Hypertonic saline solution and decompressive craniectomy for treatment of intracranial hypertension in pediatric severe traumatic brain injury.

Experimental data 8 –11 and first clinical results in adults 12,13 suggest that hypertonic saline ( 1.0) may be highly effective in lowering ICP even when mannitol has lost its therapeutic potential after prolonged and repeated use. In children, only limited experience exists with the use of hypertonic saline solutions: a randomized prospective study in children with severe head injury compared the effects on ICP (increased to 15–20 mm Hg) of isotonic (0.9% NaCl) and hypertonic (3% NaCl) saline injections, demonstrating a beneficial effect of the hypertonic solution. 14 Another prospective randomized trial compared the effects of continuous infusion of either lactated Ringer’s solution (277 mOsm/L) or hypertonic saline solution (598 mOsm/L) in children with severe head injury (Glasgow Coma Scale [GCS] score 8). 15 Patients receiving hypertonic saline were found to require fewer interventions, have fewer complications, and have shorter ICU stays. A higher serum sodium concentration was associated with a lower ICP and a higher CPP. 15,16 In a 14-year-old boy with trauma-related secondary ischemic injury of the brain stem, infusions of 2.7% and 5.4% NaCl were associated with improvement of somatosensory and brain stem auditory evoked potentials and of motor performance. 17 However, repetitive bolus infusions of highly concentrated (7–20% NaCl) hypertonic saline have not yet been used for reduction of increased ICP in pediatric head injury. Surgical treatment of severe head injury is not limited to the introduction of ventricular drainage and evacuation of mass lesions such as hematomas and large contusions. In addition, decompressive craniectomy may be performed to increase intracranial compliance considerably. This procedure may produce good results when performed early before the development of secondary brain damage occurs. 18,19 Conversely, poor results are seen when craniectomy is performed late as a last resort to prevent herniation in otherwise hopeless cases. 20 Few institutions perform decompressive craniectomy routinely in pediatric severe head injury. Results of a combination of early decompressive craniectomy and administration of hypertonic saline have not yet been reported. A new, aggressive treatment concept including such a combination was used in two children with severe head injury to reduce otherwise intractable ICP elevations.