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

Jay Jagannathan M.D., David O. Okonkwo M.D., Ph.D., Aaron S. Dumont M.D., Hazem Ahmed M.D., Abbas Bahari M.D., Daniel M. Prevedello M.D., John A. Jane Sr. M.D., Ph.D. and John A. Jane Jr. M.D.
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  • Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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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.

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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.
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