From decompressive craniectomy to cranioplasty and beyond—a pediatric neurosurgery perspective
Decompressive craniectomy (DC) is an established neurosurgical emergency technique. Patient selection, optimal timing, and technical aspects related to DC and subsequent cranioplasty remain subjects of debate. For children, the overall degree of evidence is low, compared with randomized controlled trials (RCTs) in adults.
Here, we present a detailed retrospective analysis of pediatric DC, covering the primary procedure and cranioplasty. Results are analyzed and discussed in the light of modern scientific evidence, and conclusions are drawn to stimulate future research.
The main indication for DC in children is traumatic brain injury (TBI). Primary and secondary DC is performed with similar frequency. Outcome appears to be better than that in adults, although long-term complications (especially bone flap resorption after autologous cranioplasty) are more common in children. Overt clinical signs of cerebral herniation prior to DC are predictors of poor outcome.
We conclude that DC is an important option in the armamentarium to treat life-threatening intracranial hypertension, but further research is warranted, preferentially in a multicenter prospective registry.
KeywordsIntracranial hypertension Cranial reconstruction Bone flap resorption
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- 3.Bramlett HM, Dietrich WD (2004) Pathophysiology of cerebral ischemia and brain trauma: similarities and differences. J Cereb Blood Flow Metab 24:133–150. https://doi.org/10.1097/01.WCB.0000111614.19196.04 CrossRefGoogle Scholar
- 4.Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ, RESCUEicp Trial Collaborators (2016) Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 375:1119–1130. https://doi.org/10.1056/NEJMoa1605215 CrossRefGoogle Scholar
- 5.Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D'Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:1493–1502. https://doi.org/10.1056/NEJMoa1102077 CrossRefGoogle Scholar
- 6.Kolias AG, Scotton WJ, Belli A, King AT, Brennan PM, Bulters DO, Eljamel MS, Wilson MH, Papadopoulos MC, Mendelow AD, Menon DK, Hutchinson PJ, UK Neurosurgical Research Network, RESCUE-ASDH collaborative group, Kirkpatrick PJ, Corteen EA, Santarius T, Pickard JD, McHugh GS, Mitchell PM, Cowie CJ, Rowan EN, Crick SJ (2013) Surgical management of acute subdural haematomas: current practice patterns in the United Kingdom and the Republic of Ireland. Br J Neurosurg 27:330–333. https://doi.org/10.3109/02688697.2013.779365 CrossRefGoogle Scholar
- 7.Hutchinson P (2015) Randomised evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural haematomaGoogle Scholar
- 8.Hofmeijer J, Kappelle LJ, Algra A, Amelink GJ, van Gijn J, van der Worp H, HAMLET investigators (2009) Surgical decompression for space-occupying cerebral infarction (the Hemicraniectomy After Middle Cerebral Artery infarction with Life-threatening Edema Trial [HAMLET]): a multicentre, open, randomised trial. Lancet Neurol 8:326–333. https://doi.org/10.1016/S1474-4422(09)70047-X CrossRefGoogle Scholar
- 9.Vahedi K, Vicaut E, Mateo J, Kurtz A, Orabi M, Guichard JP, Boutron C, Couvreur G, Rouanet F, Touzé E, Guillon B, Carpentier A, Yelnik A, George B, Payen D, Bousser MG, DECIMAL Investigators (2007) Sequential-design, multicenter, randomized, controlled trial of early decompressive craniectomy in malignant middle cerebral artery infarction (DECIMAL Trial). Stroke 38:2506–2517. https://doi.org/10.1161/STROKEAHA.107.485235 CrossRefGoogle Scholar
- 11.Jüttler E, Unterberg A, Woitzik J, Bösel J, Amiri H, Sakowitz OW, Gondan M, Schiller P, Limprecht R, Luntz S, Schneider H, Pinzer T, Hobohm C, Meixensberger J, Hacke W, DESTINY II Investigators (2014) Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370:1091–1100. https://doi.org/10.1056/NEJMoa1311367 CrossRefGoogle Scholar
- 12.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 17:154–162. https://doi.org/10.1007/s003810000410 CrossRefGoogle Scholar
- 15.Lee S-K, Kim S-D, Kim S-H, Lim DJ, Park JY (2012) Decompressive hemicraniectomy and duroplasty in toddlers and preschool children with refractory intracranial hypertension after unilateral hemispheric stroke. J Korean Neurosurg Soc 51:86–90. https://doi.org/10.3340/jkns.2012.51.2.86 CrossRefGoogle Scholar
- 17.van de Vijfeijken SECM, Münker TJAG, Spijker R et al (2018) Autologous bone is inferior to alloplastic cranioplasties: safety of autograft and allograft materials for cranioplasties, a systematic review. World Neurosurg 117:443–452.e8. https://doi.org/10.1016/j.wneu.2018.05.193 CrossRefGoogle Scholar
- 18.Klieverik VM, Miller KJ, Singhal A, Han KS, Woerdeman PA (2019) Cranioplasty after craniectomy in pediatric patients—a systematic review. Childs Nerv Syst. https://doi.org/10.1007/s00381-018-4025-1
- 20.Maas AIR, Hukkelhoven CWPM, Marshall LF, Steyerberg EW (2005) Prediction of outcome in traumatic brain injury with computed tomographic characteristics: a comparison between the computed tomographic classification and combinations of computed tomographic predictors. Neurosurgery 57:1173–1182CrossRefGoogle Scholar
- 23.Wagner S, Schnippering H, Aschoff A, Koziol JA, Schwab S, Steiner T (2001) Suboptimum hemicraniectomy as a cause of additional cerebral lesions in patients with malignant infarction of the middle cerebral artery. J Neurosurg 94:693–696. https://doi.org/10.3171/jns.2001.94.5.0693 CrossRefGoogle Scholar
- 25.Kolias AG, Adams H, Timofeev I, Czosnyka M, Corteen EA, Pickard JD, Turner C, Gregson BA, Kirkpatrick PJ, Murray GD, Menon DK, Hutchinson PJ (2016) Decompressive craniectomy following traumatic brain injury: developing the evidence base. Br J Neurosurg 30:246–250. https://doi.org/10.3109/02688697.2016.1159655 CrossRefGoogle Scholar
- 27.Kramer AH, Deis N, Ruddell S, Couillard P, Zygun DA, Doig CJ, Gallagher C (2016) Decompressive craniectomy in patients with traumatic brain injury: are the usual indications congruent with those evaluated in clinical trials? Neurocrit Care 25:10–19. https://doi.org/10.1007/s12028-015-0232-8 CrossRefGoogle Scholar
- 28.Rocque BG, Agee BS, Thompson EM, Piedra M, Baird LC, Selden NR, Greene S, Deibert CP, Hankinson TC, Lew SM, Iskandar BJ, Bragg TM, Frim D, Grant G, Gupta N, Auguste KI, Nikas DC, Vassilyadi M, Muh CR, Wetjen NM, Lam SK (2018) Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study. J Neurosurg Pediatr 22:225–232. https://doi.org/10.3171/2018.3.peds17234 CrossRefGoogle Scholar
- 32.Fiaschi P, Pavanello M, Imperato A, Dallolio V, Accogli A, Capra V, Consales A, Cama A, Piatelli G (2016) Surgical results of cranioplasty with a polymethylmethacrylate customized cranial implant in pediatric patients: a single-center experience. J Neurosurg Pediatr 17:705–710. https://doi.org/10.3171/2015.10.peds15489 CrossRefGoogle Scholar
- 33.Frassanito P, Massimi L, Tamburrini G, Bianchi F, Nataloni A, Canella V, Caldarelli M (2018) Custom-made hydroxyapatite for cranial repair in a specific pediatric age group (7–13 years old): a multicenter post-marketing surveillance study. Childs Nerv Syst 34:2283–2289. https://doi.org/10.1007/s00381-018-3905-8 CrossRefGoogle Scholar