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Published on: July 5, 2011
The role of decompressive craniectomy in children with severe traumatic brain injury
N El Hindy1, K P Stein2, V Hagel2
1Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany. nicolai.elhindy@uk-essen.de.
Insights
Decompressive craniectomy (DC) in children with severe traumatic brain injury (TBI) and refractory intracranial pressure (ICP) may offer similar outcomes to conservative management. Continuous ICP monitoring is crucial for surgical timing.
Area of Science:
- Pediatric Neurosurgery
- Trauma Surgery
- Critical Care Medicine
Background:
- Severe traumatic brain injury (TBI) is a leading cause of mortality in children.
- Elevated intracranial pressure (ICP) is a critical complication following severe TBI.
- Decompressive craniectomy (DC) is a surgical option for refractory ICP.
Purpose of the Study:
- To analyze the outcomes of pediatric patients with severe TBI treated with DC for elevated ICP.
- To compare outcomes between conservative management and secondary DC in children with refractory ICP.
Main Methods:
- Retrospective analysis of 56 children (<16 years) with severe TBI (2001-2011).
- Focus on children with generalized traumatic brain swelling without mass lesions.
- Comparison of outcomes between conservative treatment and secondary DC using descriptive statistics.
Main Results:
- Eight children presented with generalized brain swelling and impending herniation.
- Four children received conservative management; four underwent secondary DC.
- DC group had longer ICU stays and ventilation times; concomitant injuries were more severe.
- Glasgow Outcome Scale (GOS) was similar between conservative and DC groups.
Conclusions:
- Decompressive surgery may yield favorable outcomes comparable to conservative management in refractory ICP pediatric TBI.
- Surgical timing for DC should be guided by neurological deterioration and continuous ICP monitoring.
Objective:
Severe traumatic brain injury (TBI) remains the leading cause of death in children. The present study analyses the outcome of children after severe TBI treated by decompressive craniectomy (DC) due to elevated intracranial pressure (ICP) in a single centre.
Methods:
Fifty-six consecutive children (age < 16 years) were treated for severe TBI at our institution between 2001 and 2011. For study purposes, children with severe generalized traumatic brain swelling without concomitant mass lesion were further analysed. Descriptive statistics were used to report clinical conditions as well as outcome measurements after conservative treatment only in comparison to secondary decompressive craniectomy.
Results:
Of 56 children, a total of eight children presented with generalized and progressive traumatic brain swelling and impending brain herniation. Four children were treated conservatively following standardized local protocol for anti-oedematous management, with ICP amenable to intensified therapy. Four children required decompressive surgery due to progressive oedema refractory to intensified conservative management. Children receiving secondary DC had a longer stay in the intensive care unit as well as a longer average time of assisted ventilation compared to children treated conservatively. Concomitant injuries were more severe in the DC subgroup. Yet, Glasgow Outcome Scale was equally distributed in both groups.
Conclusion:
In children with refractory ICP conditions due to severe TBI, decompressive surgery might lead to a similar favourable outcome compared to children in whom ICP can be controlled only by conservative management. Timing of surgery depends on the neurological deterioration of the patients and a continuous ICP monitoring.
