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

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Infants with severe traumatic brain injury represent a therapeutic challenge. The internal absence of open space within the infant cranial vault makes volume increases poorly tolerated. This report presents 7 cases of decompressive craniectomy in infants with cerebral edema.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The authors reviewed the medical charts of infants with brain injuries who presented to Albany Medical Center Hospital between January 2004 and July 2007. Variables that were examined included patient age, physical examination results at admission, positive imaging findings, surgery performed, complications, requirement of permanent CSF diversion, and physical examination results at discharge and outpatient follow-up using the King's Outcome Scale for Childhood Head Injury. Seven infants met the inclusion criteria for the study. Six infants experienced nonaccidental trauma, and 1 had a large infarction of the middle cerebral artery territory secondary to a carotid dissection. At admission, all patients were minimally responsive, 4 had equal and minimally reactive pupils, 3 had anisocoria with the enlarged pupil on the same side as the brain lesion, and all had right-sided hemiparesis. Six patients received a left hemicraniectomy, whereas 1 received a left frontal craniectomy. In all cases, bone was cultured and stored at the bone bank.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Postoperatively, 3 patients who developed draining CSF fistulas needed insertions of external ventricular drains, with incisions oversewn using nylon sutures and a liquid bonding agent. After prolonged CSF drainage and wound care, these patients all developed epidural and subdural empyemas necessitating surgical drainage and debridement. Methicillin-resistant <jats:italic>Staphylococcus aureus</jats:italic> was found in 2 patients and <jats:italic>Enterococcus</jats:italic> in the third. All patients developed hydrocephalus necessitating the insertion of a ventriculoperitoneal shunt, and all had bone replaced within 1–6 months from the time of the original operation. Two patients required reoperation due to bone resorption. At outpatient follow-up visits, all had scores of 3 or 4 on the King's Outcome Scale for Childhood Head Injury. Each patient was awake, interactive, and could sit, as well as either crawl or walk with assistance. All had persistent, improving right-sided hemiparesis and spasticity.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>Despite poor initial examination results, infants with severe traumatic brain injury can safely undergo decompressive craniectomy with reasonable neurological recovery. Postoperative complications must be anticipated and treated appropriately. Due to the high rate of CSF fistulas encountered in this study, it appears reasonable to recommend both the suturing in of a dural augmentation graft and the placement of either a subdural drain or a ventriculostomy catheter to relieve pressure on the healing surgical incision. Also, one might want to consider using a T-shaped incision as opposed to the traditional reverse question mark-shaped incision because wound healing may be compromised due to the potential interruption of the circulation to the posterior and inferior limb with this latter incision.</jats:p></jats:sec>

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

“…12,23,37 The renewed interest in decompressive craniectomy in the management of TBI is evidenced by 2 clinical trials currently underway-the RESCUEicp (Randomized Evaluation of Surgery for Uncontrollable Elevation of Intracranial Pressure) trial 19 and the DECRA (DEcompressive CRAniectomy) trial. 34 There have been several reports on decompressive craniectomy in children with TBI, 1,12,20,23,25,37 but few have specifically addressed its efficacy with nonaccidental or inflicted head trauma.…”

“…1,18,20,23,25 The authors of this series made unilateral frontotemporoparietal craniectomies on the side of the mass lesion or, in the absence of a mass lesion, on the side with the most severe cerebral edema. Bifrontal mass lesions were treated with bifrontal craniectomies.…”

“…Nevertheless, these data do demonstrate a 3-fold greater odds of poor outcome in the patients with nonaccidental trauma. Kan et al 25 reported a mean KOSCHI score of 4.5 in 51 children at a mean of 18.6 months following decompressive craniectomy, and Adamo et al 1 reported KOSCHI scores of 3 or 4 at 1 year following decompressive craniectomies (86% of the patients had suffered nonaccidental trauma). Using the GOS, Jagannathan et al 20 reported a mean 2-year score of 4.2 in their report on decompressive craniectomy in pediatric patients with TBI.…”

“…24 Reports predominantly dealing with adult patients have described the results from decompressive craniectomy done late in the course of refractory intracranial hypertension, and some of these have suggested that early decompressive craniectomy can result in more favorable outcomes. 16,32 Other reports have addressed outcomes following decompressive craniectomy in children with TBI, 1,12,21,23,25,37 and a significant proportion of these patients were victims of abusive head trauma. decompressive craniectomy, in children with TBI and compares cases involving abusive head trauma with those involving other mechanisms of injury.…”

Pediatric Neurocritical Care

“…Multiple retrospective reviews and small case series have described beneficial effects of decompressive craniectomy (DC) following TBI in children [89][90][91][92][93][94][95][96]. A single, prospective, randomized controlled trial has been published.…”