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Updated: Jun 24, 2026
Controlled Cortical Impact Model for Traumatic Brain Injury
Published on: August 5, 2014
Decompressive craniectomy and postoperative complication management in infants and toddlers with severe traumatic
Matthew A Adamo1, Doniel Drazin, John B Waldman
1Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; and.
Insights
Decompressive craniectomy in infants with severe traumatic brain injury can lead to reasonable neurological recovery. Careful management of postoperative complications, such as CSF fistulas, is crucial for successful outcomes in pediatric neurosurgery.
Area of Science:
- Pediatric Neurosurgery
- Traumatic Brain Injury Management
- Cerebral Edema Treatment
Background:
- Infants with severe traumatic brain injury (TBI) present unique challenges due to limited cranial vault space, making volume increases poorly tolerated.
- Cerebral edema in infants following TBI necessitates aggressive management strategies to prevent secondary brain injury.
- Decompressive craniectomy is a surgical option to reduce intracranial pressure in severe TBI cases.
Purpose of the Study:
- To evaluate the safety and efficacy of decompressive craniectomy in infants suffering from severe traumatic brain injury and cerebral edema.
- To analyze the neurological outcomes and complications associated with this procedure in a pediatric population.
- To identify potential improvements in surgical technique and postoperative management for this patient group.
Main Methods:
- Retrospective review of medical charts for seven infants treated for severe TBI with cerebral edema between January 2004 and July 2007.
- Data collected included patient demographics, injury mechanisms (nonaccidental trauma or infarction), neurological status on admission, surgical intervention (hemicraniectomy or frontal craniectomy), and postoperative outcomes.
- Neurological recovery was assessed using the King's Outcome Scale for Childhood Head Injury (KOSCHI) during outpatient follow-up.
Main Results:
- Six infants underwent hemicraniectomy, and one had a frontal craniectomy; all had severe TBI with cerebral edema and poor initial neurological status.
- Postoperative complications included cerebrospinal fluid (CSF) fistulas in three patients, leading to external ventricular drains, epidural/subdural empyemas, and hydrocephalus requiring shunts.
- All patients had bone replacement within 1-6 months, with two requiring reoperation for bone resorption; however, all achieved functional recovery with improved motor skills and cognitive interaction.
Conclusions:
- Decompressive craniectomy can be a safe and effective procedure for infants with severe TBI, offering reasonable neurological recovery despite poor initial presentation.
- Anticipation and prompt management of postoperative complications, particularly CSF fistulas and infections, are critical for successful outcomes.
- Recommendations include dural augmentation, subdural drains or ventriculostomy, and consideration of T-shaped incisions to optimize wound healing and reduce complication rates.
Object:
Infants with severe traumatic brain injury represent a therapeutic challenge. The internal absence of open space within the infant cranial vault makes volume increases poorly tolerated. This report presents 7 cases of decompressive craniectomy in infants with cerebral edema.
Methods:
The authors reviewed the medical charts of infants with brain injuries who presented to Albany Medical Center Hospital between January 2004 and July 2007. Variables that were examined included patient age, physical examination results at admission, positive imaging findings, surgery performed, complications, requirement of permanent CSF diversion, and physical examination results at discharge and outpatient follow-up using the King's Outcome Scale for Childhood Head Injury. Seven infants met the inclusion criteria for the study. Six infants experienced nonaccidental trauma, and 1 had a large infarction of the middle cerebral artery territory secondary to a carotid dissection. At admission, all patients were minimally responsive, 4 had equal and minimally reactive pupils, 3 had anisocoria with the enlarged pupil on the same side as the brain lesion, and all had right-sided hemiparesis. Six patients received a left hemicraniectomy, whereas 1 received a left frontal craniectomy. In all cases, bone was cultured and stored at the bone bank.
Results:
Postoperatively, 3 patients who developed draining CSF fistulas needed insertions of external ventricular drains, with incisions oversewn using nylon sutures and a liquid bonding agent. After prolonged CSF drainage and wound care, these patients all developed epidural and subdural empyemas necessitating surgical drainage and debridement. Methicillin-resistant Staphylococcus aureus was found in 2 patients and Enterococcus in the third. All patients developed hydrocephalus necessitating the insertion of a ventriculoperitoneal shunt, and all had bone replaced within 1-6 months from the time of the original operation. Two patients required reoperation due to bone resorption. At outpatient follow-up visits, all had scores of 3 or 4 on the King's Outcome Scale for Childhood Head Injury. Each patient was awake, interactive, and could sit, as well as either crawl or walk with assistance. All had persistent, improving right-sided hemiparesis and spasticity.
Conclusions:
Despite poor initial examination results, infants with severe traumatic brain injury can safely undergo decompressive craniectomy with reasonable neurological recovery. Postoperative complications must be anticipated and treated appropriately. Due to the high rate of CSF fistulas encountered in this study, it appears reasonable to recommend both the suturing in of a dural augmentation graft and the placement of either a subdural drain or a ventriculostomy catheter to relieve pressure on the healing surgical incision. Also, one might want to consider using a T-shaped incision as opposed to the traditional reverse question mark-shaped incision because wound healing may be compromised due to the potential interruption of the circulation to the posterior and inferior limb with this latter incision.
