gms | German Medical Science

Objective: Decompressive craniectomy is a widely accepted method in the treatment of refractory intracranial hypertension, although current studies do not provide consistent data. Concerning subsequent cranioplasty, there is lack of evidence based guidelines, too. The objective was to gain knowledge about long term outcomes and complications after decompressive craniectomy and following cranioplasty for traumatic brain injury in pediatric patients in comparsion to a young adult control group.

Methods: Medical records of 126 patients, who underwent decompressive craniectomy and subsequent cranioplasty between 1998 and 2011, were retrospectively reviewed. 66 patients with traumatic brain injuries were included in this study and were divided into three groups: group1, 18 children under 14 years; group 2, 9 adolescents between 14 and 17 years; group 3, 39 adults between 18 and 30 years.

Results: Group 1 was dominated by falls, that led in 12 of 18 cases to severe traumatic brain injury with signs of herniation (66.7 %). 14 of those 18 children (77.8 %) required revisions, most commonly because of osteolysis. 12 patients (70.6 %) showed signs of bone resorption, eight of those had to undergo surgery (66.7 %). 10 of 18 children achieved good outcomes (55.6 %). In Group 2 traffic accidents were the reason for traumatic brain injury in eight of nine cases (88.9 %). Seven were severe (77.8 %) and five showed signs of herniation (55.6 %). Three adolescents needed revisions (33.3 %), primarily because of infections and bleedings (40.0 % each). Four of nine patients achieved good outcomes (44.4 %). In Group 3 27 of 39 patients (69.2 %) had a traffic accident. 82.1 % of the traumatic brain injuries were severe (32 of 39) and eleven patients showed signs of herniation (28.2 %). Revisions had to be done in 18 cases (46.2 %), most commonly because of infections (26.3 %). Good outcomes were assessed 25 times (64.1 %). Statistical analysis revealed significant relations between the age of the patients and the etiology of the accident (p=0.002). Furthermore, the appearance of complications was significantly dependent on people’s age: osteolysis (p≤0.001), hygromas (p=0.001) or cerebrospinal fluid leakage (p=0.003). A tendency regarding the relation of age and outcomes could be shown as well (p=0.054). Furthermore, osteolysis, the most common complication, was dependent on the severity of the trauma (p=0.005) and the means of fixation (p=0.049). Its appearance was significantly correlated with the outcomes (p=0.004).

Conclusion: The results confirm the controversial discussion in the current literature. On the one hand, the efficacy of decompressive craniectomy could be demonstrated with good outcomes in 39 of 66 patients (59.1 %), on the other hand a high complication rate of 53 % was observed (35 of 66 cases). The highest complication rate was found for the pediatric patients younger than 14 years, which emphasizes the problems of cranioplasty in the growing child.