any injury involving the skull, brain, or meninges. These injuries are classified as mild, moderate, or severe based on:

• level of consciousness (Glasgow Coma Scale),
• duration of loss of consciousness,
• duration of post-traumatic amnesia,
• and findings on CT/MRI imaging.

Severe pediatric TBI typically implies GCS ≤ 8, need for intubation and mechanical ventilation, often in the presence of intracranial hematomas, cerebral edema, or diffuse axonal injury. These conditions require immediate transfer to a specialized center with a pediatric neurosurgeon and pediatric neurointensivist.

How common are they and at what ages do they occur?

TBIs are among the most frequent causes of trauma in children, although the vast majority are mild. Severe injuries are less common but carry substantially higher morbidity.

Internationally, traumatic brain injuries represent one of the leading causes of disability and death in children and adolescents aged 1–18 years. In younger children, most cases are related to falls (stairs, playground equipment, windows), whereas in adolescents, motor vehicle accidents and certain contact sports predominate.

Fortunately, only a small proportion of injured children develop severe TBI. However, within this group the risk of permanent neurological deficits or loss of life is substantial. Early recognition and a well-organized trauma system (prehospital care, emergency department, operating room, ICU) are critical determinants of outcome.

What are the most common causes and mechanisms of injury?

Understanding “how the accident occurred” helps estimate the severity of potential brain injury.

Common mechanisms in children

• Falls (from strollers, stairs, playground equipment, bicycles, windows).
• Motor vehicle accidents as passengers, pedestrians, or cyclists.
• Sports-related injuries (soccer, basketball, cycling, skiing, contact sports).
• Non-accidental injury (especially in infants—“shaken baby” syndrome).

Trauma may result in:

• Focal lesions—epidural/subdural hematomas, intracerebral hemorrhage, skull fractures.
• Diffuse injury—diffuse axonal injury, generalized cerebral edema.
• Secondary injury—hypoxia, hypotension, elevated intracranial pressure, seizures, infection, coagulation disorders.

Which symptoms should raise concern?

When can a child be observed at home after a head injury, and when is urgent hospital evaluation required?

Symptoms that require immediate medical assessment/emergency care:

• Loss of consciousness, lethargy, difficulty arousing, or confusion.
• Repeated vomiting, severe or worsening headache.
• Unequal pupils, visual disturbances, diplopia.
• Weakness of limbs, difficulty walking or moving.
• Seizures.
• Bleeding or clear fluid from nose/ear, skull fractures, significant fall or high-speed accident.
• In infants: persistent crying, somnolence, bulging fontanelle, behavioral change.

Any child with a severe clinical presentation or high-risk mechanism should be treated as having a potential severe TBI until proven otherwise.

How is diagnosis made and what is the initial assessment?

From the emergency department to the ICU—what steps are taken to stabilize the child and assess the brain?

Initial management follows the principles of Advanced Trauma Life Support (ATLS):

• Airway, breathing, circulation (ABCs).
• Rapid assessment of consciousness using the Glasgow Coma Scale (GCS).
• Evaluation for associated injuries (chest, abdomen, skeletal trauma).

The primary imaging modality is head CT, which identifies hematomas, fractures, and signs of cerebral edema. MRI is often used later for detailed assessment of diffuse injuries.

In contrast to older practice, routine repeat CT scans without clinical indication are not recommended. Repeat imaging is reserved for neurological deterioration or suspicion of new pathology.

What happens in the ICU – principles of neurocritical care

In the Intensive Care Unit, the goal is not only survival but protection of the brain from secondary injury.

Primary ICU objectives

• Maintain adequate oxygenation and arterial blood pressure.
• Avoid hypoxia, hypotension, hypoglycemia, and hyperthermia.
• Monitor and control intracranial pressure (ICP).
• Prompt treatment of seizures and electrolyte disturbances.
• Optimal head positioning, analgesia, and sedation as indicated.

Care is multidisciplinary: pediatric neurosurgeon, intensivist, anesthesiologist, trauma specialists, nurses trained in pediatric critical care, physiotherapists, and, early on, the rehabilitation team.

What are intracranial pressure (ICP) and cerebral perfusion pressure (CPP)?

Two core concepts in neurocritical care that guide therapeutic decisions.

Intracranial pressure (ICP) is the pressure within the skull resulting from brain tissue, cerebrospinal fluid, and blood. Excessive elevation can compress brain tissue and compromise perfusion.

In children with severe TBI, international guidelines generally aim to maintain ICP below approximately 20 mmHg (with age-specific adjustments).

Cerebral perfusion pressure (CPP) reflects the pressure driving blood flow to the brain and depends on arterial pressure and ICP. In children, a CPP target of approximately 40–50 mmHg is often pursued, individualized by age and clinical context.

For precise monitoring, selected cases undergo placement of an ICP monitoring device (ventricular catheter or intraparenchymal sensor), allowing real-time assessment and tailored treatment.

Which treatments are used to control ICP?

Medications, CSF drainage, ventilation strategies—what is their role and what does the evidence show?

Hypertonic solutions & osmotherapy

• Hypertonic saline (3% NaCl) is the most evidence-based option for acute ICP elevation, administered as bolus or continuous infusion to reduce cerebral edema and maintain ICP < 20 mmHg.
• Mannitol may also be used, though pediatric evidence is less robust compared with hypertonic saline.

Cerebrospinal fluid drainage

Placement of an external ventricular drain (EVD) allows both ICP monitoring and therapeutic CSF drainage. In selected cases, lumbar drainage may be considered if there is no risk of herniation.

Ventilation & carbon dioxide

Mild hyperventilation may transiently reduce ICP; however, prophylactic hyperventilation (PaCO₂ < 30 mmHg) within the first 48 hours after TBI is not recommended, as it may dangerously reduce cerebral blood flow.

Additional measures

• Antiepileptic prophylaxis (commonly phenytoin or levetiracetam) to prevent early post-traumatic seizures.
• Avoidance of corticosteroids in TBI—they do not improve outcomes and may increase complications.
• Therapeutic hypothermia remains investigational; strict maintenance of normothermia and avoidance of fever are clearly beneficial.

When is surgery or decompressive craniectomy required?

The role of the pediatric neurosurgeon in rapid decompression and control of intracranial hypertension.

Surgery may be required:

• for evacuation of hematomas (epidural, subdural, intracerebral),
• for CSF diversion (EVD placement),
• for decompressive craniectomy when ICP remains refractory despite maximal medical therapy.

In decompressive craniectomy, a large portion of the skull is removed and the dura is expanded (duraplasty), allowing the swollen brain to expand without compression. This procedure can be life-saving and may improve outcomes in selected children with refractory intracranial hypertension. The bone flap is replaced at a later stage (cranioplasty).

What are the potential complications and long-term consequences?

Even when a child survives, recovery after severe TBI may be prolonged and demanding—physically, cognitively, and psychologically.

Potential complications include:

• Neurological deficits—weakness, spasticity, motor impairment.
• Cognitive difficulties—attention, memory, processing speed, executive function, academic performance.
• Epilepsy—early or late post-traumatic seizures requiring long-term treatment.
• Emotional & behavioral changes—irritability, anxiety, depression, social integration challenges.
• ICU- and surgery-related complications (infections, hydrocephalus, cranial deformities after craniectomy, etc.).

Early, structured neurorehabilitation (physical therapy, speech therapy, occupational therapy, neuropsychological support) is essential to limit long-term sequelae.

What is the prognosis and the role of rehabilitation?

Every child is different, yet we understand key factors influencing outcome and ways to optimize recovery and reintegration.

Prognosis depends on:

• severity of the initial injury (GCS, imaging findings),
• speed and quality of initial management,
• presence of secondary insults (hypotension, hypoxia, prolonged elevated ICP),
• associated injuries and medical conditions,
• intensity and duration of organized rehabilitation.

Many children, particularly at younger ages, can achieve remarkable neurological and functional recovery, even after severe TBI, when appropriately supported. Others may require long-term educational, psychological, and social assistance.

At Neuroknife, we emphasize early initiation of rehabilitation already in the ICU, close collaboration with specialized rehabilitation centers, and comprehensive family guidance for the post-hospital phase.