Decompressive craniectomy and postoperative complication management in infants and toddlers with severe traumatic brain injuries

Impact of timing of decompressive craniectomy on outcomes in pediatric traumatic brain injury

Background

Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC.

Methods

This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month-18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates.

Results

A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3).

Conclusion

Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.

Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma

BACKGROUND

The purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT).

METHODS

We performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL).

RESULTS

Seventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the "average" range, 17% in the "below average" range, and 70% in the "very low" range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt.

CONCLUSIONS

For patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.

Management of Severe Traumatic Brain Injury in Pediatric Patients

The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.

Evaluating the retro-auricular incision versus reversed question mark incision and Kempe's 'T-bar' incision for decompressive hemicraniectomy

Background

The proper decompression for hemicraniectomy depends on intraoperative surgical technique, so the skin incision, on the other hand, is an important variable throughout hemicraniectomy, and there are a variety of cutaneous incisions, including the Kempe T shaped, the reversed question mark and the retro-auricular incisions. We aim to compare those three types of incisions and assess their effects on the surgical outcomes regarding the skull defect size, survived beyond 1 week, post-operative complications and mortality rates.

Results

A retrospective study included 180 patients were separated into three age- and sex-matched groups according to the type of incision used for their hemicraniectomy. Data including age, sex, causes of surgery, comorbidities, the incision type, the defect area of the skull, intraoperative time and estimated blood loss were recruited for all patients. The mortality and morbidity rates at 3 months post-surgery were documented for all patients. There was a significant difference in the operative time, and the intraoperative measures of blood loss, and insignificant differences in the surviving rate after 1-week post-surgery among the three group patients. There were significant differences between the first and third patient groups compared to the second group regarding wound complications, while the first and third groups were comparable.

Conclusions

The retro-auricular incision is a safe preferable substitute for the reversed question mark and Kempe T-shaped incisions in decompressive hemicraniectomy, due to the better blood flow maintaining, lower rate of post-operative wound complications.

The Retroauricular Incision as an Effective and Safe Alternative Incision for Decompressive Hemicraniectomy

BACKGROUND

The reverse question mark (RQM) incision has been traditionally utilized to perform decompressive hemicraniectomies (DHC) to relieve refractory intracranial hypertension. Alternative incisions have been proposed in the literature but have not been compared directly.

OBJECTIVE

To present the retroauricular (RA) incision as an alternative incision that we hypothesize will increase calvarium exposure to maximize the removal of the hemicranium and will decrease wound-related complications compared to the RQM incision.

METHODS

This study is a retrospective review of all DHCs performed at our institution over a span of 34 mo, stratified based on the type of scalp incision. The surface areas of the cranial defects were calculated, normalizing to their respective skull diameters. For those patients surviving beyond 1 wk, complications were examined from both cohorts.

RESULTS

A total of 63 patients in the RQM group and 43 patients in the RA group were included. The average surface area for the RA and RQM incisions was 117.0 and 107.8 cm2 (P = .0009), respectively. The ratio of average defect size to skull size for RA incision was 0.81 compared to 0.77 for the RQM group (P = .0163). Of those who survived beyond 1 wk, the absolute risk for surgical site complications was 14.0% and 8.3% for RQM and RA group (P = .5201), respectively.

CONCLUSION

The RA incision provides a safe and effective alternative incision to the traditional RQM incision used for DHC. This incision affords a potentially larger craniectomy while mitigating postoperative wound complications.

Simulating Expansion of the Intracranial Space to Accommodate Brain Swelling after Decompressive Craniectomy: Volumetric Quantification in a 3D CAD Skull Model with Contour Elevation

Background: Decompressive craniectomy (DC) can be used to augment intracranial space and halt brainstem compromise. However, a widely adopted recommendation for optimal surgical extent of the DC procedure is lacking. In the current study, we utilized three-dimensional (3D) computer-assisted design (CAD) skull models with defect contour elevation for quantitative assessment. Methods: DC was performed for 15 consecutive patients, and 3D CAD models of defective skulls with contour elevations (0-50 mm) were reconstructed using commercial software. Quantitative assessments were conducted in these CAD subjects to analyze the effects of volumetric augmentation when elevating the length of the contour and the skull defect size. The final positive results were mathematically verified using a computerized system for numerical integration with the rectangle method. Results: Defect areas of the skull CAD models ranged from 55.7-168.8 cm², with a mean of 132.3 ± 29.7 cm². As the contour was elevated outward for 6 mm or above, statistical significance was detected in the volume and the volume-increasing rate, when compared to the results obtained from the regular CAD model. The volume and the volume-increasing rate increased by 3.665 cm³, 0.285% (p < 0.001) per 1 mm of contour elevation), and 0.034% (p < 0.001) per 1 cm² of increase of defect area, respectively. Moreover, a 1 mm elevation of the contour in Groups 2 (defect area 125-150 cm²) and 3 (defect area >150 cm², as a proxy for an extremely large skull defect) was shown to augment the volume and the volume-increasing rate by 1.553 cm³, 0.101% (p < 0.001) and 1.126 cm³, 0.072% (p < 0.001), respectively, when compared to those in Group 1 (defect area <125 cm²). The volumetric augmentation achieved by contour elevation for an extremely large skull defect was smaller than that achieved for a large skull defect. Conclusions: The 3D CAD skull model contour elevation method can be effectively used to simulate the extent of a space-occupying swollen brain and to quantitatively assess the extent of brainstem protection in terms of volume augmentation and volume-increasing rate following DC. As the tangential diameter (representing the degree of DC) exceeded the plateau value, volumetric augmentation was attenuated. However, an increasing volumetric augmentation was detected before the plateau value was reached.

Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary

The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.

Three-Dimensional CAD in Skull Reconstruction: A Narrative Review with Focus on Cranioplasty and Its Potential Relevance to Brain Sciences

In patients suffering from severe traumatic brain injury and massive stroke (hemorrhagic or ischemic), decompressive craniectomy (DC) is a surgical strategy used to reduce intracranial pressure, and to prevent brainstem compromise from subsequent brain edema. In surviving patients, cranioplasty surgery helps to protect brain tissue, and correct the external deformity. The aesthetic outcome of cranioplasty using an asymmetrical implant can negatively influence patients physically and mentally, especially young patients. Advancements in the development of biomaterials have now made three-dimensional (3-D) computer-assisted design/manufacturing (CAD/CAM)-fabricated implants an optimal choice for the repair of skull defects following DC. Here, we summarize the various materials for cranioplasty, including xenogeneic, autogenous, and alloplastic grafts. The processing procedures of the CAD/CAM technique are briefly outlined, and reflected our experiences to reconstruct skull CAD models using commercial software, published previously, to assess aesthetic outcomes of regular 3-D CAD models without contouring elevation or depression. The establishment of a 3-D CAD model ensures a possibility for better aesthetic outcomes of CAM-derived alloplastic implants. Finally, clinical consideration of the CAD algorithms for adjusting contours and their potential application in prospective healthcare are briefly outlined.

Three-Dimensional CAD in Skull Reconstruction: A Narrative Review with Focus on Cranioplasty and Its Potential Relevance to Brain Sciences

In patients suffering from severe traumatic brain injury and massive stroke (hemorrhagic or ischemic), decompressive craniectomy (DC) is a surgical strategy used to reduce intracranial pressure, and to prevent brainstem compromise from subsequent brain edema. In surviving patients, cranioplasty surgery helps to protect brain tissue, and correct the external deformity. The aesthetic outcome of cranioplasty using an asymmetrical implant can negatively influence patients physically and mentally, especially young patients. Advancements in the development of biomaterials have now made three-dimensional (3-D) computer-assisted design/manufacturing (CAD/CAM)-fabricated implants an optimal choice for the repair of skull defects following DC. Here, we summarize the various materials for cranioplasty, including xenogeneic, autogenous, and alloplastic grafts. The processing procedures of the CAD/CAM technique are briefly outlined, and reflected our experiences to reconstruct skull CAD models using commercial software, published previously, to assess aesthetic outcomes of regular 3-D CAD models without contouring elevation or depression. The establishment of a 3-D CAD model ensures a possibility for better aesthetic outcomes of CAM-derived alloplastic implants. Finally, clinical consideration of the CAD algorithms for adjusting contours and their potential application in prospective healthcare are briefly outlined.

Abusive head trauma: evidence, obfuscation, and informed management

Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.

Greenstick fracture-hinge decompressive craniotomy in infants: illustrative case and literature review of techniques for decompressive craniotomy without bone removal

PURPOSE

We present the potential usefulness of a greenstick fracture-hinge decompressive craniotomy, a variant of a hinge-craniotomy, as an alternative technique for use with a decompressive craniectomy (DC) in infants. A literature review of hinge-craniotomy procedures and technical variants is also provided, with a focus on complications associated with a DC peculiar to infants and children.

METHODS

Illustrative case presentation along with literature review.

RESULT

Significant rates of complications associated with a DC and subsequent cranioplasty have been reported, such as bone flap resorption, hydrocephalus, cerebrospinal fluid collection, and infection, especially in infants. A hinge-craniotomy is an older technique reported to have potential usefulness with some modifications, though concerns have been raised about adequate decompression and definitive indications.

CONCLUSION

A DC procedure performed in children, especially infants, includes a significantly high risk of various complications; thus, a hinge-craniotomy technique is worthwhile for consideration to avoid such complications. Additional studies are required to clarify whether this technique may contribute to reduce complications related to a DC in infants and children.

Dural Sandwich Technique for Hemicraniectomy and Benefits During Cranioplasty

OBJECTIVE

Hemicraniectomy is a commonly performed neurosurgical procedure used in the setting of medically refractory malignant intracranial hypertension. Complications from cranioplasty after hemicraniectomy can be significant, including infection and wound issues. Difficulty with scar tissue during exposure for cranioplasty can be challenging and can lead to prolonged surgical time and increased bleeding. We describe a surgical technique, termed the "dural sandwich," that could provide a significant benefit during cranioplasty as compared with traditional single-layered dural closure.

METHODS

A retrospective analysis was conducted that included 14 patients who underwent a hemicraniectomy procedure over a 4-year period. Seven patients were identified who received a cranioplasty after dural sandwich technique during craniectomy. They were compared with a similar patient group of 7 patients who received a cranioplasty after conventional hemicraniectomy with single-layered dural closure. Surgical time, estimated blood loss, and complication rates were compared between the 2 groups. Analysis of variance measures were performed to assess for statistically significant differences in blood loss and operative time between the dural sandwich and control groups. Statistical significance was defined as P < 0.05.

RESULTS

The mean estimated blood loss was 82.1 mL in the dural sandwich craniectomy group versus 150 mL in the conventional hemicraniectomy group (P < 0.05). The mean estimated surgical time was 91.7 minutes in the dural sandwich craniectomy group versus 127.5 minutes in the conventional craniectomy group (P < 0.05). There was no evidence of neurologic deterioration, cerebral spinal fluid leak, or postoperative hematoma requiring evacuation in either group. In the conventional craniectomy group, a single report of a wound infection was noted that was treated conservatively with antibiotics.

CONCLUSIONS

By layering bovine pericardium above and below the dura during initial hemicraniectomy, an artificial plane is created that improves ease of exposure during cranioplasty. This technique could reduce surgical time and blood loss during subsequent cranioplasty, and potentially reduce recovery time and postoperative complications.

Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary

OBJECTIVES

The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients.

METHODS AND MAIN RESULTS

This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology.

CONCLUSIONS

New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.

Emergent and Urgent Craniotomies in Pediatric Patients: Resource Utilization and Cost Analysis

BACKGROUND

Pediatric neurosurgeons are occasionally tasked with performing surgery expeditiously to preserve a child's neurologic faculties and life.

OBJECTIVE

This study examines the etiologies, outcomes, and costs for urgent or emergent craniotomies at a Level I Pediatric Trauma center over a 7-year time period.

METHODS

A retrospective review was conducted for each patient who underwent an emergent or urgent craniotomy within 24 hours of presentation between January 2010 and April 2017. Demographic, clinical, and surgical details were recorded for a total of 48 variables. Any readmission within 90 days was analyzed. Hospital charges for each admission and readmission were collected and adjusted for inflation to October 2018 values.

RESULTS

Among the 223 children who underwent urgent or emergent craniotomies, the majority were admitted for traumatic injuries (n = 163, 73.1%). The most common traumatic mechanism was fall (n = 51, 22.9%), and the most common non-traumatic cause was tumor (n = 21, 9.4%). Overall, craniotomies were typically performed for hematoma evacuation of one type or combination (n = 115, 51.6%) during off-peak times (n = 178, 79.8%). Seventy-seven (34.5%) subjects experienced 1 or more postoperative events, 22 of whom returned to the operating room. There were 13 (5.8%) and 33 (14.8%) readmissions within 30 days and 90 days of discharge, respectively. Non-trauma patients (compared with trauma patients) and polytrauma (compared with isolated head injury) had greater healthcare needs, resulting in higher charges.

CONCLUSION

Most urgent or emergent pediatric craniotomies were performed for the treatment of traumatic injuries involving hematoma evacuation, but non-traumatic patients were more complex requiring greater resources.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

Reduction of Cerebral Edema via an Osmotic Transport Device Improves Functional Outcome after Traumatic Brain Injury in Mice

Traumatic brain injury (TBI), the foremost cause of morbidity and mortality in persons under 45 years of age worldwide, leads to about 200,000 victims requiring hospitalization and approximately 52,000 deaths per year in the United States. TBI is characterized by cerebral edema leading to raised intracranial pressure, brain herniation, and subsequent death. Current therapies for TBI treatment are often ineffective, thus novel therapies are needed. Recent studies have shown that an osmotic transport device (OTD) is capable of reducing brain water content and improving survival in mice with severe cerebral edema. Here we compare the effects of a craniectomy and an OTD plus craniectomy on neurological function in mice after TBI. Animals treated with a craniectomy plus an OTD had significantly better neurological function 2 days after TBI compared with those treated with craniectomy only. This study suggests that an OTD for severe brain swelling may improve patient functional outcome. Future studies include a more comprehensive neurological examination, including long-term memory tests.

Decompressive craniectomy and CSF disorders in children

INTRODUCTION

Decompressive craniectomy (DC) is a lifesaving procedure but is associated to several post-operative complications, namely cerebrospinal fluid (CSF) dynamics impairment. The aim of this multicentric study was to evaluate the incidence of such CSF alterations after DC and review their impact on the overall outcome.

MATERIAL AND METHODS

We performed a retrospective multicentric study to analyze the CSF disorders occurring in children aged from 0 to 17 years who had undergone a DC for traumatic brain injury (TBI) in the major Departments of Pediatric Neurosurgery of France between January 2006 and August 2016.

RESULTS

Out of 150 children, ranging in age between 7 months and 17 years, mean 10.75 years, who underwent a DC for TBI in 10 French pediatric neurosurgical centers. Sixteen (6 males, 10 females) (10.67%) developed CSF disorders following the surgical procedure and required an extrathecal CSF shunting. External ventricular drainage increased the risk of further complications, especially cranioplasty infection (p = 0.008).

CONCLUSION

CSF disorders affect a minority of children after DC for TBI. They may develop early after the DC but they may develop several months after the cranioplasty (8 months), consequently indicating the necessity of clinical and radiological close follow-up after discharge from the neurosurgical unit. External ventricular drainage and permanent CSF shunt placement increase significantly the risk of cranioplasty infection.

Complications Associated with Decompressive Craniectomy: A Systematic Review

Decompressive craniectomy (DC) has been used for many years in the management of patients with elevated intracranial pressure and cerebral edema. Ongoing clinical trials are investigating the clinical and cost effectiveness of DC in trauma and stroke. While DC has demonstrable efficacy in saving life, it is accompanied by a myriad of non-trivial complications that have been inadequately highlighted in prospective clinical trials. Missing from our current understanding is a comprehensive analysis of all potential complications associated with DC. Here, we review the available literature, we tabulate all reported complications, and we calculate their frequency for specific indications. Of over 1500 records initially identified, a final total of 142 eligible records were included in our comprehensive analysis. We identified numerous complications related to DC that have not been systematically reviewed. Complications were of three major types: (1) Hemorrhagic (2) Infectious/Inflammatory, and (3) Disturbances of the CSF compartment. Complications associated with cranioplasty fell under similar major types, with additional complications relating to the bone flap. Overall, one of every ten patients undergoing DC may suffer a complication necessitating additional medical and/or neurosurgical intervention. While DC has received increased attention as a potential therapeutic option in a variety of situations, like any surgical procedure, DC is not without risk. Neurologists and neurosurgeons must be aware of all the potential complications of DC in order to properly advise their patients.

Decompressive craniectomy for infants: a case series of five patients

PURPOSE

Management of cerebral edema in infants is challenging. Decompressive craniectomy in young age has shown favorable outcomes for management of intracranial hypertension, but current literature is scarce and consists of only case reports or small series. The purpose of the current study is to report the challenges faced with this procedure and its complications in this peculiar age group.

METHODS

This is a retrospective chart review of infants (less than 1 year of age) undergoing unilateral or bilateral decompressive craniotomy at a tertiary care hospital in Pakistan. Kochi score was used to score outcomes of five infants who underwent the procedure.

RESULTS

Five infants were included in this series. Operative time for decompressive craniectomy (DC) ranged from 1 h and 40 min to 4 h. Three infants survived to undergo cranioplasty. Two infants recovered with good Kochi scores of 5a and one infant developed hemiparesis (Kochi score 3b).

CONCLUSIONS

Decompressive craniectomy carries good outcomes in selected patients. Risk of bleeding and hemodynamic instability makes this procedure challenging. We found coagulopathy in four of the five patients which poses another challenge to the surgical management of these patients and has not been stressed enough in the previous literature.

Special considerations in infants and children

Head injury in children is one of the most common causes of death and disability in the US and, increasingly, worldwide. This chapter reviews the causes, patterns, pathophysiology, and treatment of head injury in children across the age spectrum, and compares pediatric head injury to that in adults. Classification of head injury in children can be organized according to severity, pathoanatomic type, or mechanism. Response to injury and repair mechanisms appear to vary at different ages, and these may influence optimal treatment; however, much work is still needed before investigation leads to clearly effective clinical interventions. This is true both for the more severe injuries as well as those at the milder end of the injury spectrum, the latter of which have received increasing attention. In this chapter, neuroassessment tools for each age, newer imaging modalities including magnetic resonance imaging (MRI), and specific pediatric management issues, including intracranial pressure (ICP) monitoring and seizure prophylaxis, are reviewed. Finally, specific head injury patterns and functional outcomes relevant to pediatric patients are discussed. While head injury is common, the number of head-injured children is significantly smaller than the corresponding adult head-injured population. When divided further by specific ages, injury types, and other sources of heterogeneity, properly powered clinical research is likely to require large data sets that will allow for stratification across variables, including age. While much has been learned in the past several decades, further study will be required to determine the best management practices for optimizing recovery in individual pediatric patients. This approach is likely to depend on collaborative international head injury databases that will allow researchers to better understand the nuanced evolution of different types of head injury in patients at each age, and the pathophysiologic, treatment-related, and genetic factors that influence recovery.

Simultaneous cranioplasty and subdural-peritoneal shunting for contralateral symptomatic subdural hygroma following decompressive craniectomy

BACKGROUND

Contralateral subdural hygroma caused by decompressive craniectomy tends to combine with external cerebral herniation, causing neurological deficits.

MATERIAL AND METHODS

Nine patients who underwent one-stage, simultaneous cranioplasty and contralateral subdural-peritoneal shunting were included in this study. Clinical outcome was assessed by Glasgow Outcome Scale as well as Glasgow Coma Scale, muscle power scoring system, and complications.

RESULTS

Postoperative computed tomography scans demonstrated completely resolved subdural hygroma and reversed midline shifts, indicating excellent outcome. Among these 9 patients, 4 patients (44%) had improved GOS following the proposed surgery. Four out of 4 patients with lethargy became alert and orientated following surgical intervention. Muscle strength improved significantly 5 months after surgery in 7 out of 7 patients with weakness. Two out of 9 patients presented with drowsiness due to hydrocephalus at an average time of 65 days after surgery. Double gradient shunting is useful to eliminate the respective hydrocephalus and contralateral subdural hygroma.

CONCLUSION

The described surgical technique is effective in treating symptomatic contralateral subdural hygroma following decompressive craniectomy and is associated with an excellent structural and functional outcome. However, subdural-peritoneal shunting plus cranioplasty thoroughly resolves the subdural hygroma collection, which might deteriorate the cerebrospinal fluid circulation, leading to hydrocephalus.

Pediatric traumatic brain injuries treated with decompressive craniectomy

BACKGROUND

Traumatic brain injury (TBI) occurs in an estimated 80% of all pediatric trauma patients and is the leading cause of death and disability in the pediatric population. Decompressive craniectomy is a procedure used to decrease intracranial pressure by allowing the brain room to swell and therefore increase cerebral perfusion to the brain.

METHODS

This is a retrospective study done at St. Mary's Medical Center/Palm Beach Children's Hospital encompassing a 3 year 7 month period. All the pediatric patients who sustained a TBI and who were treated with a decompressive craniectomy were included. The patients' outcomes were monitored and scored according to the Rancho Los Amigos Score at the time of discharge from the hospital and 6 months postdischarge.

RESULTS

A total of 379 pediatric patients with a diagnosis of TBI were admitted during this time. All these patients were treated according to the severity of their injury. A total of 49 pediatric patients required neurosurgical intervention and 7 of these patients met the criteria for a decompressive craniectomy. All seven patients returned home with favorable outcomes.

CONCLUSION

This study supports the current literature that decompressive craniectomy is no longer an intervention used as a last resort but an effective first line treatment to be considered.

Outcome of patients with traumatic head injury in infants: An institutional experience at level 1 trauma center

Background:

Traumatic head injury is a common cause of mortality and acquired disability in infants and children. However, patterns and outcome of head injury in infants are different from other age groups.

Aims and Objectives:

Aim of our study was to find out epidemiological factors, characteristics of injury, and outcome in infants with traumatic brain injury.

Materials and Methods:

This is a retrospective study from March 2009 through Feb 2012, at JPNATC, AIIMS, New Delhi. The clinical records of all patients, admitted with head injury were evaluated. Twenty-nine infants with traumatic brain injury were followed up and outcome was analyzed.

Results:

Twenty-nine infants with traumatic brain injury were included in the study. Of these 17 (59%) were boys and 12 (41%) were girls. Fall from height was recorded in 27 (93%) patients and road traffic accident was the mode of injury in 2 (7%). Mild head injury (GCS 14-15) was found in 18 (62%) patients, moderate in 4 (14%) patients (GCS 9-13), severe (GCS 3-8) in 7 (24%) patients. SDH was the most common injury in 8 (27%) patients. Out of these 4 (14%) were immediately operated, 25 (86%) were managed conservatively. Overall mortality was 11% (3 patients). Glasgow Outcome Scale was 5 in 20 (69%) patients and 3 (10.3%) patients each had GOS 3 or 4.

Conclusion:

Infants suffered significant brain injury due to fall. Traumatic brain injury in infants generally carries good outcome. Severe head injury was observed to be a predictor of poor outcome.

Preservation of the temporal muscle during the frontotemporoparietal approach for decompressive craniectomy: technical note

BACKGROUND

In patients undergoing decompressive craniectomy, resection and detachment of the temporal muscle produces esthetic and functional damage, due to atrophy of the frontal portion of the temporal muscle in the temporal fossa. We have performed en-block temporal muscle detachment in decompressive craniectomy patients to avoid esthetic and functional damage to the temporal muscle.

METHODS

Twenty-one patients underwent decompressive craniectomy using a frontotemporoparietal approach. Through a three-leaf clover flap skin incision, the temporal muscle was detached en-block and overturned antero-inferiorly conjoined with the frontal myocutaneous flap. A decompressive craniectomy and duraplasty were performed. A polyethylene sheet was added to prevent adherence of the temporal muscle to the dura mater.

RESULTS

The decompressive craniectomy was effective in all patients. When subsequent cranioplasty was performed, the temporal muscle was easily repositioned. No complications resulted from the en-block temporal muscle detachment or the use of the polyethylene sheet. In 18 patients eligible for clinical and radiological follow-up, excellent (n = 4) or good (n = 14) esthetic results were detected. Chewing ability is considered normal by all patients.

CONCLUSION

Although it requires that the patient undergo two surgical procedures, en-block detachment of the temporal muscle during decompressive craniectomy allows good esthetic and functional results.

Verifying three-dimensional skull model reconstruction using cranial index of symmetry

BACKGROUND

Difficulty exists in scalp adaptation for cranioplasty with customized computer-assisted design/manufacturing (CAD/CAM) implant in situations of excessive wound tension and sub-cranioplasty dead space. To solve this clinical problem, the CAD/CAM technique should include algorithms to reconstruct a depressed contour to cover the skull defect. Satisfactory CAM-derived alloplastic implants are based on highly accurate three-dimensional (3-D) CAD modeling. Thus, it is quite important to establish a symmetrically regular CAD/CAM reconstruction prior to depressing the contour. The purpose of this study is to verify the aesthetic outcomes of CAD models with regular contours using cranial index of symmetry (CIS).

MATERIALS AND METHODS

From January 2011 to June 2012, decompressive craniectomy (DC) was performed for 15 consecutive patients in our institute. 3-D CAD models of skull defects were reconstructed using commercial software. These models were checked in terms of symmetry by CIS scores.

RESULTS

CIS scores of CAD reconstructions were 99.24±0.004% (range 98.47-99.84). CIS scores of these CAD models were statistically significantly greater than 95%, identical to 99.5%, but lower than 99.6% (p<0.001, p = 0.064, p = 0.021 respectively, Wilcoxon matched pairs signed rank test). These data evidenced the highly accurate symmetry of these CAD models with regular contours.

CONCLUSIONS

CIS calculation is beneficial to assess aesthetic outcomes of CAD-reconstructed skulls in terms of cranial symmetry. This enables further accurate CAD models and CAM cranial implants with depressed contours, which are essential in patients with difficult scalp adaptation.

Decompressive craniectomy in children: single-center series and systematic review

BACKGROUND

Decompressive craniectomy (DC) is performed as a life-saving procedure in patients with intractably increased intracranial pressure after traumatic brain injury, bleeding, cerebral infarction, or brain swelling of other causes. However, the application of DC is as controversial in the pediatric population as it is in adults.

OBJECTIVE

To find factors influencing the outcome in pediatric patients who underwent DC because of sustained high intracranial pressure.

METHODS

Between April 2000 and December 2009, 34 pediatric patients (age 0-18 years) underwent DC. Patients were stratified according to the indication for DC. Outcome was assessed according to the modified Rankin Scale score at 6 months. MEDLINE was searched for published studies or reports of DC in pediatric patients to gain a larger population. Two reviewers independently extracted data.

RESULTS

Literature data, including the current series, revealed a total of 172 pediatric patients. Overall, a favorable outcome was achieved in 106 of 172 patients (62%). A favorable outcome was achieved in 25 of 36 patients without traumatic brain injury vs 81 of 136 patients with traumatic brain injury (69% vs 60%). Patients without signs of cerebral herniation had a better outcome than patients with unilateral or bilateral dilated pupils (73% vs 60% vs 45%, respectively).

CONCLUSION

The current data indicate that DC in children with traumatic or nontraumatic brain swelling might be warranted, regardless of the underlying cause. Despite mydriasis, a favorable outcome might be achieved in a significant number of pediatric patients. Nevertheless, careful individual decision making is needed for each patient, especially when signs of cerebral herniation have persisted for a long time.

Decompressive hemicraniectomy for ischemic stroke in the pediatric population

Adult patients with space-occupying hemispheric infarctions have a poor prognosis, with an associated fatality rate of 80%. Decompressive hemicraniectomy (DH) has been studied as a treatment option for patients with malignant cerebral infarction refractory to maximal medical therapy, with reasonable outcomes demonstrated in the adult population if the patient is decompressed within 48 h. However, there are no randomized controlled trials in the pediatric literature to make the same claims. In this study, we evaluated the current literature in regards to DH following malignant stroke in the pediatric population. We found that excellent recovery, with an acceptable quality of life, is possible, particularly in the pediatric patient. Our cohort suggests that pediatric intervention beyond the 48-h time interval may still lead to positive outcomes, unlike adult patients. Regardless, randomized controlled trials are needed to determine optimal timing of intervention following symptom onset, as well as to identify predictors for positive outcome in the pediatric population.

New reconstructive technologies after decompressive craniectomy in traumatic brain injury: the role of three-dimensional titanium mesh

Functional and aesthetic reconstruction after wide decompressive craniectomy directly correlates with subsequent quality of life. Advancements in the development of biomaterials have now made three-dimensional (3-D) titanium mesh a new option for the repair of skull defects after craniectomy. The purpose of this study was to review aesthetic and surgical outcomes and complications of patients who had skull defects repaired with 3-D titanium mesh. The records of 40 adult patients (31 unilateral craniectomies and 9 bilateral craniectomies) who underwent a computer-assisted designed titanium mesh implant at a university hospital from January 2008 to January 2010 were retrospectively reviewed. Aesthetic outcomes, cranial nerve V and VII function, and complications (hardware extrusions, meningitis, osteomyelitis, brain abscess, and pneumocephalus) were evaluated. The craniofacial symmetry, implant stability, and functional outcomes were excellent for all patients. No patients had trigeminal or facial dysfunction. All had excellent cosmetic results as measured by post-reduction radiographs and personal and family perceptions of the forehead contour. Two patients had delayed wound healing and subsequent subclinical wound infections, which resolved after treatment with antibiotics for 2 weeks. Craniofacial skeletal reconstruction with 3-D titanium mesh results in excellent forehead contour and cosmesis, and subsequently a better quality of life with few complications. Titanium mesh reconstruction offers a favorable alternative to other graft materials in the repair of large skull defects.

Complications of delayed cranial repair after decompressive craniectomy in children less than 1 year old

BACKGROUND

Decompressive craniectomy is an effective treatment option in case of refractory intracranial hypertension after severe head injury. The incidence of complications following cranial repair after decompressive craniectomy for traumatic brain injury is not negligible, particularly in infants and young toddlers. However, only a few dedicated papers can be found in the literature.

METHOD

We describe the complications observed in two boys and one girl under 1 year of age that were treated in the last decade by hemicranial decompressive craniotomy and enlarging hemispheric duraplasty, and subsequent cranial repair by means of autologous bone-flap replacement.

FINDINGS

Despite good clinical and neurological outcome, the postoperative clinical course was complicated in all cases by early or late evidence of subdural fluid collections associated to the occurrence of hydrocephalus and causing recurrent dislocation and progressive resorption of the autologous bone flap.

CONCLUSIONS

Infants less than 1 year old, undergoing decompressive craniectomy after traumatic brain injury, experience a high rate of complications following subsequent cranial repair. Subdural collections and resorption of the autologous bone flap are to be considered as extremely common complications.

Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccidental blunt cranial trauma

OBJECT

The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms.

METHODS

All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed.

RESULTS

Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3).

CONCLUSIONS

Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.

Pediatric neurocritical care

Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.

In situ free-floating craniectomy for traumatic cerebral decompression in an infant: A field hospital solution

Background:

Despite refinements in neurotrauma care, the morbidity and mortality of severe traumatic brain injury (TBI) in pediatric patients remains high. We report a novel approach to the surgical management of increased intracranial pressure in severe TBI utilizing an in situ free-floating craniectomy technique, which was originally devised as a creative solution to the unique challenges in a Haitian field hospital following the 2010 earthquake.

Case Description:

A 13-month-old Haitian boy presented to Project Medishare field hospital in Port-au-Prince with left hemiplegia, a bulging fontanelle, and increasing lethargy following a traumatic head injury 4 days prior. An urgent craniectomy was performed based on clinical grounds (no brain imaging was available). A standard trauma flap incision was made, followed by a hemicraniectomy and expansion duraplasty. A small hematoma was evacuated. Frontal, temporal, and parietal bone flaps were placed on the dura in approximation to their normal anatomical configuration, but not affixed, leaving space for further brain edema, and the scalp was closed. The child experienced favorable peri-operative and early postoperative results.

Conclusion:

In situ free-floating craniectomy, while devised as a creative solution to limited resources in a natural disaster zone, may offer advantages over more traditional techniques.

Pediatric traumatic brain injury: an update

PURPOSE OF REVIEW

The developing brain is particularly vulnerable to traumatic brain injury (TBI), leading to frequent disability or death. This article is an update of the pediatric specificities of TBI management.

RECENT FINDINGS

We review the evidences with regards to general management and therapeutic goals to prevent secondary injuries in pediatric TBI patients. Recent controversies in neurocritical care, such as multimodal neuromonitoring, hyperventilation, barbiturate coma, hypothermia, and decompressive surgery, are also highlighted.

SUMMARY

Many therapeutic modalities in pediatric TBI have a low level of evidence. Further research is needed to establish clear resuscitation goals. Universal objectives may not be suitable for all patients; intensive neuromonitoring may help in identifying individual therapeutic goals and guiding the selection of treatments.

Life-saving decompressive craniectomy for diffuse cerebral edema during an episode of new-onset diabetic ketoacidosis: case report and review of the literature

PURPOSE

Diabetic ketoacidosis (DKA), a well-known complication of diabetes mellitus, is associated with severe diffuse cerebral edema leading to brain herniation and death. Survival from an episode of symptomatic cerebral edema has been associated with debilitating neurological sequelae, including motor deficits, visual impairment, memory loss, seizures, and persistent vegetative states. A review of the literature reveals scant information regarding the potential surgical options for these cases. The authors present their case in which they used a craniectomy to treat this life-threatening condition.

METHODS

After reportedly suffering nausea and vomiting, a 12-year-old male presented to the emergency room with lethargy and was diagnosed with acute DKA. After appropriate treatment, the patient became comatose. A CT scan revealed diffuse cerebral edema. To decrease intracranial pressure and prevent further progression of brain herniation, a bifrontal decompressive craniectomy with duraplasty was performed.

RESULTS

The patient's neurological function gradually improved, and he returned to school and his regular activities with only minimal cognitive deficits.

CONCLUSION

Given the high mortality and morbidity associated with DKA-related edema, we believe decompressive craniectomy should be considered for malignant cerebral edema and herniation syndrome.

Decompressive hemicraniectomy for pediatric traumatic brain injury: long-term outcome based on quality of life

AIMS

The impact of decompressive hemicraniectomy (DCH) on the overall outcome of pediatric brain injury patients has not been fully determined. In this paper, the authors performed a systematic review of patient outcome based on quality of life following DCH in a pediatric population.

METHODS

We describe our experience with decompressive craniectomy in pediatric patients and perform a literature review and pooled outcomes analysis to supplement these findings. A total of 13 children underwent DCH for intractable intracranial pressure in our institution from 2000 to 2008. Follow-up was available in 11 patients with 1 death (9%) and 7 survivors (70%) obtaining a favorable outcome (Glasgow Outcome Scale, GOS, scores = 4-5).

RESULTS

A literature review to determine the usefulness of DCH identified 17 articles that, when combined with our series, resulted in 186 pediatric DCH cases. Pooled outcomes found 42 deaths and 112 patients who had favorable outcomes at 6 months. The average 6-month mortality was 21.1%, and the pooled mean quality of life among survivors 0.75 (0.68-0.82), midway between moderate disability and good outcome.

CONCLUSIONS

Based on our findings, DCH results in a majority of pediatric patients having a good outcome based on the GOS score.

Traumatic brain injury: preferred methods and targets for resuscitation

PURPOSE OF REVIEW

Severe traumatic brain injury (TBI) is the most common cause of death and disability in pediatric trauma. This review looks at the strategies to treat TBI in a temporal fashion. We examine the targets for resuscitation from field triage to definitive care in the pediatric ICU.

RECENT FINDINGS

Guidelines for the management of pediatric TBI exist. The themes of contemporary clinical research have been compliance with these guidelines and refinement of treatment recommendations developing a more sophisticated understanding of the pathophysiology of the injured brain. In the field, the aim has been to achieve routine compliance with the resuscitation goals. In the hospital, efforts have been directed at improving our ability to monitor the injured brain, developing techniques that limit brain swelling, and customizing brain perfusion.

SUMMARY

As our understanding of pediatric TBI evolves, the ambition is that age-specific and perhaps individual brain injury strategies based upon feedback from continuous monitors will be defined. In addition, vogue methods such as hypothermia, hypertonic saline, and aggressive surgical decompression may prove to impact brain swelling and outcomes.

Waterjet dissection in pediatric cranioplasty

OBJECT

Waterjet dissection has been shown to separate tissues of different resistance, with preservation of blood vessels. In cranioplasty, separation of subcutaneous tissue and dura mater is often difficult to achieve because the various tissue layers strongly adhere to each other after decompressive craniotomy. In the present study, the potential advantages and drawbacks of the waterjet technique in cranioplasty after craniectomy and duraplasty are addressed.

METHODS

The waterjet effect on fresh human cadaveric dura mater specimens as well as on several dural repair patches was tested in vitro under standardized conditions, with waterjet pressures up to 80 bar. Subsequently, 8 pediatric patients (5 boys, 3 girls; mean age 9.9 years, range 1.2-16.7 years) who had been subjected to decompressive craniectomy (7 with duraplasty including bovine pericardium as a dural substitute, 1 without duraplasty in congenital craniosynostosis) underwent waterjet cranioplasty. The waterjet was used to separate the galea and the dura mater. The technique was applied tangentially between the dura and the galea, with different pressure levels up to 50 bar.

RESULTS

In vitro, fresh cadaveric human dura mater as well as 2 different dural repair substitutes showed a very high resistance to waterjet dissection up to 80 bar. The human dura and the various substitutes were dissected only after long-lasting exposure to the waterjet. Human dura was perforated at pressures of 60 bar and higher. Bovine pericardium dural substitute was perforated at pressures of 55 bar and higher. Artificial nonabsorbable polyesterurethane dural substitute was dissected at pressures of 60 bar and higher. In the clinical setting, the waterjet was able to separate galea and dura with minimal bleeding. No blood transfusion was required. Dissection of scarred tissue was possible by a waterjet of 40 bar pressure. Tissue layers were stretched and separated by the waterjet dissection, and a very reliable hemostasis resulted. This resulted in an effective reduction of bleeding, with < 60 ml blood loss in 7 of the 8 cases. Neither a dural tear nor a perforation of any duraplasty occurred during operative preparation. There were no operative or postoperative complications.

CONCLUSIONS

The experimental and clinical data show that waterjet separation of dura mater, dural substitute, and galea can be performed with a high level of safety to avoid dural tears. The waterjet dissection stretches tissue layers, which results in a reliable hemostasis effect. This potentially results in an effective reduction of surgical blood loss, which should be the focus of further studies.