Pediatric Neurocritical Care

  • Takashi Araki


Pediatric neurocritical care is a multidisciplinary field of medicine. The main role of pediatric neurocritical care is improving outcomes in children with primary brain injury by various neurological diseases and limiting secondary brain injury through state-of-the-art critical care delivery and the support of integrating neuronal function. Recognition of neurological deficits in children is not easy even for an experienced clinician. The diseases such as stroke, cardiac arrest, and traumatic brain injury (TBI) have distinct clinical and pathophysiological characteristics that distinguish them from their adult features and prevent the direct translation of the adult experience to pediatric patients. In addition, the importance of the application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit has been aware in both primary neurological and primary non-neurological disease. Although much can be learned from the adult experience, there is a need for evidence-based guidelines in pediatric neurocritical care since there are differences in the circumstances that surround the emergence of neurocritical care in pediatrics.


Pediatric Traumatic brain injury Stroke Cardiac arrest Neuromonitoring 


  1. 1.
    Margulies SS, Thibault KL. Infant skull and suture properties: measurements and implications for mechanisms of pediatric brain injury. J Biomech Eng. 2000;122:364–71. Pubmed: 11036559.CrossRefPubMedGoogle Scholar
  2. 2.
    Ommaya AK, Goldsmith W, Thibault L. Biomechanics and neuropathology of adult and paediatric head injury. Br J Neurosurg. 2002;16:220–42. Pubmed: 12201393.CrossRefPubMedGoogle Scholar
  3. 3.
    Bailey DK. The normal cervical spine in infants and children. Radiology. 1952;59:712–9. Pubmed: 12994006.CrossRefPubMedGoogle Scholar
  4. 4.
    Fesmire FM, Luten RC. The pediatric cervical spine: developmental anatomy and clinical aspects. J Emerg Med. 1989;7:133–42. Pubmed: 2661668.CrossRefPubMedGoogle Scholar
  5. 5.
    Stafford PW, Blinman TA, Nance ML. Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am. 2002;82:273–301. Pubmed: 12113366.CrossRefPubMedGoogle Scholar
  6. 6.
    Adewale L. Anatomy and assessment of the pediatric airway. Paediatr Anaesth. 2009;19(Suppl 1):1–8. Pubmed: 19572839.CrossRefPubMedGoogle Scholar
  7. 7.
    Jakob H, et al. Pediatric polytrauma management. Eur J Trauma Emerg Surg. 2010;36:325–38. Pubmed: 26816037.CrossRefPubMedGoogle Scholar
  8. 8.
    Gutierrez IM, Ben-Ishay O, Mooney DP. Pediatric thoracic and abdominal trauma. Minerva Chir. 2013;68:263–74. Pubmed: 23774091.PubMedGoogle Scholar
  9. 9.
    Christiano JG, Tummers M, Kennedy A. Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma. J Pediatr Surg. 2009;44:1242–8. Pubmed: 19524748.CrossRefPubMedGoogle Scholar
  10. 10.
    Williams M, Lee JK. Intraoperative blood pressure and cerebral perfusion: strategies to clarify hemodynamic goals. Paediatr Anaesth. 2014;24:657–67. Pubmed: 24725244.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Suttipongkaset P, et al. Blood pressure thresholds and mortality in pediatric traumatic brain injury. Pediatrics. 2018;142 pii: e20180594. Pubmed: 30064999.CrossRefGoogle Scholar
  12. 12.
    Schöning M, Hartig B. Age dependence of total cerebral blood flow volume from childhood to adulthood. J Cereb Blood Flow Metab. 1996;16:827–33. Pubmed: 8784227.CrossRefPubMedGoogle Scholar
  13. 13.
    Wu C, et al. Age-related changes of normal cerebral and cardiac blood flow in children and adults aged 7 months to 61 years. J Am Heart Assoc. 2016;5 pii: e002657. Pubmed: 26727967.
  14. 14.
    Kehrer M, Schöning M. A longitudinal study of cerebral blood flow over the first 30 months. Pediatr Res. 2009;66:560–4. Pubmed: 19668104.CrossRefPubMedGoogle Scholar
  15. 15.
    Wintermark M, et al. Brain perfusion in children: evolution with age assessed by quantitative perfusion computed tomography. Pediatrics. 2004;113:1642–52. Pubmed: 15173485.CrossRefPubMedGoogle Scholar
  16. 16.
    Kochanek PM, et al. Biochemical, cellular, and molecular mechanisms in the evolution of secondary damage after severe traumatic brain injury in infants and children: lessons learned from the bedside. Pediatr Crit Care Med. 2000;1:4–19. Pubmed: 12813280.CrossRefPubMedGoogle Scholar
  17. 17.
    Verlhac S. Transcranial Doppler in children. Pediatr Radiol. 2011;41(Suppl 1):S153–65. Pubmed: 21523592.CrossRefPubMedGoogle Scholar
  18. 18.
    Sharma D, Souter MJ, Moore AE, Lam AM. Clinical experience with transcranial Doppler ultrasonography as a confirmatory test for brain death: a retrospective analysis. Neurocrit Care. 2011;14:370–6. Pubmed: 20694525.CrossRefPubMedGoogle Scholar
  19. 19.
    Allen BB, Chiu YL, Gerber LM, Ghajar J, Greenfield JP. Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury. Pediatr Crit Care Med. 2014;15:62–70. Pubmed: 24196011.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Miller Ferguson N, et al. Intracranial hypertension and cerebral hypoperfusion in children with severe traumatic brain injury: thresholds and burden in accidental and abusive insults. Pediatr Crit Care Med. 2016;17:444–50. Pubmed: 27028792.CrossRefPubMedGoogle Scholar
  21. 21.
    Mehta A, et al. Relationship of intracranial pressure and cerebral perfusion pressure with outcome in young children after severe traumatic brain injury. Dev Neurosci. 2010;32:413–9. Pubmed: 20847542.CrossRefPubMedGoogle Scholar
  22. 22.
    Kochanek PM, 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–S82. Pubmed: 22217782.CrossRefPubMedGoogle Scholar
  23. 23.
    Robertson CS, et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med. 1999;27:2086–95. Pubmed: 10548187.CrossRefPubMedGoogle Scholar
  24. 24.
    Figaji AA, Fieggen AG, Argent AC, Leroux PD, Peter JC. Does adherence to treatment targets in children with severe traumatic brain injury avoid brain hypoxia? A brain tissue oxygenation study. Neurosurgery. 2008;63:83–91., discussion 91. Pubmed: 18728572.CrossRefPubMedGoogle Scholar
  25. 25.
    Paulson OB, Strandgaard S, Edvinsson L. Cerebral autoregulation. Cerebrovasc Brain Metab Rev. 1990;2:161–92. Pubmed: 2201348.PubMedGoogle Scholar
  26. 26.
    Lassen NA. Cerebral blood flow and oxygen consumption in man. Physiol Rev. 1959;39:183–238. Pubmed: 13645234.CrossRefPubMedGoogle Scholar
  27. 27.
    Altman DI, Volpe JJ. Positron emission tomography in newborn infants. Clin Perinatol. 1991;18:549–62. Pubmed: 1934855.CrossRefPubMedGoogle Scholar
  28. 28.
    Vavilala MS, Lee LA, Lam AM. The lower limit of cerebral autoregulation in children during sevoflurane anesthesia. J Neurosurg Anesthesiol. 2003;15:307–12. Pubmed: 14508171.CrossRefPubMedGoogle Scholar
  29. 29.
    Stiefel MF, et al. Brain tissue oxygen monitoring in pediatric patients with severe traumatic brain injury. J Neurosurg. 2006;105(4 Suppl):281–6. Pubmed: 17328278.CrossRefPubMedGoogle Scholar
  30. 30.
    Figaji AA, Kent SJ. Brain tissue oxygenation in children diagnosed with brain death. Neurocrit Care. 2010;12:56–61. Pubmed: 19847675.CrossRefPubMedGoogle Scholar
  31. 31.
    Prins ML. Glucose metabolism in pediatric traumatic brain injury. Childs Nerv Syst. 2017;33:1711–8. Pubmed: 29149386.CrossRefPubMedGoogle Scholar
  32. 32.
    Hutchinson P, O’Phelan K, Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring. International multidisciplinary consensus conference on multimodality monitoring: cerebral metabolism. Neurocrit Care. 2014;21(Suppl 2):S148–58. Pubmed: 25208673.CrossRefPubMedGoogle Scholar
  33. 33.
    Tolias C, Richards D, Bowery N, Sgouros S. Investigation of extracellular amino acid release in children with severe head injury using microdialysis. A pilot study. Acta Neurochir Suppl. 2002;81:377–9. Pubmed: 12168351.PubMedGoogle Scholar
  34. 34.
    Tolias CM, Richards DA, Bowery NG, Sgouros S. Extracellular glutamate in the brains of children with severe head injuries: a pilot microdialysis study. Childs Nerv Syst. 2002;18:368–74. Pubmed: 12192496.CrossRefPubMedGoogle Scholar
  35. 35.
    Ketharanathan N, et al. Combining brain microdialysis and translational pharmacokinetic modeling to predict drug concentrations in pediatric severe traumatic brain injury: the next step toward evidence-based pharmacotherapy? J Neurotrauma. 2018;36. Pubmed: 30019622.CrossRefGoogle Scholar
  36. 36.
    Rohlwink UK, et al. The relationship between intracranial pressure and brain oxygenation in children with severe traumatic brain injury. Neurosurgery. 2012;70:1220–30., discussion 1231. Pubmed: 22134142.CrossRefPubMedGoogle Scholar
  37. 37.
    Bell MJ, et al. Differences in medical therapy goals for children with severe traumatic brain injury-an international study. Pediatr Crit Care Med. 2013;14:811–8. Pubmed: 23863819.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Human T, et al. Treatment of hyponatremia in patients with acute neurological injury. Neurocrit Care. 2017;27:242–8. Pubmed: 28054290.CrossRefPubMedGoogle Scholar
  39. 39.
    Valentine SL, et al. Consensus recommendations for RBC transfusion practice in critically ill children from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med. 2018;19:884–98. Pubmed: 30180125.CrossRefPubMedGoogle Scholar
  40. 40.
    Figaji AA, et al. The effect of blood transfusion on brain oxygenation in children with severe traumatic brain injury. Pediatr Crit Care Med. 2010;11:325–31. Pubmed: 19794323.CrossRefPubMedGoogle Scholar
  41. 41.
    Dhabangi A, et al. Cerebral oximetry in Ugandan children with severe anemia: clinical categories and response to transfusion. JAMA Pediatr. 2016;170:995–1002. Pubmed: 27532507.CrossRefPubMedGoogle Scholar
  42. 42.
    Güresir E, Schuss P, Seifert V, Vatter H. Decompressive craniectomy in children: single-center series and systematic review. Neurosurgery. 2012;70:881–8, discussion 888–9CrossRefGoogle Scholar
  43. 43.
    Pérez Suárez EP, et al. Decompressive craniectomy in 14 children with severe head injury: clinical results with long-term follow-up and review of the literature. J Trauma. 2011;71:133–40. Pubmed: 21818021.CrossRefPubMedGoogle Scholar
  44. 44.
    Thomale UW, Graetz D, Vajkoczy P, Sarrafzadeh AS. Severe traumatic brain injury in children—a single center experience regarding therapy and long-term outcome. Childs Nerv Syst. 2010;26:1563–73. Pubmed: 20177687.CrossRefPubMedGoogle Scholar
  45. 45.
    Adamo MA, Drazin D, Waldman JB. Decompressive craniectomy and postoperative complication management in infants and toddlers with severe traumatic brain injuries. J Neurosurg Pediatr. 2009;3:334–9. Pubmed: 19338415.CrossRefPubMedGoogle Scholar
  46. 46.
    Jagannathan J, et al. Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up. J Neurosurg. 2007;106(4 Suppl):268–75. Pubmed: 17465359.CrossRefPubMedGoogle Scholar
  47. 47.
    Josan VA, Sgouros S. Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury. Childs Nerv Syst. 2006;22:1268–74. Pubmed: 16496158.CrossRefPubMedGoogle Scholar
  48. 48.
    Rutigliano D, et al. Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure. J Pediatr Surg. 2006;41:83–7., discussion 83. Pubmed: 16410113.CrossRefPubMedGoogle Scholar
  49. 49.
    Oluigbo CO, et al. Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccidental blunt cranial trauma. J Neurosurg Pediatr. 2012;9:125–32. Pubmed: 22295915.CrossRefPubMedGoogle Scholar
  50. 50.
    Taylor A, et al. A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst. 2001;17:154–62. Pubmed: 11305769.CrossRefPubMedGoogle Scholar
  51. 51.
    Ardissino M, Tang A, Muttoni E, Tsang K. Decompressive craniectomy in paediatric traumatic brain injury: a systematic review of current evidence. Childs Nerv Syst. 2018. Pubmed: 30215120.CrossRefGoogle Scholar
  52. 52.
    Rocque BG, et al. Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study. J Neurosurg Pediatr. 2018;22:225–32. Pubmed: 29882736.CrossRefPubMedGoogle Scholar
  53. 53.
    Moler FW, et al. Therapeutic hypothermia after out-of-hospital cardiac arrest in children. N Engl J Med. 2015;372:1898–908. Pubmed: 25913022.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Moler FW, et al.; THAPCA Trial Investigators. Therapeutic hypothermia after in-hospital cardiac arrest in children. N Engl J Med. 2017;376:318–29. Pubmed: 28118559.CrossRefGoogle Scholar
  55. 55.
    Hutchison JS, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008;358:2447–56. Pubmed: 18525042.CrossRefPubMedGoogle Scholar
  56. 56.
    Adelson PD, et al. Comparison of hypothermia and normothermia after severe traumatic brain injury in children (cool kids): a phase 3 randomised controlled trial. Lancet Neurol. 2013;12:546–53. Pubmed: 23664370.CrossRefPubMedGoogle Scholar
  57. 57.
    Crompton EM, et al. Meta-analysis of therapeutic hypothermia for traumatic brain injury in adult and pediatric patients. Crit Care Med. 2017;45:575–83. Pubmed: 27941370.CrossRefPubMedGoogle Scholar
  58. 58.
    Ma C, et al. Is therapeutic hypothermia beneficial for pediatric patients with traumatic brain injury? A meta-analysis. Childs Nerv Syst. 2013;29:979–84. Pubmed: 23503613.CrossRefPubMedGoogle Scholar
  59. 59.
    Zhang BF, et al. Meta-analysis of the efficacy and safety of therapeutic hypothermia in children with acute traumatic brain injury. World Neurosurg. 2015;83:567–73. Pubmed: 25514616.CrossRefPubMedGoogle Scholar
  60. 60.
    Rosario BL, et al. Presenting characteristics associated with outcome in children with severe traumatic brain injury: a secondary analysis from a randomized, controlled trial of therapeutic hypothermia. Pediatr Crit Care Med. 2018. Pubmed: 30067578.
  61. 61.
    Dixon RR, Nocera M, Zolotor AJ, Keenan HT. Intracranial pressure monitoring in infants and young children with traumatic brain injury. Pediatr Crit Care Med. 2016;17:1064–72. Pubmed: 27632060.CrossRefPubMedPubMedCentralGoogle Scholar
  62. 62.
    Dean NP, Boslaugh S, Adelson PD, Pineda JA, Leonard JR. Physician agreement with evidence-based recommendations for the treatment of severe traumatic brain injury in children. J Neurosurg. 2007;107(5 Suppl):387–91. Pubmed: 18459901.CrossRefPubMedGoogle Scholar
  63. 63.
    Keenan HT, Nocera M, Bratton SL. Frequency of intracranial pressure monitoring in infants and young toddlers with traumatic brain injury. Pediatr Crit Care Med. 2005;6:537–41. Pubmed: 16148812.CrossRefPubMedPubMedCentralGoogle Scholar
  64. 64.
    Anderson RC, et al. Complications of intracranial pressure monitoring in children with head trauma. J Neurosurg. 2004;101(1 Suppl):53–8. Pubmed: 16206972.CrossRefPubMedGoogle Scholar
  65. 65.
    Baldwin HZ, Rekate HL. Preliminary experience with controlled external lumbar drainage in diffuse pediatric head injury. Pediatr Neurosurg. 1991/1992;17:115–20. Pubmed: 1819324.CrossRefGoogle Scholar
  66. 66.
    Levy DI, et al. Controlled lumbar drainage in pediatric head injury. J Neurosurg. 1995;83:453–60. Pubmed: 7666222.CrossRefPubMedGoogle Scholar
  67. 67.
    Shapiro K, Marmarou A. Clinical applications of the pressure-volume index in treatment of pediatric head injuries. J Neurosurg. 1982;56:819–25. Pubmed: 7077382.CrossRefPubMedGoogle Scholar
  68. 68.
    Woernle CM, Burkhardt JK, Bellut D, Krayenbuehl N, Bertalanffy H. Do iatrogenic factors bias the placement of external ventricular catheters?—a single institute experience and review of the literature. Neurol Med Chir (Tokyo). 2011;51:180–6. Pubmed: 21441733.CrossRefGoogle Scholar
  69. 69.
    Miller C, Tummala RP. Risk factors for hemorrhage associated with external ventricular drain placement and removal. J Neurosurg. 2017;126:289–97. Pubmed: 27035168.CrossRefPubMedGoogle Scholar
  70. 70.
    Figaji AA, Zwane E, Fieggen AG, Peter JC, Leroux PD. Acute clinical grading in pediatric severe traumatic brain injury and its association with subsequent intracranial pressure, cerebral perfusion pressure, and brain oxygenation. Neurosurg Focus. 2008;25:E4. Pubmed: 18828702.CrossRefPubMedGoogle Scholar
  71. 71.
    Skippen P, et al. Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med. 1997;25:1402–9. Pubmed: 9267957.CrossRefPubMedGoogle Scholar
  72. 72.
    Warner KJ, Cuschieri J, Copass MK, Jurkovich GJ, Bulger EM. The impact of prehospital ventilation on outcomeafter severe traumatic brain injury. J Trauma. 2007;62:1330–6.CrossRefGoogle Scholar
  73. 73.
    Kasoff SS, Lansen TA, Holder D, Filippo JS. Aggressive physiologic monitoring of pediatric head trauma patients with elevated intracranial pressure. Pediatr Neurosci. 1988;14:241–9. Pubmed: 3151702.CrossRefPubMedGoogle Scholar
  74. 74.
    Marshall GT, et al. Pentobarbital coma for refractory intra-cranial hypertension after severe traumatic brain injury: mortality predictions and one-year outcomes in 55 patients. J Trauma. 2010;69:275–83. Pubmed: 20699736.CrossRefPubMedGoogle Scholar
  75. 75.
    Pittman T, Bucholz R, Williams D. Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely head-injured children. Pediatr Neurosci. 1989;15:13–7. Pubmed: 2635769.CrossRefPubMedGoogle Scholar
  76. 76.
    Mellion SA, et al. High-dose barbiturates for refractory intracranial hypertension in children with severe traumatic brain injury. Pediatr Crit Care Med. 2013;14:239–47. Pubmed: 23392360.CrossRefPubMedGoogle Scholar
  77. 77.
    Chung MG, O’Brien NF. Prevalence of early posttraumatic seizures in children with moderate to severe traumatic brain injury despite levetiracetam prophylaxis. Pediatr Crit Care Med. 2016;17:150–6. Pubmed: 26669640.CrossRefPubMedGoogle Scholar
  78. 78.
    Liesemer K, Bratton SL, Zebrack CM, Brockmeyer D, Statler KD. Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. J Neurotrauma. 2011;28:755–62. Pubmed: 21381863.CrossRefPubMedGoogle Scholar
  79. 79.
    Vaewpanich J, Reuter-Rice K. Continuous electroencephalography in pediatric traumatic brain injury: seizure characteristics and outcomes. Epilepsy Behav. 2016;62:225–30. Pubmed: 27500827.CrossRefPubMedPubMedCentralGoogle Scholar
  80. 80.
    Kurz JE, et al. Variation in anticonvulsant selection and electroencephalographic monitoring following severe traumatic brain injury in children-understanding resource availability in sites participating in a comparative effectiveness study. Pediatr Crit Care Med. 2016;17:649–57. Pubmed: 27243415.CrossRefPubMedPubMedCentralGoogle Scholar
  81. 81.
    Ostahowski PJ, et al. Variation in seizure prophylaxis in severe pediatric traumatic brain injury. J Neurosurg Pediatr. 2016;18:499–506. Pubmed: 27258588.CrossRefPubMedGoogle Scholar
  82. 82.
    O’Neill BR, Handler MH, Tong S, Chapman KE. Incidence of seizures on continuous EEG monitoring following traumatic brain injury in children. J Neurosurg Pediatr. 2015;16:167–76. Pubmed: 25955809.CrossRefPubMedGoogle Scholar
  83. 83.
    Abend NS, et al. Impact of continuous EEG monitoring on clinical management in critically ill children. Neurocrit Care. 2011;15:70–5. Pubmed: 20499208.CrossRefPubMedPubMedCentralGoogle Scholar
  84. 84.
    Shahwan A, Bailey C, Shekerdemian L, Harvey AS. The prevalence of seizures in comatose children in the pediatric intensive care unit: a prospective video-EEG study. Epilepsia. 2010;51:1198–204. Pubmed: 20163439.CrossRefPubMedGoogle Scholar
  85. 85.
    Chapman SB, McKinnon L. Discussion of developmental plasticity: factors affecting cognitive outcome after pediatric traumatic brain injury. J Commun Disord. 2000;33:333–44. Pubmed: 11001160.CrossRefPubMedGoogle Scholar
  86. 86.
    McCauley SR, et al. Recommendations for the use of common outcome measures in pediatric traumatic brain injury research. J Neurotrauma. 2012;29:678–705. Pubmed: 21644810.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Takashi Araki
    • 1
  1. 1.Department of Emergency and Critical Care Medicine, Saitama Medical CenterSaitama Medical UniversityKawagoeJapan

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