Advertisement

Child's Nervous System

, Volume 22, Issue 10, pp 1268–1274 | Cite as

Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury

  • V. A. Josan
  • S. SgourosEmail author
Original Paper

Abstract

Introduction

We compared the effect of early decompressive craniectomy (<24 h) vs non-operative treatment on the outcome of children with refractory intracranial hypertension after severe traumatic brain injury.

Material and methods

We retrospectively reviewed 12 consecutive patients treated between 1999 and 2001 for refractory intracranial hypertension after isolated severe head injury without any intracranial haematomas. In all patients, treatment included sedation, paralysis and IV mannitol under intracranial pressure monitoring. Early decompressive craniectomy was carried out in six patients (mean age: 13 years) at mean time from injury of 7 h (range: 2–18 h), whereas six patients (mean age: 11.5 years) were managed with non-operative treatment. The Marshall Grading system was used to score the severity of radiological abnormalities in CT scans. The Glasgow Outcome Scale (GOS) at 1-year follow-up was used as outcome measure.

Results

The mean Marshall grade was 3 in the craniectomy group and 2 in the non-operative group. All patients in the craniectomy group survived: four patients scored 5 and two patients scored 4 on the GOS. In the non-operative group, two patients (33%) died, one of whom received late decompressive craniectomy at 9 days, while three patients scored 5 and one patient scored 3 on the GOS.

Conclusion

In children who suffered severe head injury with refractory intracranial hypertension without intracranial haematoma, early decompressive craniectomy employed in the first few hours after injury before the onset of irreversible ischaemic changes may be an effective method to treat the secondary deterioration that commonly leads to death or severe neurological deficit.

Keywords

Decompressive craniectomy Head injury Refractory intracranial hypertension 

Notes

Acknowledgements

We would like to thank Mr. A. D. Hockley and Mr. A. R. Walsh, Consultant Neurosurgeons at the Birmingham Children’s Hospital, for allowing access upon material of their patients.

References

  1. 1.
    Hahn YS, Chyung C, Barthel MJ, Bailes J, Flannery AM, McLone DG (1988) Head injuries in children under 36 years of age. Demography and outcome. Childs Nerv Syst 4:34–40PubMedGoogle Scholar
  2. 2.
    Luerssen TG, Klauber MR, Marshall RF (1988) Outcome from head injury related to patient’s age. A longitudinal prospective study of paediatric and adult head injury. J Neurosurg 68:409–416PubMedGoogle Scholar
  3. 3.
    Zimmermann R, Bilaniulk L (1994) Paediatric head trauma. Neuroimaging Clin N Am 349–366Google Scholar
  4. 4.
    Aldrich EF, Eisenberg HM, Saydjari C, Luerssen TG, Foulkes MA, Jane JA, Marshall LF, Marmarou A, Young HF (1992) Diffuse brain swelling in severely head injured children. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 76:450–454PubMedGoogle Scholar
  5. 5.
    Berger MS, Pitts LH, Lovely M, Edwards MSB, Bartkowski HM (1985) Outcome from severe head injury children and adolescents. J Neurosurg 62:194–199PubMedGoogle Scholar
  6. 6.
    Pillai S, Praharal SS, Mohanty A, Sastri KVR (2001) Prognostic factors in children with severe diffuse brain injuries: a study of 74 patients. Pediatr Neurosurg 34(2):98–103PubMedCrossRefGoogle Scholar
  7. 7.
    Marshall LF, Smith RW, Shapiro HM (1979) The outcome with aggressive treatment in severe head injuries. The significance of intracranial pressure monitoring. J Neurosurg 50:20–25PubMedCrossRefGoogle Scholar
  8. 8.
    Bullock R, Chestnut RM, Clifton G, Ghajar J, Marion DW, Narayan RK, Newell DW, Pitts LH, Rosner MJ, Wilberger JW (1996) Guidelines for the management of severe head injury. Brain Trauma Foundation. Eur J Emerg Med 3:109–127PubMedGoogle Scholar
  9. 9.
    Dam Hieu P, Sizun J, Person H, Besson G (1996) The place of decompressive craniectomy in the treatment of uncontrollable post-traumatic intracranial hypertension in children. Childs Nerv Syst 12:270–275CrossRefGoogle Scholar
  10. 10.
    Gower DJ, Lee KS, McWhorter JM (1988) Role of subtemporal decompression in severe closed head injury. Neurosurgery 23:417–422PubMedGoogle Scholar
  11. 11.
    Venes JL, Collins WF (1975) Bifrontal decompressive craniectomy in the management of head trauma. J Neurosurg 42:429–433PubMedCrossRefGoogle Scholar
  12. 12.
    Munch E, Horn P, Schurer L, Piepgras A, Torsten P, Smiedeck P (2000) Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery 34:315–323CrossRefGoogle Scholar
  13. 13.
    Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibbals J (2001) A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst 17:154–162PubMedCrossRefGoogle Scholar
  14. 14.
    Guerra WK, Gaab MR, Dietz H, Mueller J, Piek J, Fritsh MJ (1999) Surgical decompression for traumatic brain swelling: indications and results. J Neurosurg 90:187–196PubMedGoogle Scholar
  15. 15.
    Whitfield PC, Patel H, Hutchinson PJA, Czonyska M, Parry D, Menon D, Pickard JD, Kirkpatrick PJ (2001) Bifrontal decompressive craniectomy in the management of post-traumatic intracranial hypertension. Br J Neurosurg 15:500–507PubMedCrossRefGoogle Scholar
  16. 16.
    Rekate HL (2001) Head injuries: management of primary injuries and prevention of secondary damage. A consensus conference on paediatric neurosurgery. Childs Nerv Syst 17:632–634PubMedCrossRefGoogle Scholar
  17. 17.
    Figaji AA, Fieggen AG, Peter JC (2003) Early decompressive craniotomy in children with severe traumatic brain injury. Childs Nerv Syst 19:666–673PubMedCrossRefGoogle Scholar
  18. 18.
    Marshall L, Bowers S, Klauber M (1991) A new classification of head injury based on computerized tomography. J Neurosurgery 75:514–520Google Scholar
  19. 19.
    Jennet B, Bond M (1975) Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480–484CrossRefGoogle Scholar
  20. 20.
    Bruce DA, Alavi A, Bilaniuk L, Dolinskas C, Obrist W, Uzzell B (1981) Diffuse cerebral swelling following head injuries in children : the syndrome of “malignant brain oedema”.J Neurosurg 54:170–178PubMedGoogle Scholar
  21. 21.
    Cordobes F, Lobato RD, Rivas JJ, Portillo JM, Sarabia M, Munoz MJ (1987) Post-traumatic diffuse brain swelling: isolated or associated with cerebral axonal injury. Clinical course and intracranial pressure in 18 children. Childs Nerv Syst 3:235–238PubMedCrossRefGoogle Scholar
  22. 22.
    Maas AI, Dearden M, Teasdale GM, Braakman R, Cohadon F, Iannotti F, Karimi A, Lapierre F, Murray G, Ohman J, Persson L, Servadei F, Stocchetti N, Unterberg A (1997) EBIC guidelines for management of severe head injury in adults. European Brain Injury Consortium. Acta Neurochir (Wien) 139:286–294CrossRefGoogle Scholar
  23. 23.
    Polin RS, Shaffrey ME, Bogaev CA, Tisdale N, Germanson T, Bocchicchio B, Jane JA (1997) Decompressive bifrontal craniotomy in the treatment of severe refractory posttraumatic cerebral edema. Neurosurgery 41:84–94PubMedCrossRefGoogle Scholar
  24. 24.
    Cruz J (1996) Adverse effects of pentobarbital on cerebral venous oxygenation of comatose patients with acute traumatic brain swelling; relationship to outcome. J Neurosurg 85:758–761PubMedGoogle Scholar
  25. 25.
    Kirkham FJ, Neville BGR (1986) Successful management of severe intracranial hypertension by surgical decompression. Dev Med Child Neurol 28:506–509PubMedCrossRefGoogle Scholar
  26. 26.
    Schalen W, Messeter K, Nordstrom CH (1992) Complications and side effects during thiopentone therapy in patients with severe head injuries. Acta Anaesthesiol Scand 36:369–377PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2006

Authors and Affiliations

  1. 1.Department of Paediatric NeurosurgeryBirmingham Children’s HospitalBirminghamUK

Personalised recommendations