Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study.
BACKGROUND
Severe traumatic brain injury (TBI) in childhood is associated with a high mortality and morbidity. Decompressive craniectomy has regained therapeutic interest during past years; however, treatment guidelines consider it a last resort treatment strategy for use only after failure of conservative therapy.


METHODS
We report on the clinical course of six children treated with decompressive craniectomy after TBI at a pediatric intensive care unit. The standard protocol of intensive care treatment included continuous intracranial pressure (ICP) monitoring, sedation and muscle relaxation, normothermia, mild hyperventilation and catecholamines to maintain an adequate cerebral perfusion pressure. Decompressive craniectomy including dura opening was initiated in cases of a sustained increase in ICP > 20 mmHg for > 30 min despite maximally intensified conservative therapy (optimized sedation and ventilation, barbiturates or mannitol).


RESULTS
In all cases, the ICP normalized immediately after craniectomy. At discharge, three children were without disability, two children had a mild arm-focused hemiparesis (one with a verbal impairment), and one child had a spastic hemiparesis and verbal impairment. This spastic hemiparesis improved within 6 months follow-up (no motor deficit, increased muscle tone), and all others remained unchanged.


CONCLUSIONS
These observational pilot data indicate feasibility and efficacy of decompressive craniectomy in malignant ICP rise secondary to TBI. Further controlled trials are necessary to evaluate the indication and standardization of early decompressive craniectomy as a 'second tier' standard therapy in pediatric severe head injury.
Ruf
Bettina
B
Department of Pediatrics, University Medical Centre, Justus-Liebig-University, Giessen, Germany. bettina.ruf@paediat.med.uni-giessen.de
Heckmann
Matthias
M
Schroth
Ilona
I
Hügens-Penzel
Monika
M
Reiss
Irwin
I
Borkhardt
Arndt
A
Gortner
Ludwig
L
Jödicke
Andreas
A
D001930:Brain Injuries / Q000150:complications / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D003399:Craniotomy; D003422:Critical Care / Q000379:methods*; D005260:Female; D006801:Humans; D015278:Intensive Care Units, Pediatric; D019586:Intracranial Hypertension / Q000209:etiology*; D007427:Intracranial Pressure; D008297:Male; D010865:Pilot Projects; D014057:Tomography, X-Ray Computed