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Nagy L, Morgan RD, Collins RA, Kharbat AF, Garza J, Belirgen M. Impact of timing of decompressive craniectomy on outcomes in pediatric traumatic brain injury. Surg Neurol Int 2023; 14:436. [PMID: 38213457 PMCID: PMC10783660 DOI: 10.25259/sni_472_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 11/16/2023] [Indexed: 01/13/2024] Open
Abstract
Background Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month-18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3). Conclusion Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.
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Affiliation(s)
- Laszlo Nagy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Ryan D. Morgan
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Reagan A. Collins
- School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
| | - Abdurrahman F. Kharbat
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma, United States
| | - John Garza
- Department of Mathematics, University of Texas Permian Basin, Odessa, Texas, United States
| | - Muhittin Belirgen
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas, United States
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2
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Goubran D, Batoo D, Linton J, Shankar J. Initial CT Imaging Predicts Mortality in Severe Traumatic Brain Injuries in Pediatric Population-A Systematic Review and Meta-Analysis. Tomography 2023; 9:541-551. [PMID: 36961003 PMCID: PMC10037655 DOI: 10.3390/tomography9020044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 03/04/2023] Open
Abstract
The purpose of this systematic review was to analyze evidence based on existing studies on the ability of initial CT imaging to predict mortality in severe traumatic brain injuries (TBIs) in pediatric patients. An experienced librarian searched for all existing studies based on the inclusion and exclusion criteria. The studies were screened by two blinded reviewers. Of the 3277 studies included in the search, data on prevalence of imaging findings and mortality rate could only be extracted from 22 studies. A few of those studies had patient-specific data relating specific imaging findings to outcome, allowing the data analysis, calculation of the area under the curve (AUC) and receiver operating characteristic (ROC), and generation of a forest plot for each finding. The data were extracted to calculate the sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predicted value (NPV), AUC, and ROC for extradural hematoma (EDH), subdural hematoma (SDH), traumatic subarachnoid hemorrhage (tSAH), skull fractures, and edema. There were a total of 2219 patients, 747 females and 1461 males. Of the total, 564 patients died and 1651 survived; 293 patients had SDH, 76 had EDH, 347 had tSAH, 244 had skull fractures, and 416 had edema. The studies included had high bias and lower grade of evidence. Out of the different CT scan findings, brain edema had the highest SN, PPV, NPV, and AUC. EDH had the highest SP to predict in-hospital mortality.
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Affiliation(s)
- Doris Goubran
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Divjeet Batoo
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
| | - Janice Linton
- Indigenous Health Liaison Librarian, Neil John Maclean Health Sciences Library, Winnipeg, MB R3E 3P5, Canada
| | - Jai Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University Of Manitoba, Winnipeg, MB R3E 0W2, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB R3T 5V6, Canada
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3
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Yew WX, Lee JH, Dang H, Low SYY, Sri Dewi D, Chong SL. Decompressive Craniectomy in Pediatric Traumatic Brain Injury: A Retrospective Cohort Study. J Pediatr Intensive Care 2023. [DOI: 10.1055/s-0043-1761939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
AbstractDecompressive craniectomy (DC) in children with traumatic brain injury (TBI) and refractory raised intracranial pressure (ICP) remains controversial. We aimed to describe the clinical and operative characteristics of children with moderate to severe TBI who underwent DC, and compare outcomes with those who had medical therapy. We performed a retrospective observational cohort study on children < 16 years of age with moderate to severe TBI (Glasgow coma scale [GCS] ≤13) who underwent DC in two pediatric centers in Singapore and China between 2014 and 2017, and compared their outcomes with children who underwent medical treatment, among participating centers of the Pediatric Acute and Critical Care Medicine Asian Network. We defined poor functional outcomes as moderate, severe disability, vegetative or comatose state, or mortality, using the Pediatric Cerebral Performance Category scale. We performed multivariable logistic regression to identify predictors for poor functional outcomes. We analyzed 18 children who underwent DC with 214 who had medical therapy. A greater proportion of children with DC (14, 77.8%) experienced poor functional outcomes, compared with those with medical therapy (87, 41.2%, p = 0.003). Children who underwent DC had fewer median 14-day intensive care unit (ICU)-free days (2.5 days, interquartile range [IQR]: 0.0–5.8 vs. 8.0 days, IQR: 0.0–11.0, p = 0.033), median 28-day hospital-free days (0 day, IQR: 0.0–3.5 vs. 11.0 days, IQR: 0.0–21.0, p = 0.002) and 14-day mechanical ventilation-free days (6.5 days, IQR: 0.0–12.3 vs. 11.0 days, IQR: 3.0–14.0, p = 0.011). After accounting for age, sex, GCS, cerebral edema, uncal herniation, nonaccidental injury, and need for intubation, there was no significant association between DC and poor functional outcomes (adjusted odds ratio: 1.59, 95% confidence interval: 0.35–7.24, p = 0.548). Children with DC had severe injuries, and prolonged hospital and ICU stays. Future studies are needed to understand the effectiveness of DC on children with TBI.
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Affiliation(s)
- Wan Xin Yew
- Ministry of Health Holdings, Singapore, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
| | - Hongxing Dang
- Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Sharon Yin Yee Low
- Neurosurgical Service, KK Women's and Children's Hospital, Singapore, Singapore
- Department of Neurosurgery, National Neuroscience Institute, Singapore, Singapore
- Singhealth Duke-NUS Neuroscience Academic Clinical Program, Singapore, Singapore
| | - Dianna Sri Dewi
- Research Centre, KK Women's and Children's Hospital, Singapore, Singapore
| | - Shu-Ling Chong
- Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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4
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Patterson KN, Nordin A, Beyene TJ, Onwuka A, Bergus K, Horvath KZ, Sribnick EA, Thakkar RK. Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center. J Surg Res 2022; 275:308-317. [DOI: 10.1016/j.jss.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/08/2021] [Accepted: 02/10/2022] [Indexed: 11/16/2022]
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5
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Hubertus V, Finger T, Drust R, Al Hakim S, Schaumann A, Schulz M, Gratopp A, Thomale UW. Severe Traumatic Brain Injury in children-paradigm of decompressive craniectomy compared to a historic cohort. Acta Neurochir (Wien) 2022; 164:1421-1434. [PMID: 35305153 PMCID: PMC9061678 DOI: 10.1007/s00701-022-05171-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/21/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Traumatic brain injury (TBI) is one of the leading causes of death and disability in children. Medical therapy remains limited, and decompressive craniectomy (DC) is an established rescue therapy in case of elevated intracranial pressure (ICP). Much discussion deals with clinical outcome after severe TBI treated with DC, while data on the pediatric population is rare. We report our experience of treating severe TBI in two different treatment setups at the same academic institution. METHODS Forty-eight patients (≤ 16 years) were hospitalized with severe TBI (GCS ≤ 8 points) between 2008 and 2018 in a pediatric intensive care unit (ICU) at a specialized tertiary pediatric care center. Data on treatment, clinical status, and outcome was retrospectively analyzed. Outcome data included Glasgow Outcome Scale (GOS) at 3-, 12-, and 36-month follow-up. Data was compared to a historic cohort with 53 pediatric severe TBI patients treated at the same institution in a neurointensive care unit between 1996 and 2007. Ethical approval was granted (EA2/076/21). RESULTS Between 2008 and 2018, 11 patients were treated with DC. Compared to the historic cohort, patients were younger and GCS was worse, while in-hospital mortality and clinical outcome remained similar. A trend towards more aggressive EVD placement and the internal paradigm change for treatment in a specialized pediatric ICU was observed. CONCLUSIONS In children with severe TBI treated over two decades, clinical outcome was comparable and mostly favorable in two different treatment setups. Consequent therapy is warranted to maintain the positive potential for favorable outcome in children with severe TBI.
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6
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Bruns N, Kamp O, Lange KM, Lefering R, Felderhoff-Muser U, Dudda M, Dohna-Schwake C. Functional short-term outcomes and mortality in children with severe traumatic brain injury - comparing decompressive craniectomy and medical management. J Neurotrauma 2021; 39:944-953. [PMID: 34877889 PMCID: PMC9248344 DOI: 10.1089/neu.2021.0378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The effect of decompressive craniectomy (DC) on functional outcomes and mortality in children after severe head trauma is strongly debated. The lack of high-quality evidence poses a serious challenge to neurosurgeons' and pediatric intensive care physicians' decision making in critically ill children after head trauma. This study was conducted to compare DC and medical management in severely head-injured children with respect to short-term outcomes and mortality. Data on patients < 18 years of age treated in Germany, Austria, and Switzerland during a ten-year period were extracted from TraumaRegister DGU®, forming a retrospective multi-center cohort study. Descriptive and multivariable analyses were performed to compare outcomes and mortality after DC and medical management. Of 2507 patients, 402 (16.0 %) received DC. Mortality was 20.6 % after DC and 13.7 % after medical management. Poor outcome (death or vegetative state) occurred in 27.6 % after DC and in 16.1 % after medical management. After risk adjustment by logistic regression modeling, the odds ratio was 1.56 (95% confidence interval 1.01-2.40) for poor outcome at intensive care unit discharge and 1.20 (0.74-1.95) for mortality after DC. In summary, DC was associated with increased odds for poor short-term outcomes in children with severe head trauma. This finding should temper enthusiasm for DC in children until a large randomized controlled trial has answered more precisely if DC in children is beneficial or increases rates of vegetative state.
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Affiliation(s)
- Nora Bruns
- University Hospital Essen, 39081, Department of Pediatrics I, Essen, Germany.,University Hospital Essen, 39081, Center for Translational Neuro- and Behavioural Sciences, Essen, Germany;
| | - Oliver Kamp
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Nordrhein-Westfalen, Germany;
| | - Kim Melanie Lange
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Germany;
| | - Rolf Lefering
- Witten/Herdecke University, 12263, Institute for Research in Operative Medicine, Witten, Nordrhein-Westfalen, Germany;
| | - Ursula Felderhoff-Muser
- University Hospital Essen, 39081, Department of Pediatrics I , Essen, Nordrhein-Westfalen, Germany.,University Hospital Essen, 39081, Center for Translational Neuro- and Behavioural Sciences, Essen, Germany;
| | - Marcel Dudda
- University Hospital Essen, 39081, Trauma, Hand, and Reconstructive Surgery, Essen, Germany;
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7
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Hersh DS, Anderson HJ, Woodworth GF, Martin JE, Khan YM. Bone Flap Resorption in Pediatric Patients Following Autologous Cranioplasty. Oper Neurosurg (Hagerstown) 2021; 20:436-443. [PMID: 33469664 DOI: 10.1093/ons/opaa452] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/06/2020] [Indexed: 01/31/2023] Open
Abstract
Following a decompressive craniectomy, the autologous bone flap is generally considered the reconstructive material of choice in pediatric patients. Replacement of the original bone flap takes advantage of its natural biocompatibility and the associated low risk of rejection, as well as the potential to reintegrate with the adjacent bone and subsequently grow with the patient. However, despite these advantages and unlike adult patients, the replaced calvarial bone is more likely to undergo delayed bone resorption in pediatric patients, ultimately requiring revision surgery. In this review, we describe the materials that are currently available for pediatric cranioplasty, the advantages and disadvantages of autologous calvarial replacement, the incidence and classification of bone resorption, and the clinical risk factors for bone flap resorption that have been identified to date.
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Affiliation(s)
- David S Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut.,Department of Pediatrics, UConn School of Medicine, Farmington, Connecticut
| | - Hanna J Anderson
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut School of Engineering, Storrs, Connecticut
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland.,Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jonathan E Martin
- Division of Neurosurgery, Connecticut Children's, Hartford, Connecticut.,Department of Surgery, UConn School of Medicine, Farmington, Connecticut
| | - Yusuf M Khan
- Connecticut Convergence Institute for Translation in Regenerative Engineering, UConn Health, Farmington, Connecticut.,Department of Biomedical Engineering, University of Connecticut School of Engineering, Storrs, Connecticut.,Department of Orthopedic Surgery, UConn School of Medicine, Farmington, Connecticut
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8
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Semenova ZB, Meshcheryakov S, Lukyanov V, Arsenyev S. Decompressive Craniectomy for Traumatic Intracranial Hypertension in Children. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:109-113. [PMID: 33839829 DOI: 10.1007/978-3-030-59436-7_23] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVES Decompressive craniectomy (DC) for control of refractory intracranial pressure (ICP) elevations remains a controversial procedure because of its invasiveness and lack of clearly defined indications, the absence of an established surgical technique, the variability of its outcomes, and the significant risk of complications. AIM The purpose of this study was to identify factors for unfavorable outcomes after DC in children with a severe traumatic brain injury (TBI). METHODS A longitudinal investigation of correlations was carried out in 64 children (mean age ± 4.8 years) with severe TBI and a Glasgow Coma Scale (GCS) score of 6 ± 2 on admission. The follow-up period was 6 months. RESULTS There was good recovery (with a Glasgow Outcome Scale (GOS) score of 4-5) in 45.3% of cases, severe disability in 31.0% of cases (with a GOS score of 3); and a GOS score of 1-2 in 23.4% of cases. Twelve patients (18.7%) died. Unfavorable prognostic signs were a GCS score < 5 (P = 0.0003); dilated, unreactive pupils (P < 0.05); and ICP >40 mmHg (P = 0.0003; P < 0.05). ICP characteristics appeared to be the most sensitive predictor of outcomes after secondary DC (P < 0.05). CONCLUSION DC may be effective in preventing dislocation syndrome but futile in cases of cerebral herniation. Outcomes after DC are determined by the severity of the primary and secondary brain injuries.
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Affiliation(s)
- Zhanna B Semenova
- Clinical and Research Institute of Emergency Pediatric Surgery and Trauma, Moscow, Russia.
| | - Semen Meshcheryakov
- Clinical and Research Institute of Emergency Pediatric Surgery and Trauma, Moscow, Russia
| | - Valery Lukyanov
- Clinical and Research Institute of Emergency Pediatric Surgery and Trauma, Moscow, Russia
| | - Sergey Arsenyev
- Clinical and Research Institute of Emergency Pediatric Surgery and Trauma, Moscow, Russia
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9
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Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, Davis-O'Reilly C, Hart EL, Bell MJ, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Vavilala MS, Wainwright MS. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 84:1169-1178. [PMID: 30822776 DOI: 10.1093/neuros/nyz051] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pe-diatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Nancy Carney
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - P David Adelson
- Deptartment of Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Erica L Hart
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Michael J Bell
- Department Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Susan L Bratton
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia's Children's Hospital, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Karin E Reuter-Rice
- School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina
| | - Monica S Vavilala
- Department of Anesthesiology & Pain Medicine, Department of Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, Washington
| | - Mark S Wainwright
- Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington
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10
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Elsawaf Y, Anetsberger S, Luzzi S, Elbabaa SK. Early Decompressive Craniectomy as Management for Severe Traumatic Brain Injury in the Pediatric Population: A Comprehensive Literature Review. World Neurosurg 2020; 138:9-18. [PMID: 32084616 DOI: 10.1016/j.wneu.2020.02.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Severe traumatic brain injuries (TBIs) are a principal cause of neurologic dysfunction and death in the pediatric population. After medical management, the second-tier treatment is decompressive craniectomy in cases of intractable intracranial pressure (ICP) elevation. This literature review offers evidence of early (within 24 hours) and ultraearly (6-12 hours) decompressive craniectomy as an effective form of management for severe TBI in the pediatric population. METHODS We conducted a literature review of articles published from 1996 to 2019 to elucidate neurologic outcomes after early decompressive craniectomy in pediatric patients who suffered a severe TBI. Time to decompressive craniectomy and neurologic outcomes were recorded and reported descriptively. Qualitative data describe clinically important correlations between pre- and postoperative ICP levels and improved postoperative neurologic outcomes. RESULTS Seventy-eight patients were included in this study. The median age of patients at diagnosis was 10 years of age (range, 1 months to 19 years). Median admission Glasgow Coma Scale score was 5 (range, 3-8). Time to decompressive craniectomy ranged from 1 to 24 hours. Median peak preoperative ICP was 40 (range, 3-90; n = 49). Median postoperative ICP was 20 (range, 0-80; n = 33). Median Glasgow Outcome Scale (GOS) score at discharge was 2 (range, 1-5; n = 11). Median GOS score at 3- and 6-month follow-up was 3 (range, 1-5; n = 11). Median GOS score at 7- to 23-month follow-up was 4 (range, 1-5; n = 29). Median GOS score at 24- to 83-month follow-up was 4 (range, 1-5; n = 31). Median modified Rankin Scale score at discharge was 3 (range, 2-4; n = 6). Median modified Rankin Scale score at 6- to 48-month follow-up was 2 (range, 0-3; n = 6). Median Rancho Los Amigos Scale (RLAS) score at discharge was 6 (range, 4-8; n = 5). Median RLAS score at 6-month follow-up was 10 (range, 8-10; n = 5). CONCLUSIONS Early (within 24 hours), with consideration of ultraearly (within 6-12 hours), decompressive craniectomy for severe TBI should be offered to pediatric patients in settings with refractory ICP elevation. Reduction of ICP allows for prompt disruption of pathophysiologic cascades and improved neurologic outcomes.
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Affiliation(s)
- Yasmeen Elsawaf
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Stephanie Anetsberger
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Sabino Luzzi
- Neurosurgery Unit, Department of Clinical-Surgical, Diagnostic Pediatric Sciences, University of Pavia, Pavia, Italy; Neurosurgery Unit, Department of Surgical Sciences, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Samer K Elbabaa
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA.
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11
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Tang Z, Yang K, Zhong M, Yang R, Zhang J, Jiang Q, Liu H. Predictors of 30-Day Mortality in Traumatic Brain-Injured Patients after Primary Decompressive Craniectomy. World Neurosurg 2020; 134:e298-e305. [DOI: 10.1016/j.wneu.2019.10.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/09/2019] [Indexed: 11/28/2022]
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12
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Decompressive Craniectomy for Patients with Traumatic Brain Injury: A Pooled Analysis of Randomized Controlled Trials. World Neurosurg 2020; 133:e135-e148. [DOI: 10.1016/j.wneu.2019.08.184] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 11/21/2022]
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13
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Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Rubiano AM, Carney N, Khan AA, Ammirati M. The Role of Decompressive Craniectomy in the Context of Severe Traumatic Brain Injury: Summary of Results and Analysis of the Confidence Level of Conclusions From Systematic Reviews and Meta-Analyses. Front Neurol 2019; 10:1063. [PMID: 31649610 PMCID: PMC6795698 DOI: 10.3389/fneur.2019.01063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 09/20/2019] [Indexed: 12/26/2022] Open
Abstract
Introduction: Traumatic brain injury (TBI) is a global epidemic. The incidence of TBI in low and middle-income countries (LMICs) is three times greater than in high-income countries (HICs). Decompressive craniectomy (DC) is a surgical procedure to reduce intracranial pressure (ICP) and prevent secondary injury. Multiple comparative studies, and several randomized controlled trials (RCTs) have been conducted to investigate the influence of DC for patients with severe TBI on outcomes such as mortality, ICP, neurological outcomes, and intensive care unit (ICU) and hospital length of stay. The results of these studies are inconsistent. Systematic reviews and meta-analyses have been conducted in an effort to aggregate the data from the individual studies, and perhaps derive reliable conclusions. The purpose of this project was to conduct a review of the reviews about the effectiveness of DC to improve outcomes. Methods: We conducted a systematic search of the literature to identify reviews and meta-analyses that met our pre-determined criteria. We used the AMSTAR 2 instrument to assess the quality of each of the included reviews, and determine the level of confidence. Results: Of 973 citations from the original search, five publications were included in our review. Four of them included meta-analyses. For mortality, three reviews found a positive effect of DC compared to medical management and two found no significant difference between groups. The four reviews that measured neurological outcome found no benefit of DC. The two reviews that assessed ICP both found DC to be beneficial in reducing ICP. DC demonstrated a significant reduction in ICU length of stay in the one study that measured it, and a significant reduction in hospital length of stay in the two studies that measured it. According to the AMSTAR 2 criteria, the five reviews ranged in levels of confidence from low to critically low. Conclusion: Systematic reviews and meta-analyses are important approaches for aggregating information from multiple studies. Clinicians rely of these methods for concise interpretation of scientific literature. Standards for quality of systematic reviews and meta-analyses have been established to support the quality of the reviews being produced. In the case of DC, more attention must be paid to quality standards, in the generation of both individual studies and reviews.
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Affiliation(s)
- Andrés M Rubiano
- INUB/MEDITECH Research Group, El Bosque University, Bogota, Colombia.,NIHR Global Health Research Group on Neurotrauma, MEDITECH Foundation, Cali, Colombia
| | - Nancy Carney
- School of Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Ahsan A Khan
- NIHR Global Health Research Group on Neurotrauma, MEDITECH Foundation, Cali, Colombia
| | - Mario Ammirati
- Center for Biotechnology, Department of Biology, College of Science and Technology, Temple University, Philadelphia, PA, United States.,Innovative Neurotherapeutic Research Program Sbarro Health Organization, Temple University, Philadelphia, PA, United States
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Manfiotto M, Beccaria K, Rolland A, Paternoster G, Plas B, Boetto S, Vinchon M, Mottolese C, Beuriat PA, Szathmari A, Di Rocco F, Scavarda D, Seigneuret E, Wrobleski I, Klein O, Joud A, Gimbert E, Jecko V, Vignes JR, Roujeau T, Dupont A, Zerah M, Lonjon M. Decompressive Craniectomy in Children with Severe Traumatic Brain Injury: A Multicenter Retrospective Study and Literature Review. World Neurosurg 2019; 129:e56-e62. [PMID: 31054345 DOI: 10.1016/j.wneu.2019.04.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
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Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies. Pediatr Crit Care Med 2019; 20:269-279. [PMID: 30830015 DOI: 10.1097/pcc.0000000000001737] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To produce a treatment algorithm for the ICU management of infants, children, and adolescents with severe traumatic brain injury. DATA SOURCES Studies included in the 2019 Guidelines for the Management of Pediatric Severe Traumatic Brain Injury (Glasgow Coma Scale score ≤ 8), consensus when evidence was insufficient to formulate a fully evidence-based approach, and selected protocols from included studies. DATA SYNTHESIS Baseline care germane to all pediatric patients with severe traumatic brain injury along with two tiers of therapy were formulated. An approach to emergent management of the crisis scenario of cerebral herniation was also included. The first tier of therapy focuses on three therapeutic targets, namely preventing and/or treating intracranial hypertension, optimizing cerebral perfusion pressure, and optimizing partial pressure of brain tissue oxygen (when monitored). The second tier of therapy focuses on decompressive craniectomy surgery, barbiturate infusion, late application of hypothermia, induced hyperventilation, and hyperosmolar therapies. CONCLUSIONS This article provides an algorithm of clinical practice for the bedside practitioner based on the available evidence, treatment protocols described in the articles included in the 2019 guidelines, and consensus that reflects a logical approach to mitigate intracranial hypertension, optimize cerebral perfusion, and improve outcomes in the setting of pediatric severe traumatic brain injury.
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med 2019; 20:280-289. [PMID: 30830016 DOI: 10.1097/pcc.0000000000001736] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Ardissino M, Tang A, Muttoni E, Tsang K. Decompressive craniectomy in paediatric traumatic brain injury: a systematic review of current evidence. Childs Nerv Syst 2019; 35:209-216. [PMID: 30215120 PMCID: PMC6351512 DOI: 10.1007/s00381-018-3977-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/05/2018] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Paediatric traumatic brain injury (pTBI) is one of the most frequent neurological presentations encountered in emergency departments worldwide. Every year, more than 200,000 American children suffer pTBIs, many of which lead to long-term damage. OBJECTIVES We aim to review the existing evidence on the efficacy of the decompressive craniectomy (DC) in controlling intracranial pressure (ICP) and improving long-term outcomes in children with pTBI. METHODS A comprehensive search of the MEDLINE and EMBASE databases led to the screening of 212 studies, 12 of which satisfied inclusion criteria. Data extracted included the number and ages of patients, Glasgow Coma Scale scores at presentation, treatment protocols and short- and long-term outcomes. RESULTS Each of the nine studies including ICP as an outcome reported that it was successfully controlled by DC. The 6-12 month outcome scores of patients undergoing DC were positive, or superior to those of medically treated groups in nine of 11 studies. Mortality was compared in only two studies, and was lower in the DC group in both.Very few studies are currently available investigating short- and long-term outcomes in children with TBI undergoing DC. CONCLUSION The currently available evidence may support a beneficial role of DC in controlling ICP and improving long-term outcomes.
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Affiliation(s)
- Maddalena Ardissino
- Imperial College School of Medicine, Imperial College London, London, SW7 2AZ, UK.
| | - Alice Tang
- Imperial College School of Medicine, Imperial College London, London, SW7 2AZ, UK
| | - Elisabetta Muttoni
- St. Helens and Knowsley Teaching Hospitals, Whiston Hospital NHS Trust, Liverpool, UK
| | - Kevin Tsang
- Department of Neurosurgery, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
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Araki T. Pediatric Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Garg K, Singh P, Singla R, Aggarwal A, Borle A, Singh M, Chandra PS, Kale S, Mahapatra A. Role of Decompressive Craniectomy in Traumatic Brain Injury – A Meta-analysis of Randomized Controlled Trials. Neurol India 2019; 67:1225-1232. [PMID: 31744947 DOI: 10.4103/0028-3886.271260] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Choudhary NK, Bhargava R. Decompressive Craniectomy in Diffuse Traumatic Brain Injury: An Industrial Hospital Study. Asian J Neurosurg 2018; 13:314-318. [PMID: 29682027 PMCID: PMC5898098 DOI: 10.4103/ajns.ajns_281_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
CONTEXT High intracranial pressure is the most frequent cause of mortality and disability after severe traumatic brain injury (TBI) which is treated by first-line therapeutic measures. When these measures fail, second-line therapies are started. Among second-line therapies, decompressive craniectomy (DC) has been used. It improves the functional outcome in these patients. AIM This study aims to analyze the clinicoradiological factors associated with the prognosis of severe TBI in patients undergoing DC. SETTINGS AND DESIGN It was a retrospective case series study from April 2014 to March 2016. SUBJECTS AND METHODS A total of 85 patients (admitted at Tata Main Hospital, Jamshedpur) with severe diffuse TBI with clinical and radiological evidence of intracranial hypertension who were refractory to first-tier therapies and required DC were included in our study. Cases excluded were patients with age <10 years and polytrauma patients. RESULTS Out of 85 cases, 55 were males, and thirty were females (male:female = 1.8:1) with the age ranging from 17 to 68 years. Road traffic accident was the leading cause of injury in 69.5% cases. A total of 49 (58%) patients were of Glasgow coma scale (GCS) 4-6 whereas 36 (42%) patients had GCS 7-8. Computed tomography (CT) scan brain was classified as per Marshall CT classification. Bifrontotemporal DC was done in 29% cases, and unilateral frontotemporoparietal craniectomy was done in 71%. CONCLUSIONS Patients with younger age, early surgical intervention, better preoperative GCS score, and with low Marshall CT score have better prognosis.
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Affiliation(s)
| | - Rinku Bhargava
- Department of Neurology, Tata Main Hospital, Jamshedpur, Jharkhand, India
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Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis. Sci Rep 2017; 7:8800. [PMID: 28821777 PMCID: PMC5562822 DOI: 10.1038/s41598-017-08959-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 07/17/2017] [Indexed: 11/24/2022] Open
Abstract
We aim to perform a systematic review and meta-analysis to examine the prognostic value of decompressive craniectomy (DC) in patients with traumatic intracranial hypertension. PubMed, EMBASE, Cochrane Controlled Trials Register, Web of Science, http://clinicaltrials.gov/ were searched for eligible studies. Ten studies were included in the systematic review, with four randomized controlled trials involved in the meta-analysis, where compared with medical therapies, DC could significantly reduce mortality rate [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.47–0.74, P < 0.001], lower intracranial pressure (ICP) [mean difference (MD), −2.12 mmHg; 95% CI, −2.81 to −1.43, P < 0.001], decrease the length of ICU stay (MD, −4.63 days; 95% CI, −6.62 to −2.65, P < 0.001) and hospital stay (MD, −14.39 days; 95% CI, −26.00 to −2.78, P = 0.02), but increase complications rate (RR, 1.94; 95% CI, 1.31–2.87, P < 0.001). No significant difference was detected for Glasgow Outcome Scale at six months (RR, 0.85; 95% CI, 0.61–1.18, P = 0.33), while in subgroup analysis, early DC would possibly result in improved prognosis (P = 0.04). Results from observational studies supported pooled results except prolonged length of ICU and hospital stay. Conclusively, DC seemed to effectively lower ICP, reduce mortality rate but increase complications rate, while its benefit on functional outcomes was not statistically significant.
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Brown DA, Wijdicks EFM. Decompressive craniectomy in acute brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:299-318. [PMID: 28187804 DOI: 10.1016/b978-0-444-63600-3.00016-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Decompressive surgery to reduce pressure under the skull varies from a burrhole, bone flap to removal of a large skull segment. Decompressive craniectomy is the removal of a large enough segment of skull to reduce refractory intracranial pressure and to maintain cerebral compliance for the purpose of preventing neurologic deterioration. Decompressive hemicraniectomy and bifrontal craniectomy are the most commonly performed procedures. Bifrontal craniectomy is most often utilized with generalized cerebral edema in the absence of a focal mass lesion and when there are bilateral frontal contusions. Decompressive hemicraniectomy is most commonly considered for malignant middle cerebral artery infarcts. The ethical predicament of deciding to go ahead with a major neurosurgical procedure with the purpose of avoiding brain death from displacement, but resulting in prolonged severe disability in many, are addressed. This chapter describes indications, surgical techniques, and complications. It reviews results of recent clinical trials and provides a reasonable assessment for practice.
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Affiliation(s)
- D A Brown
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - E F M Wijdicks
- Division of Critical Care Neurology, Mayo Clinic and Neurosciences Intensive Care Unit, Mayo Clinic Campus, Saint Marys Hospital, Rochester, MN, USA.
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Abstract
Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.
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Margulies SS, Kilbaugh T, Sullivan S, Smith C, Propert K, Byro M, Saliga K, Costine BA, Duhaime AC. Establishing a Clinically Relevant Large Animal Model Platform for TBI Therapy Development: Using Cyclosporin A as a Case Study. Brain Pathol 2016; 25:289-303. [PMID: 25904045 DOI: 10.1111/bpa.12247] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/05/2015] [Indexed: 11/26/2022] Open
Abstract
We have developed the first immature large animal translational treatment trial of a pharmacologic intervention for traumatic brain injury (TBI) in children. The preclinical trial design includes multiple doses of the intervention in two different injury types (focal and diffuse) to bracket the range seen in clinical injury and uses two post-TBI delays to drug administration. Cyclosporin A (CsA) was used as a case study in our first implementation of the platform because of its success in multiple preclinical adult rodent TBI models and its current use in children for other indications. Tier 1 of the therapy development platform assessed the short-term treatment efficacy after 24 h of agent administration. Positive responses to treatment were compared with injured controls using an objective effect threshold established prior to the study. Effective CsA doses were identified to study in Tier 2. In the Tier 2 paradigm, agent is administered in a porcine intensive care unit utilizing neurological monitoring and clinically relevant management strategies, and intervention efficacy is defined as improvement in longer term behavioral endpoints above untreated injured animals. In summary, this innovative large animal preclinical study design can be applied to future evaluations of other agents that promote recovery or repair after TBI.
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Mhanna MJ, Mallah WE, Verrees M, Shah R, Super DM. Outcome of children with severe traumatic brain injury who are treated with decompressive craniectomy. J Neurosurg Pediatr 2015; 16:508-514. [PMID: 26230458 DOI: 10.3171/2014.10.peds14117] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) is controversial. The authors sought to determine if DC improves the outcome of children with severe TBI. METHODS In a retrospective, case-control study, medical records of all patients admitted to the pediatric ICU between May 1998 and May 2008 with severe TBI and treated with DC were identified and matched to patients who were treated medically without DC. Medical records were reviewed for patients' demographic data and baseline characteristics. RESULTS During the study period, 17 patients with severe TBI treated with DC at a median of 2 hours (interquartile range [IQR] 1-14 hours) after admission were identified and matched to 17 contemporary controls. On admission, there were no differences between DC and control patients regarding age (10.2 ± 5.9 years vs 12.4 ± 5.4 years, respectively [mean ± SD]), sex, weight, Glasgow Coma Scale score (median 5 [IQR 3-7] vs 4 [IQR 3-6], respectively; p = 0.14), or the highest intracranial pressure (median 42 [IQR 22-54] vs 30 [IQR 21-36], respectively; p = 0.77). However, CT findings were significant for a higher rate of herniation and cerebral edema among patients with DC versus controls (7/17 vs 2/17, respectively, had herniation [p = 0.05] and 14/17 vs 6/17, respectively, had cerebral edema [p = 0.006]). Overall there were no significant differences in survival between patients with DC and controls (71% [12/17] vs 82% [14/17], respectively; p = 0.34). However, among survivors, at 4 years (IQR 1-6 years) after the TBI, 42% (5/12) of the DC patients had mild disability or a Glasgow Outcome Scale score of 5 vs none (0/14) of the controls (p = 0.012). CONCLUSIONS In this retrospective, small case-control study, the authors have shown that early DC in pediatric patients with severe TBI improves outcome in survivors. Future prospective randomized controlled studies are needed to confirm these findings.
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Affiliation(s)
| | | | | | - Rajiv Shah
- Radiology, MetroHealth Medical Center, Cleveland, Ohio
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Wang R, Li M, Gao WW, Guo Y, Chen J, Tian HL. Outcomes of Early Decompressive Craniectomy Versus Conventional Medical Management After Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2015; 94:e1733. [PMID: 26512565 PMCID: PMC4985379 DOI: 10.1097/md.0000000000001733] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This meta-analysis examined whether early decompressive craniectomy (DC) can improve control of intracranial pressure (ICP) and mortality in patients with traumatic brain injury (TBI).Medline, Cochrane, EMBASE, and Google Scholar databases were searched until May 14, 2015, using the following terms: traumatic brain injury, refractory intracranial hypertension, high intracranial pressure, craniectomy, standard care, and medical management. Randomized controlled trials in which patients with TBI received DC and non-DC medical treatments were included.Of the 84 articles identified, 8 studies were selected for review, with 3 randomized controlled trials s having a total of 256 patients (123 DCs, 133 non-DCs) included in the meta-analysis. Patients receiving DC had a significantly greater reduction of ICP and shorter hospital stay. They also seemed to have lower odds of death than patients receiving only medical management, but the P value did not reach significance (pooled odds ratio 0.531, 95% confidence interval 0.209-1.350, Z = 1.95, P = 0.183) with respect to the effect on overall mortality; a separate analysis of 3 retrospective studies yielded a similar result.Whereas DC might effectively reduce ICP and shorten hospital stay in patients with TBI, its effect in decreasing mortality has not reached statistical significance.
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Affiliation(s)
- Ren Wang
- From the Department of Neurosurgery (RW, W-WG, YG, JC, H-LT); and Department of Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China (ML)
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Prasad GL, Gupta DK, Mahapatra AK, Sharma BS. Surgical results of decompressive craniectomy in very young children: A level one trauma centre experience from India. Brain Inj 2015; 29:1717-24. [DOI: 10.3109/02699052.2015.1075146] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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El Hindy N, Stein KP, Hagel V, Dammann P, Sure U, Mueller O. The role of decompressive craniectomy in children with severe traumatic brain injury. Eur J Trauma Emerg Surg 2014; 40:481-7. [PMID: 26816244 DOI: 10.1007/s00068-013-0337-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/30/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Severe traumatic brain injury (TBI) remains the leading cause of death in children. The present study analyses the outcome of children after severe TBI treated by decompressive craniectomy (DC) due to elevated intracranial pressure (ICP) in a single centre. METHODS Fifty-six consecutive children (age < 16 years) were treated for severe TBI at our institution between 2001 and 2011. For study purposes, children with severe generalized traumatic brain swelling without concomitant mass lesion were further analysed. Descriptive statistics were used to report clinical conditions as well as outcome measurements after conservative treatment only in comparison to secondary decompressive craniectomy. RESULTS Of 56 children, a total of eight children presented with generalized and progressive traumatic brain swelling and impending brain herniation. Four children were treated conservatively following standardized local protocol for anti-oedematous management, with ICP amenable to intensified therapy. Four children required decompressive surgery due to progressive oedema refractory to intensified conservative management. Children receiving secondary DC had a longer stay in the intensive care unit as well as a longer average time of assisted ventilation compared to children treated conservatively. Concomitant injuries were more severe in the DC subgroup. Yet, Glasgow Outcome Scale was equally distributed in both groups. CONCLUSION In children with refractory ICP conditions due to severe TBI, decompressive surgery might lead to a similar favourable outcome compared to children in whom ICP can be controlled only by conservative management. Timing of surgery depends on the neurological deterioration of the patients and a continuous ICP monitoring.
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Affiliation(s)
- N El Hindy
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany.
| | - K P Stein
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - V Hagel
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - P Dammann
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - U Sure
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - O Mueller
- Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
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Martin KD, Franz B, Kirsch M, Polanski W, von der Hagen M, Schackert G, Sobottka SB. Autologous bone flap cranioplasty following decompressive craniectomy is combined with a high complication rate in pediatric traumatic brain injury patients. Acta Neurochir (Wien) 2014; 156:813-24. [PMID: 24532225 DOI: 10.1007/s00701-014-2021-0] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 01/30/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Decompressive craniectomy (DC) is a last treatment option of refractory intracranial hypertension in traumatic brain injury (TBI) patients. Replacement of the autologous bone flap is the preferred method to cover the cranial defect after brain swelling has subsided. Long term outcomes and complications after replacement of the autologous bone flap in pediatric patients were studied in comparison to young, healthy adults. METHODS Medical records of 27 pediatric patients who underwent DC and subsequent replacement of the bone flap between 1998 and 2011 were reviewed retrospectively. Patients were divided into two age groups (group 1: 18 children < 15 years; group 2:9 adolescents 15-18 years). For comparative reasons, a young adult control group of 39 patients between 18 and 30 years was additionally evaluated. RESULTS With 81.8 % resorption of the bone flap, this was the major complication in young children. In up to 54.4 % of patients, a surgical revision of the osteolytic bone flap became necessary. However, in some pediatric patients, the osteolysis resolved spontaneously and further operations were not required. Probable enabling factors for bone flap resorption were young age (0-7 years), size of craniectomy, permanent shunt placement, and extent of dural opening/duraplasty. Other complications were bone flap infections, loosening of the re-inserted bone flap, and postoperative hematomas. CONCLUSION There is an unacceptably high complication rate after reimplantation of the autologous bone following DC in pediatric TBI patients, especially in young children up to seven years of age. Artificial or synthetic cranioplasties may be considered as alternatives to initial bone flap reimplantation in the growing child. Despite the fact that DC is an effective treatment in TBI with persistent intracranial hypertension, it is important to realize that DC is not only combined with replacement of the autologous bone flap but also with a high rate of additional complications especially in pediatric patients.
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Affiliation(s)
- K Daniel Martin
- Department of Neurological Surgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Fetscherstr. 74, 01307, Dresden, Germany,
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Melo JRT, Di Rocco F, Bourgeois M, Puget S, Blauwblomme T, Sainte-Rose C, Meyer PG, Zerah M. Surgical options for treatment of traumatic subdural hematomas in children younger than 2 years of age. J Neurosurg Pediatr 2014; 13:456-61. [PMID: 24559279 DOI: 10.3171/2014.1.peds13393] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Subdural hematoma (SDH) is the most common finding on cranial CT in pediatric victims of abusive head trauma (AHT). The hematomas are commonly bilateral and sometimes associated with interhemispheric hyperdensity and/or convexity hemorrhages. There is no consensus regarding the best surgical treatment in such cases nor are there standardized surgical protocols. The authors report their experience and discuss the routine surgical options in the management of traumatic SDH at a Level 1 Pediatric Trauma Center. METHODS In this paper, the authors describe a cross-sectional study with consecutive revision of data described in the medical records of Hôpital Universitaire Necker-Enfants Malades between January 2008 and January 2013. During this period, all children younger than 2 years of age who were admitted with a traumatic SDH identified on CT scans were included in this study. RESULTS One hundred eighty-four children who had SDH and were younger than 2 years of age were included. Their median age was 5.8 months (range 5 days-23 months), and 70% of the children were male. On admission CT scans, the SDH was bilateral in 52% of cases and homogeneously hypodense in 77%. Neurosurgical treatment was undertaken in 111 children (60%) with an admission Glasgow Coma Scale score of 12 or less, bulging fontanels, or other signs suggestive of intracranial hypertension. The first surgical option was craniotomy in 1.8% (2) of these 111 cases, decompressive craniectomy in 1.8% (2), transcutaneous subdural puncture in 15% (17), external subdural drainage in 16% (18), subdural-subgaleal shunt placement in 17% (19), and subdural-peritoneal shunt placement in 48% (53). In 82% of the children initially treated with transcutaneous subdural puncture and in 50% of those treated with external subdural drainage, increase or persistence of the SDH, CSF or skin infection, or shunt system malfunction was observed and further surgical intervention was required. There was a 26% rate of complications in patients initially treated with a subdural-peritoneal shunt. Although 52% of the patients had bilateral SDH, bilateral drainage was only required in 9.4%. CONCLUSIONS The choice of treatment should be determined by the clinical and radiological characteristics of the individual case. Although effective on an emergency basis, subdural puncture and external subdural drainage are frequently insufficient to obtain complete resolution of SDH, and temporary placement of a subdural-peritoneal shunt is needed in most cases.
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Kim YJ. The impact of time to surgery on outcomes in patients with traumatic brain injury: a literature review. Int Emerg Nurs 2014; 22:214-9. [PMID: 24680689 DOI: 10.1016/j.ienj.2014.02.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 01/24/2014] [Accepted: 02/18/2014] [Indexed: 11/25/2022]
Abstract
AIM To review the relationship between the time interval to surgery and outcomes in patients with traumatic brain injury (TBI). METHODS A literature review was conducted by employing several search strategies, including electronic database searches and footnote chasing. The quality of the selected studies was assessed in terms of internal and external validity. Data regarding authors, publication year, sample size, surgical procedure, time interval to surgery, and outcome was extracted. RESULTS Among 16 finally selected studies, five studies (31.3%) found that patient outcome was significantly affected by the timing of surgery and 11 (68.7%) did not. The impact of time to surgery on outcomes was not significant in most (75%) of the studies targeting patients with severe TBI. The effect of time to surgery on outcome showed different findings depending on the type of surgical procedure. A significant effect of time to surgery on outcome was reported in one (14.2%) of the seven studies targeting patients who underwent haematoma evacuation and in four (44.4%) of the nine studies on patients who underwent decompressive craniectomy. CONCLUSION This review shows that current opinion is still divided regarding when to operate. Despite this discrepancy, most authors agree that the timing of decompression is crucial to outcome.
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Affiliation(s)
- Young-Ju Kim
- Sungshin University, College of Nursing, Republic of Korea.
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Khan SA, Shallwani H, Shamim MS, Murtaza G, Enam SA, Qureshi RO, Tahir MZ. Predictors of poor outcome of decompressive craniectomy in pediatric patients with severe traumatic brain injury: a retrospective single center study from Pakistan. Childs Nerv Syst 2014; 30:277-81. [PMID: 23873518 DOI: 10.1007/s00381-013-2225-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 07/02/2013] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study aimed to determine the risk factors associated with poor outcome of decompressive craniectomy (DC) for severe traumatic brain injury (TBI) in pediatric patients. METHODS This retrospective study is conducted on pediatric population (age 1-15 years) presenting with TBI who underwent DC at our institute between January 2000 and 2010. Based on Glasgow outcome score (GOS) at a minimum follow-up of 5 months, patients were divided into two groups, namely poor outcome (GOS 1, 2, and 3) and good outcome (GOS 4 and 5). Records were reviewed and analyzed for preoperative and intraoperative predictors. RESULTS We found 25 patients who were eligible as per selection criteria. Mean age at presentation was 6 ± 4 years and there was male preponderance (84%). Fall (60%) was the most common mechanism of injury followed by gunshots and road traffic accident. On univariate analysis, presenting GCS ≤5 (p value = 0.009), delay in presentation of more than 150 min (p value = 0.010), DC performed after more than 4 h of arrival in hospital (p value = 0.042), and intraoperative blood loss exceeding 300 ml (p value = 0.001) were significant predictors of poor outcome. CONCLUSION Our study suggests that DC in children is not only a life-saving procedure, but also leads to a good functional outcome after severe injury. However, patient selection still remains an important aspect, and the above-mentioned factors should be considered while deciding for DC to improve survival. Further prospective studies on larger sample size are warranted to validate our results.
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Affiliation(s)
- Saad Akhtar Khan
- Section of Neurosurgery, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Güresir E, Schuss P, Seifert V, Vatter H. Decompressive craniectomy in children: single-center series and systematic review. Neurosurgery 2012; 70:881-8; discussion 888-9. [PMID: 21946506 DOI: 10.1227/neu.0b013e318237a6a6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is performed as a life-saving procedure in patients with intractably increased intracranial pressure after traumatic brain injury, bleeding, cerebral infarction, or brain swelling of other causes. However, the application of DC is as controversial in the pediatric population as it is in adults. OBJECTIVE To find factors influencing the outcome in pediatric patients who underwent DC because of sustained high intracranial pressure. METHODS Between April 2000 and December 2009, 34 pediatric patients (age 0-18 years) underwent DC. Patients were stratified according to the indication for DC. Outcome was assessed according to the modified Rankin Scale score at 6 months. MEDLINE was searched for published studies or reports of DC in pediatric patients to gain a larger population. Two reviewers independently extracted data. RESULTS Literature data, including the current series, revealed a total of 172 pediatric patients. Overall, a favorable outcome was achieved in 106 of 172 patients (62%). A favorable outcome was achieved in 25 of 36 patients without traumatic brain injury vs 81 of 136 patients with traumatic brain injury (69% vs 60%). Patients without signs of cerebral herniation had a better outcome than patients with unilateral or bilateral dilated pupils (73% vs 60% vs 45%, respectively). CONCLUSION The current data indicate that DC in children with traumatic or nontraumatic brain swelling might be warranted, regardless of the underlying cause. Despite mydriasis, a favorable outcome might be achieved in a significant number of pediatric patients. Nevertheless, careful individual decision making is needed for each patient, especially when signs of cerebral herniation have persisted for a long time.
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Affiliation(s)
- Erdem Güresir
- Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany.
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37
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[Intracranial hypertension]. Med Clin (Barc) 2012; 139:268-72. [PMID: 22704277 DOI: 10.1016/j.medcli.2012.04.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 03/30/2012] [Accepted: 04/12/2012] [Indexed: 01/04/2023]
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Oluigbo CO, Wilkinson CC, Stence NV, Fenton LZ, McNatt SA, Handler MH. Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccidental blunt cranial trauma. J Neurosurg Pediatr 2012; 9:125-32. [PMID: 22295915 DOI: 10.3171/2011.11.peds09449] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms. METHODS All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed. RESULTS Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3). CONCLUSIONS Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.
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Affiliation(s)
- Chima O Oluigbo
- Department of Neurosurgery, The Children's Hospital and University of Colorado, Aurora, Colorado 80045, USA
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Abstract
Pediatric neurocritical care is an emerging multidisciplinary field of medicine and a new frontier in pediatric critical care and pediatric neurology. Central to pediatric neurocritical care is the goal of improving outcomes in critically ill pediatric patients with neurological illness or injury and limiting secondary brain injury through optimal critical care delivery and the support of brain function. There is a pressing need for evidence based guidelines in pediatric neurocritical care, notably in pediatric traumatic brain injury and pediatric stroke. These diseases have distinct clinical and pathophysiological features that distinguish them from their adult counterparts and prevent the direct translation of the adult experience to pediatric patients. Increased attention is also being paid to the broader application of neuromonitoring and neuroprotective strategies in the pediatric intensive care unit, in both primary neurological and primary non-neurological disease states. Although much can be learned from the adult experience, there are important differences in the critically ill pediatric population and in the circumstances that surround the emergence of neurocritical care in pediatrics.
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Affiliation(s)
- Sarah Murphy
- MassGeneral Hospital for Children, Boston, MA 02114, USA.
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Decompressive Craniectomy in 14 Children With Severe Head Injury: Clinical Results With Long-Term Follow-Up and Review of the Literature. ACTA ACUST UNITED AC 2011; 71:133-40. [DOI: 10.1097/ta.0b013e318211071f] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Contemporary management of traumatic intracranial hypertension: is there a role for therapeutic hypothermia? Neurocrit Care 2011; 11:427-36. [PMID: 19644773 DOI: 10.1007/s12028-009-9256-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Intracranial hypertension (ICH) remains the single most difficult therapeutic challenge for the acute management of severe traumatic brain injury (TBI). We reviewed the published trials of therapeutic moderate hypothermia to determine its effect on ICH and compared its efficacy to other commonly used therapies for ICH. METHODS A PubMed database search was done using various combinations of the search terms "brain injury," "therapeutic hypothermia," "intracranial hypertension," "barbiturates," "mannitol," "hypertonic saline," "hyperventilation," "decompressive craniectomy," and "CSF drainage." RESULTS We identified 11 prospective randomized clinical TBI trials comparing hypothermia vs. normothermia treatment for which intracranial pressure (ICP) data was provided, and 6 prospective cohort studies that provided ICP data before and during hypothermia treatment. In addition, we identified 37 clinical TBI studies of lumbar CSF drainage, mannitol, hyperventilation, barbiturates, hypertonic saline, and decompressive craniectomy that provided pre- and posttreatment ICP data. Hypothermia was at least as effective as the traditional therapies for ICH (hyperventilation, mannitol, and barbiturates), but was less effective than hypertonic saline, lumbar CSF drainage, and decompressive craniectomy. Ultimately, however, therapeutic hypothermia does appear to have a favorable risk/benefit profile. CONCLUSION Therapeutic moderate hypothermia is as effective, or more effective, than most other treatments for ICH. If used for 2-3 days or less there is no evidence that it causes clinically significant adverse events. The lack of consistent evidence that hypothermia improves long-term neurologic outcome should not preclude consideration of its use for the primary treatment of ICH since no other ICP therapy is held to this standard.
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Kilbaugh TJ, Bhandare S, Lorom DH, Saraswati M, Robertson CL, Margulies SS. Cyclosporin A preserves mitochondrial function after traumatic brain injury in the immature rat and piglet. J Neurotrauma 2011; 28:763-74. [PMID: 21250918 DOI: 10.1089/neu.2010.1635] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cyclosporin A (CsA) has been shown to be neuroprotective in mature animal models of traumatic brain injury (TBI), but its effects on immature animal models of TBI are unknown. In mature animal models, CsA inhibits the opening of the mitochondrial permeability transition pore (MPTP), thereby maintaining mitochondrial homeostasis following injury by inhibiting calcium influx and preserving mitochondrial membrane potential. The aim of the present study was to evaluate CsA's ability to preserve mitochondrial bioenergetic function following TBI (as measured by mitochondrial respiration and cerebral microdialysis), in two immature models (focal and diffuse), and in two different species (rat and piglet). Three groups were studied: injured+CsA, injured+saline vehicle, and uninjured shams. In addition, we evaluated CsA's effects on cerebral hemodynamics as measured by a novel thermal diffusion probe. The results demonstrate that post-injury administration of CsA ameliorates mitochondrial dysfunction, preserves cerebral blood flow (CBF), and limits neuropathology in immature animals 24 h post-TBI. Mitochondria were isolated 24 h after controlled cortical impact (CCI) in rats and rapid non-impact rotational injury (RNR) in piglets, and CsA ameliorated cerebral bioenergetic crisis with preservation of the respiratory control ratio (RCR) to sham levels. Results were more dramatic in RNR piglets than in CCI rats. In piglets, CsA also preserved lactate pyruvate ratios (LPR), as measured by cerebral microdialysis and CBF at sham levels 24 h after injury, in contrast to the significant alterations seen in injured piglets compared to shams (p<0.01). The administration of CsA to piglets following RNR promoted a 42% decrease in injured brain volume (p<0.01). We conclude that CsA exhibits significant neuroprotective activity in immature models of focal and diffuse TBI, and has exciting translational potential as a therapeutic agent for neuroprotection in children.
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Affiliation(s)
- Todd J Kilbaugh
- University of Pennsylvania School of Medicine, Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Quinn TM, Taylor JJ, Magarik JA, Vought E, Kindy MS, Ellegala DB. Decompressive craniectomy: technical note. Acta Neurol Scand 2011; 123:239-44. [PMID: 20637010 DOI: 10.1111/j.1600-0404.2010.01397.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Decompressive craniectomy is a neurosurgical technique in which a portion of the skull is removed to reduce intracranial pressure. The rationale for this procedure is based on the Monro-Kellie Doctrine; expanding the physical space confining edematous brain tissue after traumatic brain injury will reduce intracranial pressure. There is significant debate over the efficacy of decompressive craniectomy despite its sound rationale and historical significance. Considerable variation in the employment of decompressive craniectomy, particularly for secondary brain injury, explains the inconsistent results and mixed opinions of this potentially valuable technique. One way to address these concerns is to establish a consistent methodology for performing decompressive craniectomies. The purpose of this paper is to begin accomplishing this goal and to emphasize the critical points of the hemicraniectomy and bicoronal (Kjellberg type) craniectomy.
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Affiliation(s)
- T M Quinn
- Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, SC 29425, USA
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Jacob AT, Heuer GG, Grant R, Georgoff P, Danish SF, Storm PB, Stein SC. Decompressive hemicraniectomy for pediatric traumatic brain injury: long-term outcome based on quality of life. Pediatr Neurosurg 2011; 47:81-6. [PMID: 21934271 DOI: 10.1159/000329624] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 04/12/2011] [Indexed: 11/19/2022]
Abstract
AIMS The impact of decompressive hemicraniectomy (DCH) on the overall outcome of pediatric brain injury patients has not been fully determined. In this paper, the authors performed a systematic review of patient outcome based on quality of life following DCH in a pediatric population. METHODS We describe our experience with decompressive craniectomy in pediatric patients and perform a literature review and pooled outcomes analysis to supplement these findings. A total of 13 children underwent DCH for intractable intracranial pressure in our institution from 2000 to 2008. Follow-up was available in 11 patients with 1 death (9%) and 7 survivors (70%) obtaining a favorable outcome (Glasgow Outcome Scale, GOS, scores = 4-5). RESULTS A literature review to determine the usefulness of DCH identified 17 articles that, when combined with our series, resulted in 186 pediatric DCH cases. Pooled outcomes found 42 deaths and 112 patients who had favorable outcomes at 6 months. The average 6-month mortality was 21.1%, and the pooled mean quality of life among survivors 0.75 (0.68-0.82), midway between moderate disability and good outcome. CONCLUSIONS Based on our findings, DCH results in a majority of pediatric patients having a good outcome based on the GOS score.
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Affiliation(s)
- Arun T Jacob
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, PA 19104, USA.
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Weiner GM, Lacey MR, Mackenzie L, Shah DP, Frangos SG, Grady MS, Kofke A, Levine J, Schuster J, Le Roux PD. Decompressive craniectomy for elevated intracranial pressure and its effect on the cumulative ischemic burden and therapeutic intensity levels after severe traumatic brain injury. Neurosurgery 2010; 66:1111-8; discussion 1118-9. [PMID: 20386136 DOI: 10.1227/01.neu.0000369607.71913.3e] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Increased intracranial pressure (ICP) can cause brain ischemia and compromised brain oxygen (PbtO2 < or = 20 mm Hg) after severe traumatic brain injury (TBI). OBJECTIVE We examined whether decompressive craniectomy (DC) to treat elevated ICP reduces the cumulative ischemic burden (CIB) of the brain and therapeutic intensity level (TIL). METHODS Ten severe TBI patients (mean age, 31.4 +/- 14.2 years) who had continuous PbtO2 monitoring before and after delayed DC were retrospectively identified. Patients were managed according to the guidelines for the management of severe TBI. The CIB was measured as the total time spent between a PbtO2 of 15 to 20, 10 to 15, and 0 to 10 mm Hg. The TIL was calculated every 12 hours. Mixed-effects models were used to estimate changes associated with DC. RESULTS DC was performed on average 2.8 days after admission. DC was found to immediately reduce ICP (mean [SEM] decrease was 7.86 mm Hg [2.4 mm Hg]; P = .005). TIL, which was positively correlated with ICP (r = 0.46, P < or = .001), was reduced within 12 hours after surgery and continued to improve within the postsurgical monitoring period (P </= .001). The duration and severity of CIB were significantly reduced as an effect of DC in this group. The overall mortality rate in the group of 10 patients was lower than predicted at the time of admission (P = .015). CONCLUSION These results suggest that a DC for increased ICP can reduce the CIB of the brain after severe TBI. We suggest that DC be considered early in a patient's clinical course, particularly when the TIL and ICP are increased.
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Affiliation(s)
- Gregory M Weiner
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
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47
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Huang X, Wen L. Technical considerations in decompressive craniectomy in the treatment of traumatic brain injury. Int J Med Sci 2010; 7:385-90. [PMID: 21103073 PMCID: PMC2990073 DOI: 10.7150/ijms.7.385] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 11/03/2010] [Indexed: 11/17/2022] Open
Abstract
Refractory intracranial hypertension is a leading cause of poor neurological outcomes in patients with severe traumatic brain injury. Decompressive craniectomy has been used in the management of refractory intracranial hypertension for about a century, and is presently one of the most important methods for its control. However, there is still a lack of conclusive evidence for its efficacy in terms of patient outcome. In this article, we focus on the technical aspects of decompressive craniectomy and review different methods for this procedure. Moreover, we review technical improvements in large decompressive craniectomy, which is currently recommended by most authors and is aimed at increasing the decompressive effect, avoiding surgical complications, and facilitating subsequent management. At present, in the absence of prospective randomized controlled trials to prove the role of decompressive craniectomy in the treatment of traumatic brain injury, these technical improvements are valuable.
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Affiliation(s)
| | - L. Wen
- Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Thomale UW, Graetz D, Vajkoczy P, Sarrafzadeh AS. Severe traumatic brain injury in children--a single center experience regarding therapy and long-term outcome. Childs Nerv Syst 2010; 26:1563-73. [PMID: 20177687 DOI: 10.1007/s00381-010-1103-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Accepted: 01/29/2010] [Indexed: 11/30/2022]
Abstract
OBJECT The impact of intracranial pressure (ICP), decompressive craniectomy (DC), extent of ICP therapy, and extracranial complications on long-term outcome in a single-center pediatric patient population with severe traumatic brain injury (TBI) is examined. METHODS Data of pediatric (≤16 years) TBI patients were retrospectively reviewed using a prospectively acquired database on neurosurgical interventions between April 1996 and March 2007 at the Charité Berlin. The patients' records, neuroimages, admission Glasgow Coma Scale (GCS) score, the time to craniectomy for hematoma evacuation/DC, and the extent of ICP therapy were reviewed. Twelve-month and long-term outcome was evaluated (Glasgow Outcome Scale). RESULTS Fifty-three pediatric TBI patients [mean age 8.41 (0-16) years] were studied. Patients were categorized into two groups, with DC (n = 14) and without DC (n = 39). DC was performed 3 ± 3.98 median, quartiles 2 (0-3.75) days post-trauma. In the majority of children (n = 9; 64%), surgical decompression was performed early within 2 days post-trauma. (0.8 ± 0.9 days). The DC group tended to be older (median age 12 vs. 7 years, p = 0.052), had a lower GCS (3 vs. 6.5, p < 0.01), and had a 3-fold longer stay on the ICU (20 vs. 6.5 days, p < 0.03) compared to the conservatively treated group. Mean follow-up duration (n = 30) was 5.2 ± 2.4 years (range 1-10.5). At the most recent follow-up examination, 92% of survivors had returned to school. CONCLUSION Though initial GCS was worse in pediatric TBI patients who underwent decompressive craniectomy compared to the conservatively treated patients, long-term outcome was comparable. In children, decompressive craniectomy might be favored early in the management of uncontrollable ICP.
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Affiliation(s)
- Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Charité, Campus Virchow Klinikum, Universitätsmedizin Berlin, Berlin, Germany
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Martin JE, Teff RJ, Spinella PC. Care of pediatric neurosurgical patients in Iraq in 2007: clinical and ethical experience of a field hospital. J Neurosurg Pediatr 2010; 6:250-6. [PMID: 20809709 DOI: 10.3171/2010.6.peds1031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Care for host-nation pediatric casualties and disease or nonbattle injuries is an essential mission of deployed military medical assets. Clinical experience with pediatric patients at field hospitals has been increasingly reported since 2001, with neurotrauma identified as a major cause of morbidity and death in this population. A concentrated pediatric neurosurgical experience at a deployed medical facility has not been reported. The authors reviewed their experience with pediatric neurosurgical patients at a field hospital in Iraq in 2007 to provide insight into the management of this patient population. METHODS A retrospective review was conducted using a prospective database constructed by the authors for quality improvement during a single combat rotation in 2007. RESULTS Forty-two patients among 287 consultations were 17 years of age or younger. Twenty-six of these children were 8 years old or younger. Penetrating head injuries were the most common indication for consultation (22 of 42 patients). Twenty-eight of 130 surgical procedures were performed in the children. One patient died in the perioperative period, for a trauma-related operative mortality rate of 4%. Seven patients received palliative care based on the extent of presenting injuries. Twenty-five patients were discharged with minimal or no neurological deficits. CONCLUSIONS Pediatric patients represent a significant proportion of the neurosurgical patient volume at field medical hospitals in the Iraqi theater. The mature medical theater environment present in 2007 allowed for remarkable diagnostic evaluation and treatment of these patients. Penetrating and closed craniospinal injuries were the most common indication for consultation. Disease and nonbattle injuries were also encountered, with care provided when deemed appropriate. The deployed environment presents unique medical and ethical challenges to neurosurgeons serving in forward medical facilities.
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Affiliation(s)
- Jonathan E Martin
- Department of Surgery, Division of Neurosurgery, University of Connecticut School of Medicine, Connecticut Children's Medical Center, Hartford, Connecticut 06106, USA.
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Utilización de la craniectomía descompresiva en el manejo de la hipertensión intracraneal refractaria en la edad pediátrica. An Pediatr (Barc) 2010; 73:12-8. [DOI: 10.1016/j.anpedi.2010.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Revised: 01/04/2010] [Accepted: 02/02/2010] [Indexed: 11/22/2022] Open
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