gms | German Medical Science

Objective: Ischemic stroke occurs in only 1.2 to 3.6 children per 100,000 per year, and less than 2% of cases account for space-occupying or malignant ischemic strokes. Here we review the current evidence for decompressive craniectomy (DC) in children with supra- and infratentorial ischemic stroke.

Methods: A systematic search of the PubMed database was performed for "decompressive craniectomy", with a filter for "Child: birth to 18 years". Relevant articles on ischemic stroke were identified manually. Methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline.

Results: We identified 14 articles on DC for supratentorial ischemic stroke, reporting data on 28 children (27 MCA territory, 1 PCA territory) with a mean age of 7.5 years (range 6 months to 16 years). In 57% (N = 16) mydriasis occurred before DC, which was performed with a mean latency of 37 hours (range 2 to 291 hours) after stroke onset. 96% (N = 27) reached good outcome (i.e. mRS 1-3 or GOS 4-5). DC for infratentorial ischemic stroke was reported in 3 articles with data on 5 children with a mean age of 6.5 years (range 5 months to 11 years). DC was performed within 72 hours and reported outcome was good in all cases. No study exceeded evidence level 4 (i.e. case series), according to the definition of the Oxford Centre of Evidence-based Medicine.

Conclusion: In the absence of high-level evidence, most authors adduce findings from studies in adults as reference for treatment decisions in children. However, when reviewing the reported cases it seems that DC for supratentorial stroke is performed rather late, as a high proportion of children had preoperative mydriasis indicating herniation. Nevertheless the outcome appears to be much better than in adults, which could either be attributed to brain plasticity and higher potential of recovery in childhood or be explained by reporting bias.