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Published on: August 16, 2019
Bilateral decompressive craniectomy as a damage control strategy for a preschooler multilobar bihemispheric firearm
Caio Perret1,2, Leonardo B Oliveira3, Maria Fernanda P Santana4
1Department of Neurosurgery, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil.
Insights
Bilateral decompressive hemicraniectomy is a viable strategy for managing severe pediatric gunshot wounds to the head with bihemispheric lesions. This approach, detailed in a case report, shows promising outcomes in young children.
Area of Science:
- Neurosurgery
- Pediatric Trauma
- Emergency Medicine
Background:
- Management guidelines for pediatric gunshot wounds to the head (GSWH) with bihemispheric lesions are lacking.
- Prompt and diverse damage control strategies are crucial for these complex injuries.
Observation:
- A 4-year-old girl with a GSWH sustained bihemispheric lesions and presented with neurological deficits.
- Initial management involved staged bilateral decompressive hemicraniectomies with autologous pericranium augmentation duraplasty.
- The patient demonstrated significant neurological recovery and was discharged with minor residual deficits.
Findings:
- A systematic review identified limited evidence for GSWH management in preschoolers.
- The case report and review suggest bilateral decompressive hemicraniectomy is a feasible strategy for bihemispheric GSWH in this age group.
- Low-quality evidence necessitates further research into optimal management protocols.
Implications:
- Bilateral decompressive hemicraniectomy may be a critical intervention for severe pediatric GSWH with bihemispheric involvement.
- This case highlights the potential for positive outcomes with aggressive surgical management.
- Further research is needed to establish evidence-based guidelines for this rare but devastating injury.
Abstract:
The absence of guidelines for managing gunshot wounds to the head (GSWH) with bihemispheric lesions in pediatric patients highlights the need for prompt and diverse damage control strategies. This article aims to systematically evaluate the evidence surrounding the management of GSWH in preschoolers and to report a novel approach. We present a case of a 4-year-old girl who sustained a gunshot wound to the left parietal region. She was admitted to a level 1 trauma center 90 min post-injury with stable vital signs, a Glasgow coma scale (GCS) of 12 (E3, V3, M6), and grade III hemiparesis in her right upper limb. Initial surgical management included left hematoma decompression and right frontotemporoparietal decompressive hemicraniectomy in two stages under the same anesthesia. Due to massive brain swelling during the left-sided procedure, it was converted to a left frontotemporoparietal decompressive hemicraniectomy. Both procedures included autologous pericranium augmentation duraplasty and watertight suturing. A right-side decompressive hemicraniectomy followed without exploring bullet lodging, using bilateral Kempe incisions. Bone flaps were stored under cryopreservation. During a 30-day hospital stay, neurological assessments showed a gradual recovery of right upper limb strength to grade IV + , with no other deficits or operative complications. Postoperative CT scans at 7, 14, and 28 days showed minor pseudomeningoceles and a reduction of intraparenchymal edema. Multidisciplinary care continued throughout the stay. The patient showed no signs of endocrinological, infectious, or residual neurological issues and underwent bilateral autologous cranioplasty on day 35. She was discharged on day 38 with a GCS extended of 8 (full recovery/minor deficits not affecting daily activities) and minor right upper limb apraxia. A systematic review identified nine patients under 6 years old with GSWH, with only one previously reported case of a 3-year-old patient with bihemispheric lesions undergoing bilateral craniectomies and achieving positive outcomes. Our case and the review suggest that bilateral decompressive hemicraniectomy is a feasible strategy for managing multilobar bihemispheric GSWH in preschoolers. However, the evidence of management for this population remains of low quality, highlighting the need for further research, and justifying this case report.
