Frontal Cerebral Vulnerability and Executive Deficits from Raised Intracranial Pressure in Child Traumatic Brain Injury

In severe pediatric traumatic brain injury (TBI), a common focus of treatment is raised intracranial pressure (ICP). The aim of this investigation was to test whether raised ICP is associated with later prefrontal executive deficits and regional brain tissue loss, consistent with an anterior vascular compartment syndrome. Thirty-three participants were assigned to one of two severe TBI groups based on whether or not they had increased ICP complicating their critical illness. At follow-up (average 3.9 years), the participants underwent magnetic resonance imaging and a battery of neuropsychological testing focused on prefrontal function. The ICP group had white matter loss that was diffuse as well as regional in the corpus callosum, periventricular tissue, and frontal region. Loss of gray matter in the ICP group was more regionally specific, with bilateral loss in the caudate nuclei and frontal regions, including the right dorsolateral region, right supplementary motor area, and the left orbitofrontal cortex. Both groups had normal intelligence quotients (IQs), but the ICP group showed long-term deficits on various measures of attention and executive function such as working memory, decision-making, and impulsivity. These findings suggest that raised ICP leads to diffuse brain injury and a predilection to hypo-perfusion in, at least, the distribution of the anterior cerebral artery. Furthermore, since voxel-based morphometry (VBM) and measures of attention and executive function are sensitive to the phenomenon of raised ICP, we consider that these techniques warrant inclusion in trials assessing ICP-directed therapy.