Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up

Restricted access

Object

The authors examine the indications for and outcomes following decompressive craniectomy in a single-center pediatric patient population with traumatic brain injury (TBI).

Methods

A retrospective review of data was performed using a prospectively acquired database of patients who underwent decompressive craniectomy at the authors' institution between January 1995 and April 2006. The patients' neuroimages were examined to evaluate the extent of intracranial injury, and the patients' records were reviewed to determine the admission Glasgow Coma Scale (GCS) score, the extent of systemic injuries, the time to craniectomy, and the indications for craniectomy. Long-term functional outcome and independence levels were evaluated using the Glasgow Outcome Scale (GOS) and a Likert patient quality-of-life rating scale.

Twenty-three craniectomies were performed in children during the study period. The mean patient age at craniectomy was 11.9 years (range 2–19 years). In all patients, the computed tomography scans obtained at presentation revealed pathological findings, with diffuse axonal injury and traumatic contusions being the most common abnormalities. The median presenting GCS score was 4.6 (range 3–9). Nineteen patients (83%) suffered from other systemic injuries. One patient (4%) died intraoperatively and six patients (26%) died postoperatively. Postoperative intracranial pressure (ICP) control was obtained in 19 patients (83%); an ICP greater than 20 mm Hg was found to have the strongest correlation with subsequent brain death (p = 0.001). The mean follow-up duration was 63 months (range 11–126 months, median 49 months). The mean GOS score at the 2-year follow-up examination was 4.2 (median 5). At the most recent follow-up examination, 13 (81%) of 16 survivors had returned to school and only three survivors (18%) were dependent on caregivers.

Conclusions

Although the mortality rate for children with severe TBI remains high, decompressive craniectomy is effective in reducing ICP and is associated with good outcomes in surviving patients.

Abbreviations used in this paper:ADL = activities of daily living; CBF = cerebral blood flow; CT = computed tomography; DAI = diffuse axonal injury; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ICU = intensive care unit; ISS = injury severity scale; QOL = quality of life; TBI = traumatic brain injury.
Article Information

Contributor Notes

Address reprint requests to: Jay Jagannathan, M.D., Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, Virginia 22908. email: jj5a@virginia.edu.

© AANS, except where prohibited by US copyright law.

Headings
References
  • 1

    Adelson PDBratton SLCarney NAChesnut RMdu Coudray HEGoldstein B: Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 19 The role of antiseizure prophylaxis following severe pediatric traumatic brain injury. Pediatr Crit Care Med 4:3 SupplS72S752003

    • Search Google Scholar
    • Export Citation
  • 2

    Alberico AMWard JDChoi SCMarmarou AYoung HF: Outcome after severe head injury. Relationship to mass lesions, diffuse injury, and ICP course in pediatric and adult patients. J Neurosurg 67:6486561987

    • Search Google Scholar
    • Export Citation
  • 3

    Baker SPO'Neill B: The injury severity score: an update. J Trauma 16:8828851976

  • 4

    Baker SPO'Neill BHaddon W JrLong WB: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:1871961974

    • Search Google Scholar
    • Export Citation
  • 5

    Barie PSGhajar JBFirlik ADChang VAHariri RJ: Contribution of increased cerebral blood volume to posttraumatic intracranial hypertension. J Trauma 35:88961993

    • Search Google Scholar
    • Export Citation
  • 6

    Berger MSPitts LHLovely MEdwards MSBartkowski HM: Outcome from severe head injury in children and adolescents. J Neurosurg 62:1941991985

    • Search Google Scholar
    • Export Citation
  • 7

    Berger SSchwarz MHuth R: Hypertonic saline solution and decompressive craniectomy for treatment of intracranial hypertension in pediatric severe traumatic brain injury. J Trauma 53:5585632002

    • Search Google Scholar
    • Export Citation
  • 8

    Biagas KVGrundl PDKochanek PMSchiding JKNemoto EM: Posttraumatic hyperemia in immature, mature, and aged rats: autoradiographic determination of cerebral blood flow. J Neurotrauma 13:1892001996

    • Search Google Scholar
    • Export Citation
  • 9

    Bruce DAAlavi ABilaniuk LDolinskas CObrist WUzzell B: Diffuse cerebral swelling following head injuries in children: the syndrome of “malignant brain edema. J Neurosurg 54:1701781981

    • Search Google Scholar
    • Export Citation
  • 10

    Caley DWMaxwell DS: Development of the blood vessels and extracellular spaces during postnatal maturation of rat cerebral cortex. J Comp Neurol 138:31471970

    • Search Google Scholar
    • Export Citation
  • 11

    Chambers IRJones PAMinns RAStobbart LMendelow ADTasker RC: Which paediatric head injured patients might benefit from decompression? Thresholds of ICP and CPP in the first six hours. Acta Neurochir Suppl 95:21232005

    • Search Google Scholar
    • Export Citation
  • 12

    Cooper PRHagler HClark WKBarnett P: Enhancement of experimental cerebral edema after decompressive craniectomy: implications for the management of severe head injuries. Neurosurgery 4:2963001979

    • Search Google Scholar
    • Export Citation
  • 13

    Cushing H: Subtemporal decompressive operations for the intracranial complications associated with bursting fractures of the skull. Ann Surg 47:6416441908

    • Search Google Scholar
    • Export Citation
  • 14

    Dam Hieu PSizun JPerson HBesson G: The place of decompressive surgery in the treatment of uncontrollable post-traumatic intracranial hypertension in children. Childs Nerv Syst 12:2702751996

    • Search Google Scholar
    • Export Citation
  • 15

    Dietrich AMBowman MJGinn-Pease MEKosnik EKing DR: Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography?. Ann Emerg Med 22:153515401993

    • Search Google Scholar
    • Export Citation
  • 16

    Evans CAReynolds JMReynolds MLSaunders NRSegal MB: The development of a blood-brain barrier mechanism in foetal sheep. J Physiol 238:3713861974

    • Search Google Scholar
    • Export Citation
  • 17

    Figaji AAFieggen AGPeter JC: Early decompressive craniotomy in children with severe traumatic brain injury. Childs Nerv Syst 19:6666732003

    • Search Google Scholar
    • Export Citation
  • 18

    Jiang JYGao GYLi WPYu MKZhu C: Early indicators of prognosis in 846 cases of severe traumatic brain injury. J Neurotrauma 19:8698742002

    • Search Google Scholar
    • Export Citation
  • 19

    Jorge RE: Neuropsychiatric consequences of traumatic brain injury: a review of recent findings. Curr Opin Psychiatry 18:2892992005

  • 20

    Kan PAmini AHansen KWhite GBrockmeyer DWalker M: Outcomes after decompressive craniectomy for severe traumatic brain injury in children. J Neurosurgery 105:5 Suppl Pediatrics3373422006

    • Search Google Scholar
    • Export Citation
  • 21

    Kelly DFMartin NAKordestani RCounelis GHovda DABergsneider M: Cerebral blood flow as a predictor of outcome following traumatic brain injury. J Neurosurg 86:6336411997

    • Search Google Scholar
    • Export Citation
  • 22

    Kirkness CJBurr RLCain KCNewell DWMitchell PH: Relationship of cerebral perfusion pressure levels to outcome in traumatic brain injury. Acta Neurochir Suppl 95:13162005

    • Search Google Scholar
    • Export Citation
  • 23

    Kita HMarmarou A: The cause of acute brain swelling after the closed head injury in rats. Acta Neurochir Suppl (Wien) 60:4524551994

    • Search Google Scholar
    • Export Citation
  • 24

    Kjellberg RNPrieto A Jr: Bifrontal decompressive craniotomy for massive cerebral edema. J Neurosurg 34:4884931971

  • 25

    Kraus JFRock AHemyari P: Brain injuries among infants, children, adolescents, and young adults. Am J Dis Child 144:6846911990

  • 26

    Lang DATeasdale GMMacpherson PLawrence A: Diffuse brain swelling after head injury: more often malignant in adults than children?. J Neurosurg 80:6756801994

    • Search Google Scholar
    • Export Citation
  • 27

    Murgio AAndrade FASanchez Munoz MABoetto SLeung KM: International Multicenter Study of Head Injury in Children. ISHIP Group. Childs Nerv Syst 15:3183211999

    • Search Google Scholar
    • Export Citation
  • 28

    Paolin ARodriguez GBetetto MSimini G: Cerebral hemodynamic response to CO2 after severe head injury: clinical and prognostic implications. J Trauma 44:4955001998

    • Search Google Scholar
    • Export Citation
  • 29

    Pfenninger JKaiser GLutschg JSutter M: Treatment and outcome of the severely head injured child. Intensive Care Med 9:13161983

    • Search Google Scholar
    • Export Citation
  • 30

    Polin RSShaffrey MEBogaev CATisdale NGermanson TBocchicchio B: Decompressive bifrontal craniectomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 41:84941997

    • Search Google Scholar
    • Export Citation
  • 31

    Prabhakaran PReddy ATOakes WJKing WDWinkler MKGivens TG: A pilot trial comparing cerebral perfusion pressure-targeted therapy to intracranial pressure-targeted therapy in children with severe traumatic brain injury. J Neurosurg 100:5 Suppl Pediatrics4544592004

    • Search Google Scholar
    • Export Citation
  • 32

    Ruf BHeckmann MSchroth IHugens-Penzel MReiss IBorkhardt A: Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study. Crit Care 7:R133R1382003

    • Search Google Scholar
    • Export Citation
  • 33

    Rutigliano DEgnor MRPriebe CJMcCormack JEStrong NScriven RJ: Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure. J Pediatr Surg 41:83872006

    • Search Google Scholar
    • Export Citation
  • 34

    Taylor AButt WRosenfeld JShann FDitchfield MLewis E: A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 17:1541622001

    • Search Google Scholar
    • Export Citation
  • 35

    Timofeev IKirkpatrick PJCorteen EHiler MCzosnyka MMenon DK: Decompressive craniectomy in traumatic brain injury: outcome following protocol-driven therapy. Acta Neurochir Suppl 96:11162006

    • Search Google Scholar
    • Export Citation
  • 36

    Yoshino EYamaki THiguchi THorikawa YHirakawa K: Acute brain edema in fatal head injury: analysis by dynamic CT scanning. J Neurosurg 63:8308391985

    • Search Google Scholar
    • Export Citation
TrendMD
Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 284 281 17
Full Text Views 178 128 5
PDF Downloads 161 85 4
EPUB Downloads 0 0 0
PubMed
Google Scholar