Decompressive craniectomy with massive intractable intraoperative cerebral edema: utilization of silicone sheet for temporary scalp closure

Case report

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The authors present a case of extreme brain herniation encountered during decompressive craniectomy in a 21-month-old boy who suffered a trauma event that necessitated temporary scalp closure in which a sterile silicone sheet was placed. Although the clinical situation is usually expected to lead to brain death or severe disability, the patient's 3-year follow-up examination revealed a highly functional child with a good quality of life. The authors discuss the feasibility and advantages of temporary scalp expansion as a treatment option when extreme brain herniation is encountered during craniotomy.

Abbreviations used in this paper:DIC = disseminated intravascular coagulopathy; ICP = intracranial pressure.

Article Information

Address correspondence to: Gerald Tuite, M.D., Neuroscience Institute, All Children's Hospital, 601 5th Street South, Suite 511, Saint Petersburg, Florida 33701. email: geraldtuite@gmail.com.

Please include this information when citing this paper: published online July 13, 2012; DOI: 10.3171/2012.6.PEDS11567.

© AANS, except where prohibited by US copyright law.

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Figures

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    Preoperative CT scans of the head obtained at the referring hospital. Left and Right: Axial images at presentation to the original emergency department indicating left frontal acute-on-chronic subdural hematoma with extension to the parafalcine region. There is associated mass effect and midline shift with effacement of bihemispheric sulci.

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    Axial CT scan obtained after the initial craniotomy. Note the left frontotemporal craniectomy. Mass effect is still present with extracranial herniation through craniectomy site. Parafalcine hematoma is again noted. Monitoring of ICP indicated an intractable increase.

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    Intraoperative photographs taken during the second operation. Note the silicone sheet that augments skin closure.

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    Postoperative axial CT scan obtained after application of the Silastic sheet. The image was acquired 1 day after the repeat craniectomy. Note the significant extracranial herniation of entire left cerebral hemisphere with associated multifocal intraparenchymal hematoma.

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    Photographic and radiographic follow-up. A: Photograph and axial CT scan obtained 8 weeks postoperatively. B: Axial CT scans acquired 12 months postoperatively (status after cranioplasty). C: Follow-up MR T1- and T2-weighted images obtained 3.5 years postoperatively.

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    Clinical follow-up. Moderate right facial weakness is only present when patient is asked to smile. Right hemiplegia persists as documented using the Developmental Motor Scale.

References

  • 1

    Aghakhani NDurand PChevret LParker FDevictor DTardieu M: Decompressive craniectomy in children with nontraumatic refractory high intracranial pressure. Clinical article. J Neurosurg Pediatr 3:66692009

    • Search Google Scholar
    • Export Citation
  • 2

    Appelboom GZoller SDPiazza MASzpalski CBruce SSMcDowell MM: Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery. Neurosurg Focus 31:5E52011

    • Search Google Scholar
    • Export Citation
  • 3

    Bourke-Taylor H: Melbourne Assessment of Unilateral Upper Limb Function: construct validity and correlation with the Pediatric Evaluation of Disability Inventory. Dev Med Child Neurol 45:92962003

    • Search Google Scholar
    • Export Citation
  • 4

    Burger RDuncker DUzma NRohde V: Decompressive craniotomy: durotomy instead of duroplasty to reduce prolonged ICP elevation. Acta Neurochir Suppl 102:93972008

    • Search Google Scholar
    • Export Citation
  • 5

    Cushing H: The establishment of cerebral hernia as a decompressive measure for inaccessible brain tumors; with the description of intermuscular methods of making the bone defect in temporal and occipital regions. Surg Gynecol Obstet 1:2973141905

    • Search Google Scholar
    • Export Citation
  • 6

    Frye RE: Advances and limitations in our knowledge of cortical reorganization in cerebral palsy. Dev Med Child Neurol 54:2982992012. (Letter)

    • Search Google Scholar
    • Export Citation
  • 7

    Guresir ESchuss PSeifert VVatter H: Decompressive craniectomy in children. Single center series and systematic review. Neurosurgery 68:152715342011

    • Search Google Scholar
    • Export Citation
  • 8

    Jacob ATHeuer GGGrant RGeorgoff PDanish SFStorm PB: Decompressive hemicraniectomy for pediatric traumatic brain injury: long-term outcome based on quality of life. Pediatr Neurosurg 47:81862011

    • Search Google Scholar
    • Export Citation
  • 9

    Johnston MV: Plasticity in the developing brain: implications for rehabilitation. Dev Disabil Res Rev 15:941012009

  • 10

    Ma JYou CMa LHuang S: Is decompressive craniectomy useless in severe traumatic brain injury?. Crit Care 15:1932011

  • 11

    Quinn TMTaylor JJMagarik JAVought EKindy MSEllegala DB: Decompressive craniectomy: technical note. Acta Neurol Scand 123:2392442011

    • Search Google Scholar
    • Export Citation
  • 12

    Timmons SDUllman JSEisenberg HM: Craniectomy in diffuse traumatic brain injury. N Engl J Med 365:3732011. (Letter)

  • 13

    Wang HHLiao HFHsieh CL: Reliability, sensitivity to change, and responsiveness of the peabody developmental motor scales-second edition for children with cerebral palsy. Phys Ther 86:135113592006

    • Search Google Scholar
    • Export Citation
  • 14

    Zimmerman ILCastilleja NF: The role of a language scale for infant and preschool assessment. Ment Retard Dev Disabil Res Rev 11:2382462005

    • Search Google Scholar
    • Export Citation

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