Outcomes after decompressive craniectomy for severe traumatic brain injury in children.
OBJECTIVE
Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution.


METHODS
Children with severe TBI who underwent decompressive craniectomy at the Primary Children's Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King's Outcome Scale for Closed Head Injury (KOSCHI). Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months.


CONCLUSIONS
Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.
Kan
Peter
P
Department of Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah 84113-1100, USA.
Amini
Aminullah
A
Hansen
Kristine
K
White
George L
GL
Brockmeyer
Douglas L
DL
Walker
Marion L
ML
Kestle
John R W
JR
D000293:Adolescent; D000927:Anticonvulsants / Q000627:therapeutic use; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000601:surgery*; D002557:Cerebrospinal Fluid Shunts; D002648:Child; D002675:Child, Preschool; D003399:Craniotomy / Q000009:adverse effects / Q000401:mortality; D019299:Decompression, Surgical / Q000009:adverse effects / Q000401:mortality; D004827:Epilepsy / Q000188:drug therapy / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D015600:Glasgow Coma Scale; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000601:surgery; D007223:Infant; D007427:Intracranial Pressure; D008297:Male; D011183:Postoperative Complications; D011184:Postoperative Period; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D000927:Anticonvulsants