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Local Coverage for Acute Severely Herniated Brain Using Scalp and Forehead Flaps in a Pediatric Patient With Head
Matthew Brown1, Navid Pourtaheri, Kristopher Katira
1*Division of Plastic Surgery †Department of Neurosurgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH.
Insights
This case study details successful temporary coverage of malignant brain herniation in a pediatric head trauma patient using local tissue flaps. The innovative approach ensured brain protection and good cosmetic outcomes.
Area of Science:
- Neurosurgery
- Pediatric Trauma Care
- Reconstructive Surgery
Background:
- Acute subdural hematoma in pediatric head trauma can lead to malignant brain herniation.
- Management of severe brain swelling and intracranial pressure is critical.
Observation:
- A 4-year-old boy with severe head trauma experienced massive sinus hemorrhage and brain swelling.
- Emergent craniectomy and drainage were performed, requiring complex wound management.
Findings:
- Temporary coverage of herniated brain was achieved using synthetic dural substitute and acellular dermal matrix.
- Subsequent coverage with scalp and forehead flaps, along with cadaveric skin grafting, facilitated recovery.
- Final reconstruction utilized autologous banked bone after resolution of intracranial pressure and hydrocephalus.
Implications:
- Local tissue flaps offer an effective, tissue-preserving method for temporary coverage in pediatric malignant brain herniation.
- This technique avoids the sacrifice of patient's own skin or the need for free flap options.
- Successful application demonstrates potential for good functional and cosmetic recovery in severe pediatric head trauma cases.
Abstract:
A 4-year-old-boy required emergent craniectomy and drainage of a large right-sided acute subdural hematoma after head trauma, during which massive sinus hemorrhage with brain swelling occurred. Acute intraoperative management entailed dural cover using synthetic dural membrane substitute and scalp coverage over the herniated brain using acellular dermal matrix. After intensive monitoring and control of raised intracranial pressure over the next few days, the exposed brain was then covered by scalp and forehead flaps with cadaveric skin grafting to the donor site. This temporary coverage continued until adequate resolution of the intracranial swelling and control of the hydrocephalus using a ventriculoperitoneal shunt. Ultimately, the flaps were derotated and the craniectomy site was reconstructed with autologous banked bone. The child had a significant functional recovery with some residual left-sided weakness. This case is the first report of local tissue flaps used for temporary coverage of malignant brain herniation in a pediatric head trauma patient and highlights their effective use. Through serial surgical procedures the brain was successfully covered without significant blood loss and the patient's local tissues returned to their original donor sites with good cosmetic outcome, without sacrifice of the patient's own skin or free flap options.
