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Impact of Decompressive Craniectomy on Diagnosing Brain Death in Children
Betül Ekici1, İrem Ersayoğlu2, Pınar Yazıcı Özkaya2
1Department of Pediatrics, Ege University School of Medicine, İzmir, Turkey.
Insights
Decompressive craniectomy (DC) complicates brain death (BD) diagnosis in children, leading to more examinations and delayed determination. Current guidelines lack specific recommendations for these pediatric intensive care unit cases.
Area of Science:
- Pediatric critical care medicine
- Neurology
- Neurosurgery
Background:
- Brain death (BD) determination is critical in pediatric intensive care units (PICUs).
- Decompressive craniectomy (DC) is a surgical procedure used to reduce intracranial pressure.
- The impact of DC on the BD determination process in children is not well-defined.
Purpose of the Study:
- To evaluate the effects of decompressive craniectomy (DC) on the brain death (BD) determination process in the pediatric intensive care unit (PICU).
Main Methods:
- Retrospective review of pediatric patients diagnosed with BD in the PICU from 2009-2020.
- Comparison of BD examination frequency and time intervals between patients with and without DC.
- Analysis of patient demographics, causative mechanisms, and ancillary tests used for BD diagnosis.
Main Results:
- 70 pediatric BD cases were identified (13.6% of total deaths).
- Patients with DC underwent a higher median number of BD examinations (3 vs. 2) and had a significantly longer time interval between the first examination and BD declaration (45.5 hours vs. 15 hours).
- Transcranial Doppler ultrasound was used in 94.3% of cases, often combined with the apnea test.
Conclusions:
- Decompressive craniectomy may complicate BD determination, particularly for cerebral flow imaging techniques.
- The absence of specific guidelines for patients with DC contributes to delayed BD diagnosis.
- Further research and guideline clarification are needed for accurate BD diagnosis in pediatric patients who have undergone DC.
Objective:
In this study, we aimed to evaluate the effects of decompressive craniectomy (DC) on the brain death (BD) determination process in the pediatric intensive care unit (PICU).
Materials And Methods:
All children who were diagnosed with BD in the PICU between 2009 and 2020 were included in this study. Patient demographics, causative mechanisms, BD examinations, and ancillary tests used were recorded. The time intervals (from PICU admission to first BD examination, from first BD examination to BD diagnosis) and number of BD examinations were compared between patients with and without DC.
Results:
During the study period, 70 pediatric cases were diagnosed with BD among 513 total deaths (13.6%). Their median age was 54.5 months [interquartile range (IQR): 24-140]. Transcranial Doppler ultrasound (TCD) was performed in 66 patients (94.3%). The most common combination of ancillary tests was the apnea test and TCD combination, which was performed in 56 patients (80%). Thirty-four children (48.6%) experienced immediate surgery for DC. Patients with DC had a higher median number of BD examinations than patients without DC [3 (IQR: 2-3) vs. 2 (IQR: 1-2), P < .001]. The patients with DC had a longer time interval between the first examination and declaration of BD than patients without DC [45.5 hours (IQR: 21.7-91.7) versus 15 hours (IQR: 2-31.2), P < .006].
Conclusion:
Decompressive craniectomy may complicate BD determination and cause challenges for brain death diagnosis based on cerebral flow imaging techniques. The lack of specific recommendations for this patient group in the guidelines causes a delayed diagnosis of BD. Cite this article as: Ekici B, Ersayoğlu İ, Yazıcı Özkaya P, Cebeci K, Koç G, Turanlı EE. Impact of decompressive craniectomy on diagnosing brain death in children. Turk Arch Pediatr. 2024;59(1):93-97.
