Child's Nervous System

, Volume 30, Issue 8, pp 1393–1398 | Cite as

Intraoperative blood loss during decompressive craniectomy for intractable intracranial hypertension after severe traumatic brain injury in children

  • François-Pierrick DesgrangesEmail author
  • Etienne Javouhey
  • Carmine Mottolese
  • Anne Migeon
  • Alexandru Szathmari
  • Florent Baudin
  • Mathilde de Queiroz
  • Bérengère Cogniat
  • Dominique Chassard
Original Paper



There are no data available on the risk of intraoperative bleeding during decompressive craniectomy (DC) after traumatic brain injury (TBI) in children. The objectives of this study were to assess the risk of intraoperative bleeding during DC for intractable intracranial hypertension after TBI, to identify potential factors associated with the risk of bleeding during DC, and to assess the impact of DC on systemic and cerebral hemodynamics and on coagulation.


Twelve children were identified as having undergone DC after TBI from April 2009 to June 2013 in our center. Subjects were allocated into two groups according to the percentage of blood loss (IBL) during the intraoperative period (<or ≥50 % of the estimated blood volume (EBV)).


The median IBL during DC was 49 [17–349] % of the EBV. Children with an IBL ≥ 50 % of EBV had higher preoperative intracranial pressure (ICP) (p = 0.03) and international normalized ratio (INR) (p = 0.02) than those with an IBL < 50 % of EBV. DC induced significant decreases in ICP (p = 0.0005), mean arterial pressure (p = 0.01), and a significant increase in norepinephrine flow rate (p = 0.04) between the immediate pre- and postoperative periods.


DC allows a significant decrease in ICP after severe pediatric TBI but is a surgical procedure at a high risk of bleeding. High ICP and INR during the immediate preoperative period are the main factors associated with increased IBL during DC. Further studies are needed to confirm our results and to assess the impact of the amount of IBL on the postoperative survival and functional outcome.


Decompressive craniectomy Traumatic brain injury Child Blood loss Coagulopathy Hemodynamics 


Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Glick RP, Ksendzovsky A, Greesh J, Raksin P (2011) Initial observations of combination barbiturate coma and decompressive craniectomy for the management of severe pediatric traumatic brain injury. Pediatr Neurosurg 47:152–157PubMedCrossRefGoogle Scholar
  2. 2.
    Appelboom G, Zoller SD, Piazza MA, Szpalski C, Bruce SS, McDowell MM, Vaughan KA, Zacharia BE, Hickman Z, D’Ambrosio A, Feldstein NA, Anderson RC (2011) Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery. Neurosurg Focus 31:E5PubMedCrossRefGoogle Scholar
  3. 3.
    Jacob AT, Heuer GG, Grant R, Georgoff P, Danish SF, Storm PB, Stein SC (2011) Decompressive hemicraniectomy for pediatric traumatic brain injury: long-term outcome based on quality of life. Pediatr Neurosurg 47:81–86PubMedCrossRefGoogle Scholar
  4. 4.
    Jagannathan J, Okonkwo DO, Dumont AS, Ahmed H, Bahari A, Prevedello DM, Jane JA Sr, Jane JA Jr (2007) Outcome following decompressive craniectomy in children with severe traumatic brain injury: a 10-year single-center experience with long-term follow up. J Neurosurg 106(4 Suppl):268–275PubMedGoogle Scholar
  5. 5.
    Thomale UW, Graetz D, Vajkoczy P, Sarrafzadeh AS (2010) Severe traumatic brain injury in children—a single center experience regarding therapy and long-term outcome. Childs Nerv Syst 26:1563–1573PubMedCrossRefGoogle Scholar
  6. 6.
    Kochanek PM, Carney N, Adelson PD, Ashwal S, Bell MJ, Bratton S, Carson S, Chesnut RM, Ghajar J, Goldstein B, Grant GA, Kissoon N, Peterson K, Selden NR, Tasker RC, Tong KA, Vavilala MS, Wainwright MS, Warden CR, American Academy of Pediatrics-Section on Neurological Surgery; American Association of Neurological Surgeons/Congress of Neurological Surgeons; Child Neurology Society; European Society of Pediatric and Neonatal Intensive Care; Neurocritical Care Society; Pediatric Neurocritical Care Research Group; Society of Critical Care Medicine; Paediatric Intensive Care Society UK; Society for Neuroscience in Anesthesiology and Critical Care; World Federation of Pediatric Intensive and Critical Care Societies (2012) Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents—second edition. Pediatr Crit Care Med 13(Suppl 1):S1–S82PubMedGoogle Scholar
  7. 7.
    Güresir E, Schuss P, Seifert V, Vatter H (2012) Decompressive craniectomy in children: single-center series and systematic review. Neurosurgery 70:881–888PubMedCrossRefGoogle Scholar
  8. 8.
    Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibballs 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
  9. 9.
    Talving P, Lustenberger T, Lam L, Inaba K, Mohseni S, Plurad D, Green DJ, Demetriades D (2011) Coagulopathy after isolated severe traumatic brain injury in children. J Trauma 71:1205–1210PubMedCrossRefGoogle Scholar
  10. 10.
    Carrick MM, Tyroch AH, Youens CA, Handley T (2005) Subsequent development of thrombocytopenia and coagulopathy in moderate and severe head injury: support for serial laboratory examination. J Trauma 58:725–729PubMedCrossRefGoogle Scholar
  11. 11.
    Chiaretti A, Piastra M, Pulitanò S, Pietrini D, De Rosa G, Barbaro R, Di Rocco C (2002) Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst 18:129–136PubMedCrossRefGoogle Scholar
  12. 12.
    Gerlach R, Krause M, Seifert V, Goerlinger K (2009) Hemostatic and hemorrhagic problems in neurosurgical patients. Acta Neurochir 151:873–900PubMedCrossRefGoogle Scholar
  13. 13.
    Miller P, Mack CD, Sammer M, Rozet I, Lee LA, Muangman S, Wang M, Hollingworth W, Lam AM, Vavilala MS (2006) The incidence and risk factors for hypotension during emergent decompressive craniotomy in children with traumatic brain injury. Anesth Analg 103:869–875PubMedCrossRefGoogle Scholar
  14. 14.
    Chaiwat O, Sharma D, Udomphorn Y, Armstead WM, Vavilala MS (2009) Cerebral hemodynamic predictors of poor 6-month Glasgow Outcome Score in severe pediatric traumatic brain injury. J Neurotrauma 26:657–663PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Vavilala MS, Bowen A, Lam AM, Uffman JC, Powell J, Winn HR, Rivara FP (2003) Blood pressure and outcome after severe pediatric traumatic brain injury. J Trauma 55:1039–1044PubMedCrossRefGoogle Scholar
  16. 16.
    Orliaguet GA, Meyer PG, Baugnon T (2008) Management of critically ill children with traumatic brain injury. Paediatr Anaesth 18:455–461PubMedCrossRefGoogle Scholar
  17. 17.
    Manohar C, Avitsian R, Lozano S, Gonzalez-Martinez J, Cata JP (2011) The effect of antiepileptic drugs on coagulation and bleeding in the perioperative period of epilepsy surgery: the Cleveland Clinic experience. J Clin Neurosci 18:1180–1184PubMedCrossRefGoogle Scholar
  18. 18.
    Goobie SM, Meier PM, Pereira LM, McGowan FX, Prescilla RP, Scharp LA, Rogers GF, Proctor MR, Meara JG, Soriano SG, Zurakowski D, Sethna NF (2011) Efficacy of tranexamic acid in pediatric craniosynostosis surgery: a double-blind, placebo-controlled trial. Anesthesiology 114:862–871PubMedCrossRefGoogle Scholar
  19. 19.
    Piastra M, Di Rocco C, Caresta E, Zorzi G, De Luca D, Caldarelli M, La Torre G, Conti G, Antonelli M, Eaton S, Pietrini D (2008) Blood loss and short-term outcome of infants undergoing brain tumour removal. J NeuroOncol 90:191–200PubMedCrossRefGoogle Scholar
  20. 20.
    Philip S, Udomphorn Y, Kirkham FJ, Vavilala MS (2009) Cerebrovascular pathophysiology in pediatric traumatic brain injury. J Trauma 67(2 Suppl):S128–S134PubMedCrossRefGoogle Scholar
  21. 21.
    Haas T, Spielmann N, Mauch J, Madjdpour C, Speer O, Schmugge M, Weiss M (2012) Comparison of thromboelastometry (ROTEM®) with standard plasmatic coagulation testing in paediatric surgery. Br J Anaesth 108:36–41PubMedCrossRefGoogle Scholar
  22. 22.
    Tauber H, Innerhofer P, Breitkopf R, Westermann I, Beer R, El Attal R, Strasak A, Mittermayr M (2011) Prevalence and impact of abnormal ROTEM® assays in severe blunt trauma: results of the ‘Diagnosis and Treatment of Trauma-Induced Coagulopathy (DIA-TRE-TIC) study’. Br J Anaesth 107:378–387PubMedCrossRefGoogle Scholar
  23. 23.
    Afshari A, Wikkelsø A, Brok J, Møller AM, Wetterslev J (2011) Thrombelastography (TEG) or thromboelastometry (ROTEM) to monitor haemotherapy versus usual care in patients with massive transfusion. Cochrane Database Syst Rev 16, CD007871Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • François-Pierrick Desgranges
    • 1
    • 4
    Email author
  • Etienne Javouhey
    • 2
  • Carmine Mottolese
    • 3
  • Anne Migeon
    • 1
  • Alexandru Szathmari
    • 3
  • Florent Baudin
    • 2
  • Mathilde de Queiroz
    • 1
  • Bérengère Cogniat
    • 1
  • Dominique Chassard
    • 1
  1. 1.Department of Pediatric Anesthesia, Hôpital Femme Mère Enfant (Hospices Civils de Lyon)Université Claude Bernard Lyon 1LyonFrance
  2. 2.Department of Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant (Hospices Civils de Lyon)Université Claude Bernard Lyon 1LyonFrance
  3. 3.Department of Pediatric Neurosurgery, Hôpital Neurologique Pierre Weirtheimer et Hôpital Femme Mère Enfant (Hospices Civils de Lyon)Université Claude Bernard Lyon 1LyonFrance
  4. 4.Département d’Anesthésie-Réanimation, Hôpital Femme Mère EnfantHospices Civils de LyonBronFrance

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