(844) Clinical Predictors of Raised Intracranial Pressure in Children With Nontraumatic Coma in the PICU

Introduction: Early recognition and treatment of raised ICP can prevent secondary ischemic brain injury. Invasive ICP monitoring is not always available in resource limited settings, hence clinical and neuroimaging can help to identify raised ICP earlier in children with non-traumatic coma (NTC). This retrospective cohort study aimed to identify clinical predictors of raised ICP in children with NTC who underwent invasive ICP monitoring.

Methods: Children, one to 12 y old with NTC having clinical and/or radiological features of raised ICP and who underwent invasive intraparenchymal ICP monitoring from 2019-2022 in a quaternary care PICU, were included. They were divided into two groups based on invasive ICP values: Children with invasive normal ICP and invasive raised ICP values (>20mm Hg). Clinical presentation, neurological signs, non-invasive neuromonitoring like optic nerve sheath diameter (ONSD), NIRS, and outcome parameters were compared between the two groups. Data were analysed using SPSS 20. Potential predictors of invasive raised ICP were identified and analysed by univariate and multivariate regression.

Results: We enrolled 79 children (51 males) with NTC with a median age of 62 months (IQR 39, 96). Viral encephalitis and bacterial meningitis were the commonest etiologies. 37% (n=29) children with clinical/ radiological features of raised ICP had normal ICP values on invasive ICP monitoring. Abnormal pupillary response at admission and at ICP catheter insertion, GCS < 4, and decerebrate posturing at ICP catheter insertion were significantly associated with invasive raised ICP. On multivariate, abnormal pupillary response at ICP catheter insertion, was an independent predictor of invasive raised ICP. Increase in ONSD was significantly associated with invasive raised ICP (4.7+2 Vs 5.2+3 mm, p=0.0001).

Conclusions: Clinical symptoms and signs are great masquerades, and their presence doesn’t always indicate raised ICP. We found abnormal pupillary response as the only clinical sign that predicted actual raised ICP among children with clinical features of raised ICP. Raised ONSD has also shown promise in detecting raised ICP. Combination of clinical signs, neuroimaging findings and noninvasive neuromonitoring modalities may predict raised ICP better than clinical signs alone in children with NTC.