Outcome of children with severe traumatic brain injury who are treated with decompressive craniectomy

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) is controversial. The authors sought to determine if DC improves the outcome of children with severe TBI.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>In a retrospective, case-control study, medical records of all patients admitted to the pediatric ICU between May 1998 and May 2008 with severe TBI and treated with DC were identified and matched to patients who were treated medically without DC. Medical records were reviewed for patients’ demographic data and baseline characteristics.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>During the study period, 17 patients with severe TBI treated with DC at a median of 2 hours (interquartile range [IQR] 1–14 hours) after admission were identified and matched to 17 contemporary controls. On admission, there were no differences between DC and control patients regarding age (10.2 ± 5.9 years vs 12.4 ± 5.4 years, respectively [mean ± SD]), sex, weight, Glasgow Coma Scale score (median 5 [IQR 3–7] vs 4 [IQR 3–6], respectively; p = 0.14), or the highest intracranial pressure (median 42 [IQR 22–54] vs 30 [IQR 21–36], respectively; p = 0.77). However, CT findings were significant for a higher rate of herniation and cerebral edema among patients with DC versus controls (7/17 vs 2/17, respectively, had herniation [p = 0.05] and 14/17 vs 6/17, respectively, had cerebral edema [p = 0.006]). Overall there were no significant differences in survival between patients with DC and controls (71% [12/17] vs 82% [14/17], respectively; p = 0.34). However, among survivors, at 4 years (IQR 1–6 years) after the TBI, 42% (5/12) of the DC patients had mild disability or a Glasgow Outcome Scale score of 5 vs none (0/14) of the controls (p = 0.012).</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>In this retrospective, small case-control study, the authors have shown that early DC in pediatric patients with severe TBI improves outcome in survivors. Future prospective randomized controlled studies are needed to confirm these findings.</jats:p></jats:sec>

Rescue Decompressive Craniectomy in Children with Severe Traumatic Brain Injury

“…Of note, as it has been recently clarified, the optimal control of ICP cannot exclude the presence of undergoing cerebral injuries and cannot guarantee a good neurological outcome. 24,25 Some pediatric and adult studies have demonstrated that craniectomy was associated with optimal neurological outcome, 3,4,[26][27][28][29][30] while, on the contrary, there are studies that have shown that patients underwent DC had poor outcome compared with medical treatment. 31,32 In both recent RCTs, craniectomy patients presented significantly less favorable outcome at six months postinjury.…”

Successful Decompressive Craniectomy in a Child with Severe Head Trauma

“…Az sayıda çalışma bu tedavinin ağır travmatik beyin hasarı sonrası çocuklarda uzun dönemde pozitif etkisini göstermiştir. 7,9 Taylor ve ark. 'nın 7 ağır kafa travmalı bir yaşın üzerinde 27 çocuk hastayla yaptıkları çalışmada bitemporal kraniektomi ile tıbbi tedavi karşılaştırılmıştır.…”

“…Bazı çalışmalar da erken cerrahinin daha iyi sonuçlar verdiğini göstermiştir. 7,9,11,12 Mhanna ve ark. 'nın 9 çocuk hastalarda yaptıkları çalışmada dekompresif kraniektomi yapılan 17 hasta ile işlemin uygulanmadığı 17 hasta kontrol grubu olarak değerlendirilmiştir.…”

“…Bu çalışmada ortalama operasyon zamanı 2 saat olarak tespit edilmiş ve hastaların mortalitelerinde anlamlı fark olmamasına rağmen morbiditelerinin kontrol grubuna göre daha iyi olduğu gösterilmiştir. 9 Bazı çalışmalarda ise cerrahinin zamanı ile sonuçlar arasında bir ilişki saptanamamıştır. 13,14 Çavuşoğlu ve ark.…”

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

“…Similarly, TBI represents a significant cause of morbidity and mortality in children admitted to the PICU (31,36,42,100). As shown in other fields, protocolized care and adherence to guidelines, even if of low evidence level, can be associated with improved outcomes.…”