gms | German Medical Science

Objective: In the pediatric age group data on the role of decompressive craniectomy (DC) for severe traumatic brain injury (TBI) is limited. We present a detailed analysis of our surgical experience in this field.

Methods: We compiled a retrospective case series of all patients younger than 18 years who underwent DC for severe TBI at our institution since 2010.

Results: Twelve children (7 boys, 5 girls) with a mean age of 12 years (range 1–17) were enrolled. Trauma mechanisms were road traffic accidents (RTA) as pedestrians or cyclists (N=6), falls from large height (N=3), RTA as passengers (N=2) and violence (N=1). Mean initial GCS was 4 (range 3–7). Mydriasis was present prior to DC in 6 cases. Radiological findings were acute subdural hematoma (N=9), significant traumatic subarachnoid hemorrhage (N=8), cerebral contusions (N=6), skull fractures (N=7), cerebral edema (N=5) and signs of diffuse axonal injury (N=3). Mean midline shift was 6mm (range 0–16) and basal cisterns were compressed in all cases. Additional injuries were present in 11 children, mainly thoracic trauma. DC with evacuation of space-occupying traumatic lesion was performed immediately in seven cases, and the remainder underwent DC for refractory intracranial hypertension within 1 to 6 days. Unilateral hemicraniectomy was performed in 6, bilateral hemicraniectomy in 3 and bifrontal craniectomy in 3 cases. Four patients (33%; median age 10.5 years) died. Among survivors, poor outcome occurred in 3 cases (25%; median age 17 years) and good outcome in 5 cases (42%; median age 14 years) at a mean follow-up of 26 months. The only significant predictor of death was presence of non-reactive mydriasis prior to DC (Fisher’s exact test, p=0.0303). Complications of DC requiring revision within 30 days occurred in 3 cases, i.e. contralateral epidural hematoma (N=2) and hygroma (N=1).

Conclusion: Good outcome was observed in 40% of children. In this small series, the only significant predictor of death was mydriasis and, but only by tendency, younger age. The majority of children underwent immediate DC for space occupying lesions. While this is the subgroup with least therapeutic uncertainty, in contrast the optimal indication and timing of delayed DC for refractory intracranial hypertension are less clear. This study provides a status quo of DC for severe pediatric TBI, but only large prospective studies will allow for an evidence-based approach.