Decompressive craniectomy for infants: a case series of five patients

A rare case of pediatric distal middle cerebral artery aneurysm

Pediatric middle cerebral artery aneurysms are often complicated by subsequent rupture and subarachnoid hemorrhage. Unruptured middle cerebral artery aneurysms are rare in infancy. Here, we present a rare case of a 13-month-old male who underwent clip ligation for the treatment of an incidental M3 aneurysm.

Predictive factors for cranioplasty complications - A decade's experience

Introduction

Cranioplasty (CP) following craniectomy provides cerebral protection, improves cerebrospinal fluid dynamics, and restores cosmesis. Although often viewed as minor, CP can have major complications.

Research question

This study aims to identify the predictive factors for post-operative complications in patients undergoing CP after decompressive craniectomy.

Methods

We conducted a retrospective study at a tertiary hospital, analyzing patients who underwent CP after decompressive craniectomy (DC) from 2008 to 2019. Patient demographics, medical history, and surgery details were retrieved from hospital records. Complications included symptomatic intracerebral haemorrhage, extradural or subdural haemorrhage, hydrocephalus, infection, or bone resorption.

Results

The study included 168 patients: 139 adults (mean age 47.6 ± 12.68 years) and 29 pediatric patients (mean age 11.8 ± 5.62 years), with a slight male predominance. The overall complication rate was 26.2%, with infection being the most common (8.9%). Predictive factors for CP complications identified by binomial logistic regression, controlling for age and sex, included primary coagulopathy (14.3-fold risk increase, p = 0.034), intraoperative ventricular puncture (7.9-fold risk increase, p = 0.009), and intraoperative dural layer breach (2.8-fold risk increase, p = 0.033). Pre-CP home living was a protective factor.

Conclusions

CP requires vigilant management to prevent complications. Primary coagulopathy, intraoperative ventricular puncture, and dural layer breach are significant risk factors for complications.

Decompressive craniectomy in pediatric non-traumatic intracranial hypertension: a single center experience

Purpose: To study the clinical profile and predictors of outcome in children undergoing decompressive craniectomy (DC) for non-traumatic intracranial hypertension (ICH).Materials and methods: Mixed observational study of children, aged 1 month-12 years, who underwent DC for non-traumatic ICH in a tertiary care pediatric intensive care unit from 2012 to 2017. Data on clinical profile and outcome were retrieved retrospectively and survivors were assessed prospectively. The primary outcome was neurological outcome using Glasgow Outcome Scale-Extended (GOS-E) at minimum 6 months' post-discharge. GOS-E of 1-4 were classified as a poor and 5-8 as a good outcome.Results: Thirty children, median (IQR) age of 6.5 (2, 50) months, underwent DC; of which 26 (86.7%) were boys. Altered sensorium (n = 26, 86.7%), seizures (n = 25, 83.3%), pallor (n = 19, 63.3%) and anisocoria (n = 14, 46.7%) were common signs and symptoms. Median (IQR) Glasgow Coma Scale at admission was 9 (6,11). Commonest etiology was intracranial bleed (n = 24; 80%). Median (IQR) time to DC was 24 (24,72) h. Eight (26.7%) children died; 2 during PICU stay and 6 during follow-up. Neurological sequelae at discharge (n = 28) were seizures (n = 25; 89.2%) and hemiparesis (n = 16; 57.1%). Twenty-one children were followed-up at median (IQR) duration of 12 (6,54) months. Good neurological outcome was seen in 14/29 (48.2%) and hemiparesis in 10/21 (47.6%) patients. On regression analysis, anisocoria at admission was an independent predictor of poor outcome [OR 7.33; 95%CI: 1.38-38.87; p = 0.019].Conclusions: DC is beneficial in children with non-traumatic ICH due to a focal pathology and midline shift. Evidence on indications and timing of DC in NTC is still evolving.

Resistant Pseudomeningocele following Craniotomy for Non-Traumatic Acute Intracranial Haematoma in Very Young Children: Report of Four Cases

BACKGROUND

The incidence of non-traumatic intracranial haemorrhage among neonates is less than among adults. However, the outcomes are generally poor, with high rates of morbidity and mortality. Non-traumatic intracranial haemorrhage can cause a sudden increase in intracranial pressure, requiring emergency craniotomy for evacuation.

METHODS

We report 4 cases following craniotomy for non-traumatic acute intracranial haematoma in very young children. The surgical technique and postoperative course are discussed, with emphasis on dural repair to avoid resistant pseudomeningocele.

RESULTS

Despite successful management of the acutely raised intracranial pressure, all patients afterwards developed tense pseudomeningoceles and required formal dural repair. This led to a change in institutional practice and modifications to the surgical technique.

CONCLUSION

The authors highlight the postoperative occurrence of resistant pseudomeningoceles in young children after clot evacuations and leaving the dura open. They describe the surgical procedures to avoid these pseudomeningoceles.

Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.