Stereotactic radiosurgery for central neurocytomas: an international multicenter retrospective cohort study

OBJECTIVE

Central neurocytomas (CNs) are uncommon intraventricular tumors, and their rarity renders the risk-to-benefit profile of stereotactic radiosurgery (SRS) unknown. The aim of this multicenter, retrospective cohort study was to evaluate the outcomes of SRS for CNs and identify predictive factors.

METHODS

The authors retrospectively analyzed a cohort of patients with CNs treated with SRS at 10 centers between 1994 and 2018. Tumor recurrences were classified as local or distant. Adverse radiation effects (AREs) and the need for a CSF shunt were also evaluated.

RESULTS

The study cohort comprised 60 patients (median age 30 years), 92% of whom had undergone prior resection or biopsy and 8% received their diagnosis based on imaging alone. The median tumor volume and margin dose were 5.9 cm3 and 13 Gy, respectively. After a median clinical follow-up of 61 months, post-SRS tumor recurrence occurred in 8 patients (13%). The 5- and 10-year local tumor control rates were 93% and 87%, respectively. The 5- and 10-year progression-free survival rates were 89% and 80%, respectively. AREs were observed in 4 patients (7%), but only 1 was symptomatic (2%). Two patients underwent post-SRS tumor resection (3%). Prior radiotherapy was a predictor of distant tumor recurrence (p = 0.044). Larger tumor volume was associated with pre-SRS shunt surgery (p = 0.022).

CONCLUSIONS

Treatment of appropriately selected CNs with SRS achieves good tumor control rates with a reasonable complication profile. Distant tumor recurrence and dissemination were observed in a small proportion of patients, which underscores the importance of close post-SRS surveillance of CN patients. Patients with larger CNs are more likely to require shunt surgery before SRS.

Trans-labyrinthine Infra-trigeminal Approach for Recurrent Pontomedullary Cavernoma: A Step-wise Technical Note

Recurrent brainstem cavernoma is a challenging lesion due to the neurological risks associated with different surgical approaches. In this technical report, we present a 35-year-old female with a history of multiple brain cavernomas. She underwent midline suboccipital craniotomy and trans-fourth ventricle approach for resection of the brain stem cavernoma following two major bleeding episodes, one year prior to the presentation. Following the trans-labyrinthine infra-trigeminal approach, the patient recovered well postoperatively with a baseline neuro exam and was discharged to acute rehab on postoperative day 5 (POD5). The translabyrinthine approach is a safe and effective corridor for pontine or pontomedullary lesions in carefully selected patients. Appropriate selection of surgical approach (based on location), meticulous surgical technique, and intraoperative neuromonitoring help in maximizing surgical resection while minimizing neurological deficits.

Predictors of Thirty-day Mortality and Length of Stay in Operative Subdural Hematomas

The rate of postoperative morbidity and mortality after subdural hematoma (SDH) evacuation is high. The aim of this study was to compare mortality statistics from a high-volume database to historical figures and determine the most significant preoperative predictors of mortality and length of stay (LOS). The National Surgical Quality Improvement Program registry was searched (2005-2016) for patients with operatively treated SDHs, of which 2709 were identified for univariate analysis. After exclusion for missing data, 2010 individuals were analyzed with multivariable logistic regression. Primary outcome was 30-day mortality. The average patient age was 68.8 ± 14.9 years, and 64.1% were males. Upon multivariate analysis, nine variables were found to be associated with increased mortality: platelet count < 135,000 (OR 2.04, 95% CI 1.39-2.99), INR >1.2 (OR 1.87, 95% CI 1.34-2.6), bleeding disorder (OR 1.80, 95% CI 1.32-2.46), need for dialysis within two weeks preoperatively (OR 5.69, 95% CI 3.15-10.27), ventilator dependence in the 48 hours preceding surgery (OR 3.99, 95% CI 2.82-5.63), disseminated cancer (OR 2.95, 95% CI 1.34-6.47), WBC count >10,000 (OR 1.55, 95% CI 1.15-2.08), totally dependent functional status (OR 1.84, 95% CI 1.2-2.8), and each increasing year of age (OR 1.04, 95% CI 1.031-1.05). It is not surprising that chronic conditions and functional status were associated with increased mortality. However, specific laboratory abnormalities were also associated with increased mortality at levels generally considered within normal limits. More studies are needed to determine if correcting lab abnormalities preoperatively can improve outcomes in patients with intrinsic coagulopathy.

Mitochondrial NIX Promotes Tumor Survival in the Hypoxic Niche of Glioblastoma

Cancer cells rely on mitochondrial functions to regulate key survival and death signals. How cancer cells regulate mitochondrial autophagy (mitophagy) in the tumor microenvironment as well as utilize mitophagy as a survival signal is still not well understood. Here, we elucidate a key survival mechanism of mitochondrial NIX-mediated mitophagy within the hypoxic region of glioblastoma, the most malignant brain tumor. NIX was overexpressed in the pseudopalisading cells that envelop the hypoxic-necrotic regions, and mitochondrial NIX expression was robust in patient-derived glioblastoma tumor tissues and glioblastoma stem cells. NIX was required for hypoxia and oxidative stress-induced mitophagy through NFE2L2/NRF2 transactivation. Silencing NIX impaired mitochondrial reactive oxygen species clearance, cancer stem cell maintenance, and HIF/mTOR/RHEB signaling pathways under hypoxia, resulting in suppression of glioblastoma survival in vitro and in vivo. Clinical significance of these findings was validated by the compelling association between NIX expression and poor outcome for patients with glioblastoma. Taken together, our findings indicate that the NIX-mediated mitophagic pathway may represent a key therapeutic target for solid tumors, including glioblastoma. SIGNIFICANCE: NIX-mediated mitophagy regulates tumor survival in the hypoxic niche of glioblastoma microenvironment, providing a potential therapeutic target for glioblastoma.Graphical Abstract: http://cancerres.aacrjournals.org/content/canres/79/20/5218/F1.large.jpg.

Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension.

CASE PRESENTATION

We report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient's symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up.

CONCLUSIONS

The absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.

Feasibility of Bundled Payments in Anterior, Middle, and Posterior Cranial Fossa Skull Base Meningioma Surgery: MarketScan Analysis of Health Care Utilization and Outcomes

BACKGROUND

The aim of our study was to compare the health care utilization and outcomes after surgery for anterior cranial fossa skull base meningioma (AFM), middle cranial fossa skull base meningioma (MFM), and posterior cranial fossa skull base meningioma (PFM) across the United States.

METHODS

We queried the MarketScan database using International Classification of Diseases, Ninth Revision and Current Procedural Terminology 4, from 2000 to 2016. We included adult patients who had at least 24 months of enrollment after the surgical procedure. The outcome of interest was length of hospital stay, disposition, complications, and reoperation after the procedure.

RESULTS

A cohort of 1191 patients was identified from the database. Less than half of patients (43.66%) were in the AFM cohort, 32.24% were in the MFM cohort, and only 24.1% were in the PFM cohort. Patients who underwent surgery for PFM had longer hospital stay (P = 0.0009), high complication rate (P = 0.0011), and less likely to be discharged home (P = 0.0013) during index hospitalization. There were no differences in overall payments at 12 months and 24 months among the cohorts. There was no significant difference in 90-day median payments among the groups ($66,212 [AFM] vs. $65,602 [MFM] and $71,837 [PFM]; P = 0.198). Male gender, commercial insurance (compared with Medicare), and higher comorbidity scores (score 3 compared with score 0) were associated with higher 90-day payments in the PFM cohort.

CONCLUSIONS

Overall payments (at 12 months and 24 months) and 90-day payments were not different among the cohorts. Patients with PFM had longer hospital stay and higher complication rate and were less likely to be discharged home with higher utilization of outpatient services at 12 months and 24 months.

National trends in cerebral bypass for unruptured intracranial aneurysms: a National (Nationwide) Inpatient Sample analysis of 1998–2015

OBJECTIVE

The development and recent widespread dissemination of flow diverters may have reduced the utilization of surgical bypass procedures to treat complex or giant unruptured intracranial aneurysms (UIAs). The aim of this retrospective cohort study was to observe trends in cerebral revascularization procedures for UIAs in the United States before and after the introduction of flow diverters by using the National (Nationwide) Inpatient Sample (NIS).

METHODS

The authors extracted data from the NIS database for the years 1998–2015 using the ICD-9/10 diagnostic and procedure codes. Patients with a primary diagnosis of UIA with a concurrent bypass procedure were included in the study. Outcomes and hospital charges were analyzed.

RESULTS

A total of 216,212 patients had a primary diagnosis of UIA during the study period. The number of patients diagnosed with a UIA increased by 128% from 1998 (n = 7718) to 2015 (n = 17,600). Only 1328 of the UIA patients (0.6%) underwent cerebral bypass. The percentage of patients who underwent bypass in the flow diverter era (2010–2015) remained stable at 0.4%. Most patients who underwent bypass were white (51%), were female (62%), had a median household income in the 3rd or 4th quartiles (57%), and had private insurance (51%). The West (33%) and Midwest/North Central regions (30%) had the highest volume of bypasses, whereas the Northeast region had the lowest (15%). Compared to the period 1998–2011, bypass procedures for UIAs in 2012–2015 shifted entirely to urban teaching hospitals (100%) and to an elective basis (77%). The median hospital stay (9 vs 3 days, p < 0.0001), median hospital charges ($186,746 vs $66,361, p < 0.0001), and rate of any complication (51% vs 17%, p < 0.0001) were approximately threefold higher for the UIA patients with bypass than for those without bypass.

CONCLUSIONS

Despite a significant increase in the diagnosis of UIAs over the 17-year study period, the proportion of bypass procedures performed as part of their treatment has remained stable. Therefore, advances in endovascular aneurysm therapy do not appear to have affected the volume of bypass procedures performed in the UIA population. The authors’ findings suggest a potentially ongoing niche for bypass procedures in the contemporary treatment of UIAs.

Endoscopic Endonasal Surgery for the Resection of a Cavernous Hemangioma with a Sellar Extension

Cavernous hemangiomas with an intrasellar extension are very rare, generally benign lesions that manifest by the compression of nearby structures. The presenting symptoms usually range from visual disturbances to an endocrine imbalance. Occasional extension into the cavernous sinus has been reported, which can cause cranial nerve compression. We present the case of a 69-year-old man presenting with facial pain and decreased libido. On investigation, a lesion was identified and the parasellar region was homogeneously hyper-intense on gadolinium-enhanced magnetic resonance imaging (MRI). Endoscopic endonasal surgery remains one of the favored approaches for the resection of sellar lesions. Such pathology needs to remain on the neurosurgeon’s differential diagnosis, making an intraoperative frozen section of these lesions a useful tool in the surgeon's armamentarium, to guide further surgical resection.

Hitomi X-ray studies of Giant Radio Pulses from the Crab pulsar

To search for giant X-ray pulses correlated with the giant radio pulses (GRPs) from the Crab pulsar, we performed a simultaneous observation of the Crab pulsar with the X-ray satellite Hitomi in the 2 - 300 keV band and the Kashima NICT radio observatory in the 1.4 - 1.7 GHz band with a net exposure of about 2 ks on 25 March 2016, just before the loss of the Hitomi mission. The timing performance of the Hitomi instruments was confirmed to meet the timing requirement and about 1,000 and 100 GRPs were simultaneously observed at the main and inter-pulse phases, respectively, and we found no apparent correlation between the giant radio pulses and the X-ray emission in either the main or inter-pulse phases. All variations are within the 2 sigma fluctuations of the X-ray fluxes at the pulse peaks, and the 3 sigma upper limits of variations of main- or inter-pulse GRPs are 22% or 80% of the peak flux in a 0.20 phase width, respectively, in the 2 - 300 keV band. The values become 25% or 110% for main or inter-pulse GRPs, respectively, when the phase width is restricted into the 0.03 phase. Among the upper limits from the Hitomi satellite, those in the 4.5-10 keV and the 70-300 keV are obtained for the first time, and those in other bands are consistent with previous reports. Numerically, the upper limits of main- and inter-pulse GRPs in the 0.20 phase width are about (2.4 and 9.3) ×10^-11 erg cm^-2, respectively. No significant variability in pulse profiles implies that the GRPs originated from a local place within the magnetosphere and the number of photon-emitting particles temporally increases. However, the results do not statistically rule out variations correlated with the GRPs, because the possible X-ray enhancement may appear due to a > 0.02% brightening of the pulse-peak flux under such conditions.

The p38 signaling pathway mediates quiescence of glioma stem cells by regulating epidermal growth factor receptor trafficking

EGFR pathway is upregulated in malignant gliomas, and its downstream signaling is important for self-renewal of glioma cancer stem-like cells (GSC). p38 mitogen-activated protein kinase (MAPK) signaling, a stress-activated signaling cascade with suppressive and permissive effects on tumorigenesis, can promote internalization and ubiquitin ligase mediated degradation of EGFR. In this study, we investigated the role of p38 MAPK signaling on the self-renewal of GSCs with the hypothesis that inhibition may lead to enhanced self-renewal capacity by retention of EGFR. Inhibition of p38 MAPK pathway led to increase in EGFR expression but surprisingly, reduced proliferation. Additional functional evaluation revealed that p38 inhibition was associated with decrease in cell death and maintenance of undifferentiated state. Further probing the effect of p38 inhibition demonstrated attenuation of EGFR downstream signaling activity in spite of prolonged surface expression of the receptor. In vitro observations were confirmed in xenograft in vivo experiments. These data suggest that p38 MAPK control of EGFR signaling activity may alter GSC cell cycle state by regulating quiescence and passage into transit amplifying state.

Laser interstitial thermal therapy for palliative ablation of a chordoma metastasis to the spine: case report

The authors present the first report of laser interstitial thermal therapy (LITT) ablation of a recurrent chordoma metastasis to the cervical spine. This patient was a 75-year-old woman who was diagnosed and treated for a sacral chordoma, and then developed metastases to the lung and upper thoracic spine. Unfortunately she experienced symptomatic recurrence at the C-7 spinous process. She underwent an uncomplicated LITT to the lesion. The patient convalesced without incident and was discharged on postoperative Day 1. She received stereotactic spinal radiosurgery to the lesion at a dose of 24 Gy in 1 fraction. At the 3-month follow-up evaluation she had radiographic response and improvement in her symptoms.

Primary versus revision transsphenoidal resection for nonfunctioning pituitary macroadenomas: matched cohort study

OBJECTIVE

The object of this study was to compare the outcomes of primary and revision transsphenoidal resection (TSR) of nonfunctioning pituitary macroadenomas (NFPMAs) using endoscopic methods.

METHODS

The authors retrospectively reviewed the records of 287 consecutive patients who had undergone endoscopic endonasal TSR for NFPMAs at their institution in the period from 2005 to 2011. Fifty patients who had undergone revision TSR were retrospectively matched for age, sex, and duration of follow-up to 46 patients who had undergone primary TSR. Medical and surgical complications were documented, and Kaplan-Meier analysis was performed to assess rates of radiological progression-free survival (PFS).

RESULTS

The median follow-up periods were 45 and 46 months for the primary and revision TSR groups, respectively. There were no significant differences between the primary and revision groups in rates of new neurological deficit (0 in each), vascular injury (2% vs 0), postoperative CSF leak (6% vs 2%), transient diabetes insipidus (DI; 15% vs 12%), chronic DI (2% vs 2%), chronic sinusitis (4% vs 6%), meningitis (2% vs 2%), epistaxis (7% vs 0), or suprasellar hematoma formation (0 vs 2%). However, patients who underwent primary TSR had significantly higher rates of syndrome of inappropriate antidiuretic hormone (SIADH; 17% vs 4%, p = 0.04). Patients who underwent primary operations also had significantly higher rates of gross-total resection (GTR; 63% vs 28%, p < 0.01) and significantly lower rates of adjuvant radiotherapy (13% vs 42%, p < 0.01). Radiological PFS rates were similar at 2 years (98% vs 96%) and 5 years (87% vs 80%, p = 0.668, log-rank test).

CONCLUSIONS

Patients who underwent primary TSR of NFPMAs experienced higher rates of SIADH than those who underwent revision TSR. Patients who underwent revision TSR were less likely to have GTR of their tumor, although they still had a PFS rate similar to that in patients who underwent primary TSR. This finding may be attributable to an increased rate of adjuvant radiation treatment to subtotally resected tumors in the revision TSR group.

An X-ray and Radio Study of the Varying Expansion Velocities in Tycho's Supernova Remnant

We present newly obtained X-ray and radio observations of Tycho's supernova remnant using Chandra and the Karl G. Jansky Very Large Array in 2015 and 2013/14, respectively. When combined with earlier epoch observations by these instruments, we now have time baselines for expansion measurements of the remnant of 12-15 year in the X-rays and 30 year in the radio. The remnant's large angular size allows for proper motion measurements at many locations around the periphery of the blast wave. We find, consistent with earlier measurements, a clear gradient in the expansion velocity of the remnant, despite its round shape. The proper motions on the western and southwestern sides of the remnant are about a factor of two higher than those in the east and northeast. We showed in an earlier work that this is related to an offset of the explosion site from the geometric center of the remnant due to a density gradient in the ISM, and using our refined measurements reported here, we find that this offset is ∼ 23'' towards the northeast. An explosion center offset in such a circular remnant has implications for searches for progenitor companions in other remnants.

The role of radiosurgery in the management of WHO Grade II and III intracranial meningiomas

Object

WHO Grade II and III intracranial meningiomas are uncommon, but they portend a significantly worse prognosis than their benign Grade I counterparts. The mainstay of current management is resection to obtain cytoreduction and histological tissue diagnosis. The timing and benefit of postoperative fractionated external beam radiation therapy and stereotactic radiosurgery remain controversial. The authors review the stereotactic radiosurgery outcomes for Grade II and III meningiomas.

Methods

A comprehensive literature search was performed using PubMed to identify all radiosurgery series reporting the treatment outcomes for Grade II and III meningiomas. Case reports and case series involving fewer than 10 patients were excluded.

Results

From 1998 to 2013, 19 radiosurgery series were published in which 647 Grade II and III meningiomas were treated. Median tumor volumes were 2.2–14.6 cm3. The median margin doses were 14–21 Gy, although generally the margin doses for Grade II meningiomas were 16–20 Gy and the margin doses for Grade III meningiomas were 18–22 Gy. The median 5-year PFS was 59% for Grade II tumors and 13% for Grade III tumors, which may have been affected by patient age, prior radiation therapy, tumor volume, and radiosurgical dose and timing. The median complication rate following radiosurgery was 8%.

Conclusions

The current data for radiosurgery suggest that it has a role in the management of residual or recurrent Grade II and III meningiomas. However, better studies are needed to fully define this role. Due to the relatively low prevalence of these tumors, it is unlikely that prospective studies will be feasible. As such, well-designed retrospective analyses may improve our understanding of the effect of radiosurgery on tumor recurrence and patient survival and the incidence and impact of treatment-induced complications.

Gamma Knife surgery for large vestibular schwannomas: a single-center retrospective case-matched comparison assessing the effect of lesion size

Object

Gamma Knife surgery (GKS) is a safe and effective treatment for patients with small to moderately sized vestibular schwannomas (VSs). Reports of stereotactic radiosurgery for large VSs have demonstrated worse tumor control and preservation of neurological function. The authors endeavored to assess the effect of size of VSs treated using GKS.

Methods

This study was a retrospective comparison of 24 patients with large VSs (> 3 cm in maximum diameter) treated with GKS compared with 49 small VSs (≤ 3 cm) matched for age, sex, radiosurgical margin and maximal doses, length of follow-up, and indication.

Results

Actuarial tumor progression-free survival (PFS) for the large VS cohort was 95.2% and 81.8% at 3 and 5 years, respectively, compared with 97% and 90% for small VSs (p = 0.009). Overall clinical outcome was better in small VSs compared with large VSs (p < 0.001). Patients with small VSs presenting with House-Brackmann Grade I (good facial function) had better neurological outcomes compared with patients with large VSs (p = 0.003). Treatment failure occurred in 6 patients with large VSs; 3 each were treated with resection or repeat GKS. Treatment failure did not occur in the small VS group. Two patients in the large VS group required ventriculoperitoneal shunt placement. Univariate analysis did not identify any predictors of treatment failure among the large VS cohort.

Conclusions

Patients with large VSs treated using GKS had shorter PFS and worse clinical outcomes compared with age-, sex-, and indication-matched patients with small VSs. Nevertheless, GKS has efficacy for some patients with large VSs and represents a reasonable treatment option for selected patients.

Measuring nonequilibrium vesicle dynamics in neurons under tension

Vesicle transport in neurons is a highly complex nonequilibrium process. Their subcellular environment is undergoing constant fluctuations from thermal energy and molecular motors. Vesicle transport is an interplay between random motion (passive) and directed motion (active) driven by molecular motors along cytoskeletal filaments. It has been shown that growth, guidance, and vesicle dynamics of neurons is affected by mechanical tension. Here we present a method to analyze vesicle transport via a temporal Mean Square Displacement (tMSD) analysis while applying mechanical strain to neurons. The tMSD analysis allows characterization of active and passive vesicle motion as well as many other parameters including: power law scaling, velocity, direction, and flux. Our results suggest: (1) The tMSD analysis is able to capture vesicle motion alternating between passive and active states, and indicates that vesicle motion in Aplysia neurons is primarily passive (exhibiting active motion for ~8% of the time). (2) Under mechanical stretch (increased neurite tension), active transport of vesicles increases to ~13%, while vesicle velocity remains unchanged. (3) Upon unstretching (decreased tension), the level of active transport returns to normal but vesicle velocity decreases. These results suggest that vesicle transport in neurons is highly sensitive to mechanical stimulation. Our method allows precise characterization of vesicle dynamics in response to applied mechanical strain.

Stereotactic radiosurgery for WHO II and III meningiomas: analysis of long-term clinical and radiographic outcomes

BACKGROUND/AIM

WHO grade II and III meningiomas are challenging tumors to treat, and the role of stereotactic radiosurgery (SRS) in their treatment is not well defined. We evaluate our experience to better define its role and assess for clinical and radiographic predictors of failure.

METHODS

This is a retrospective analysis of all patients with histological diagnosis of WHO II or III meningioma. Thirteen patients were included. The mean dose to the periphery was 16 Gy (12-20), the mean maximum dose was 31 Gy (13-40), and the mean isodose line was 49% (35-50).

RESULTS

The median age was 48 years. The median follow up was 50 months (7-67). All cases had undergone at least one previous resection, and six patients had undergone external beam radiation (EBRT). The median pre SRS Karnofsky performance score (KPS) was 90. The progression free survival (PFS) was 92% and 31% at 1 and 4 years, respectively. Eleven patients required further treatment after SRS. The final tumor volume was decreased in 7 patients, stable in 1, and increased in 6.

CONCLUSIONS

WHO grade II and III meningiomas are aggressive tumors that will require multiple treatments. SRS may be a useful as an adjuvant treatment or for recurrence.

Decompressive craniectomy in pediatric traumatic brain injury: a review of the literature

BACKGROUND

Pediatric traumatic brain injury accounts for approximately 37,000 hospitalizations and 2,685 deaths in the United State annually. The 2003 guidelines consolidated and summarized the body of literature on this subject. Among the material covered was the role of surgical management of elevated intracranial pressure. Here we review the guideline recommendations, recent literature on the topic, and important recent results in the adult population.

METHODS

A Medline literature review was performed to identify studies published since 2000 addressing decompressive craniectomy in the pediatric and adult populations. Important articles included in the 2003 guidelines were also reviewed. All references were reviewed to identify additional relevant studies.

RESULTS

There is little new data that addresses the key issues for investigation proposed in the 2003 pediatric guidelines. The only randomized trial in the pediatric population remains a 2001 study, which demonstrated a benefit of decompressive craniectomy. One recent randomized trial in adults demonstrated no benefit of the procedure and an additional randomized trial in adults is underway. No pediatric randomized trial is planned. Smaller, non-randomized series appear to support the practice.

CONCLUSION

Based on the only randomized trial in children and the abundance of smaller studies, it is our belief that decompressive craniectomy does provide a benefit in terms of the management of intracranial hypertension and overall outcome in children.