Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure.
BACKGROUND
Care of pediatric traumatic brain injury (TBI) has placed emphasis on maximizing cerebral perfusion to prevent ischemia and reperfusion injury. A subset of patients with TBI will continue to have refractory intracranial pressure (ICP) elevation despite aggressive therapy including ventriculostomy, pentobarbital coma, hypertonic saline, and diuretics. Decompressive craniectomy (DC) is a controversial treatment of severe TBI. It is our hypothesis that DC can enhance survival and minimize secondary brain injury in this patient subset.


METHODS
Patients younger than 20 years treated at a level I regional trauma center between November 2001 and November 2004, who met inclusion criteria for the Brain Trauma Foundation TBI-trac clinical database were included. All patients with a mechanism of injury consistent with TBI and Glasgow Coma Scale score of less than 9 for at least 6 hours after resuscitation and who did not die in the emergency department are entered into a clinical database. Patients who arrived at the study hospital more than 24 hours after injury are excluded.


RESULTS
There were 30 patients with TBI identified. The mean Glasgow Coma Scale score at presentation was 8 with a range of 3 to 13. Six patients underwent DC for intractable elevated ICP. Of 6 patient's postoperative ICP, 5 were less than 20 mm Hg. One patient required a return to the operating room where further débridement of brain was performed. All patients who received a DC survived and were discharged to a TBI rehabilitation facility.


CONCLUSIONS
Although this is a small sample, DC should be considered in patients with TBI with refractory elevated ICP. Long-term follow-up of this patient population should consist of neuropsychiatric evaluation in conjunction with measurement of social function.
Rutigliano
Daniel
D
Division of Pediatric Surgery, Department of Surgery, State University of New York, Stony Brook, NY 11794-8191, USA.
Egnor
Michael R
MR
Priebe
Cedric J
CJ
McCormack
Jane E
JE
Strong
Nancy
N
Scriven
Richard J
RJ
Lee
Thomas K
TK
D000293:Adolescent; D001930:Brain Injuries / Q000150:complications*; D002648:Child; D019299:Decompression, Surgical / Q000379:methods*; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000209:etiology* / Q000601:surgery*; D007427:Intracranial Pressure; D008297:Male; D012720:Severity of Illness Index; D012886:Skull / Q000601:surgery; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome