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Table 14.8 Decompressive Craniectomy and Related Surgeries for the Acute Management of Pediatric TBI

Author Year

Country

Study Design

Sample Size

Methods Outcomes

Taylor et al.

(2001)

Australia

RCT

PEDro=6

N=27

 

Population: TBI; Median Age=10.1yr; Standard Management Group (n=14): Median Time Post Injury=17.2 hr; Median GCS=5. Standard Management + Craniectomy Group (n=13): Median Time Post Injury=15.0 hr; Median GCS=6.

Intervention: Patients were randomized to standard medical management (control group) or standard medical management plus decompressive craniectomy (treatment group). Outcome status was assessed at 6mo post-injury either by telephone interview or by chart review.

Outcome Measure: Glasgow Outcome Scale (GOS), Health State Utility (HSU), Intracranial Pressure (ICP), Length of Stay (LOS).

1.       Favourable outcomes on the GOS and HSU were more prevalent for the treatment group compared to the control group but no statistically significant difference was found.

2.       Although the treatment group demonstrated a greater reduction in ICP from pre- to post-treatment, this difference between groups only approached significance (p=0.057).

3.       The median LOS was 26.8 d for the treatment group and 47.7 d for the control group but this did not reach statistical significance (p=0.330).

Rallis et al. (2017a)

Greece

Case Series

N=14

Population: TBI; Mean Age=7.7yr; Gender: Male=5, Female=9; Median Time Post Injury=19 h; Median GCS=6.

Intervention: Patients with severe TBI who underwent decompressive craniectomy (DC) were retrospectively identified.

Outcome Measure: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Mortality, Neurological Outcomes.

1.      DC resulted in significantly reduced postoperative peak ICP (31 mmHg to 19 mmHg) and elevation of minimum CPP (41 mmHg to 58 mmHg) (both p<0.001).

2.      Seventy-one percent of patients survived.

3.      At 6 mo post-injury, 6 patients were in a vegetative state, and 2 suffered severe impairment.

Manfiotto et al. (2017) France Pre-Post Test N=150

Population: TBI; Mean Age=10.75yr; Gender: Male=103, Female=47.

Intervention: Patients who underwent decompressive craniectomy (DC) were retrospectively analyzed.

Outcome Measure: Complications.

1.       Sixteen patients required the insertion of a CSF shunt device for CSF dynamics impairment. These patients were at increased risk of developing further complications and requiring additional treatment; particularly a cranioplasty infection (p=0.008).

2.       Females were more likely to present post-DC CSF disorder (p=0.010).

3.       The rate of overall complications was 42%.

Benifla et al. (2016)

Israel

Case Series

N=14

Population: TBI; Age=5-16yr; Gender: Male=7, Female=7; GCS=7-14.

Intervention: Anterior frontal space occupying lesions were treated with a supraciliary “keyhole” small craniotomy. Chart reviews were gathered and analyzed for pre- and post-operative statistics.

Outcome Measure: Post-operative Outcomes, Complications

1.       The operation was performed either on the left side of the brain (n=9) or on the right side (n=5).

2.       With the exception of one patient who developed a recurring post-surgical epidural hematoma, there were no major operative or post-operative complications observed.  .

3.       At long-term follow-up, surgical scars were nearly invisible.

Matsuo et al. (2016)

Japan

Case Series

N=25

Population: TBI; Mean Age=6.1mo; Gender: Male=21, Female=4.

Intervention: Patients with chronic subdural hematoma and subdural hygroma (CSDH/SDHy) who underwent burr-hole craniotomy without continuous drainage were retrospectively identified.

Outcome Measure: CSDH/SDHy reoccurrence, Complications.

1.       Patients presented either with bilateral (n=17) or unilateral (n=8) CSDH/SDHy, resulting in a total of 42 burr-hole craniotomies.

2.       CSDH/SDHy reoccurred in 5 patients (20%). These patients underwent a second operation at an average of 0.92 mo after the initial procedure.

3.       No complications related to the surgical procedures were reported.

Pechmann et al. (2015)

Germany

Case Series

N=12

Population: TBI; Mean Age=8.5yr; Gender: Male=8, Female=4; Mean GCS=4.5.

Intervention: Data was collected retrospectively from records of patients who received a decompressive craniectomy from January 2005 to February 2013 at a university hospital.

Outcome Measure: Glasgow Outcome Scale (GOS), Post-surgical Complications.

1.       Patients achieved a mean GOS of 3.3 at follow-up (median 29.4mo).

2.       Seven patients reached favourable outcomes, three required total care, and one was deceased.

3.       Complications were observed in the majority of the patients with nine patients (75%) requiring additional surgery.

4.       Long term complications included: hygroma (83%), aseptic bone resorption (50%), post-traumatic hydrocephalus (42%), secondary infection (25-33%), and epilepsy (33%).

Prasad et al. (2015)

India

Case Series

N=71

 

Population: TBI; Mean Age=1.6yr; Gender: Male=43, Female=28; Mean Time Post Injury=11.5 hr; GCS Severity: Mild=9, Moderate=26, Severe=36.

Intervention: A retrospective of young children who underwent a decompressive craniectomy (DC) for elevated intracranial pressure (ICP) was conducted.

Outcome Measure: ICP Monitoring and Levels, Mortality, Type of Operation, Complications.

1.       Mean pre-op ICP was 22.2 mmHg and the threshold for DC was 15 mmHg.

2.       Primary DC occurred in 54% of patients and secondary DC occurred in 46%; DC was further broken down into unilateral (82%), bilateral (6%), bifrontal (7%), and posterior fossa (5%).

3.       DC performed within 2 hr of elevated ICP had survival rate of 58% compared to 42% after 2 hr.

4.       Complications include: ventilator assisted pneumonia (31%), hydrocephalus (18%), subdural hygroma (15%), wound infection (10%), septicemia (8%), and late onset seizures (3%).

5.       Perioperative mortality was overall 44%, where 50% with severe TBI and 58% of infants died. Mean pre-op ICP for patients who died was 27 mmHg, with 90% over 20 mmHg.

Khan et al.

(2014)

Pakistan

Case Series

N=25

Population: TBI; Mean Age=6.8yr; Gender: Male=21, Female=4; Mean GCS=6.

Intervention: Data was collected retrospectively from records of patients who received a decompressive craniectomy (DC) from January 2000 to January 2010 at a university hospital.

Outcome Measure: Glasgow Outcome Scale (GOS).

1.       DC performed >4 hr after arrival to hospital was a significant predictor of worse GOS score (p=0.042).

2.       Intraoperative blood loss exceeding 300 ml significantly predicted poor outcome on the GOS after a DC (p=0.001).

3.       Single skull fractures also resulted in a worse GOS score than multiple fractures but this was not statistically significant (p=0.069).

Oluigbo et al. (2012)

USA

Case Control

N=37

Population: TBI; Non-Accidental Trauma Group (n=14): Mean Age=2.2yr; Mean GCS=4.5. Accidental Trauma Group (n=23): Mean Age=8.4yr; Mean GCS=6.2.

Intervention: Data was collected retrospectively from records of patients who received a decompressive craniectomy from January 2000 to December 2008 at a single children’s hospital.

Outcome Measure: Mortality rate, King’s Outcome Scale for Closed Head Injury (KOSCHI), Visual Impairment.

1.       Poor outcomes as measured by the KOSCHI were observed in 57% of non-accidental trauma patients compared to 30% of accidental trauma patients but this was not statistically significant (p=0.170).

2.       The odds ratio for mortality in non-accidental trauma patients was 12.2 times greater than those with accidental trauma (p=0.020).

3.       Surviving non-accidental trauma patients scored a mean of 3.7 on the KOSCHI but this was not significantly lower than accidental trauma patients who scored a mean of 4.0.

4.       At discharge, 66.7% of non-accidental trauma patients were noted to have visual impairments, compared to 9.1% of accidental trauma patients (p<0.050).

Adamo et al. (2009)

USA

Case Control

N=218

Population: TBI; Age Range=0-36mo; Accidental Trauma Group(n=164): Gender: Male=92, Female=72; Severity: Mild=142, Moderate=13, Severe=9. Non-Accidental Trauma Group (n=54): Gender: Male=32, Female=22; Severity: Mild=25, Moderate=20, Severe=8, Unknown=1.

Intervention: A retrospective chart review of patients who were admitted between January 1st 2002 and December 31st 2008 and who had been entered into the New York State Trauma Registry was conducted.

Outcome Measure: King’s Outcome Scale for Childhood Head Injury (KOSCHI).

1.       18 patients (33%) in the non-accidental trauma group required a decompressive craniectomy or craniotomy compared to only 6 (<1%) patients in the accidental trauma group.

2.       Patients who had sustained an accidental trauma were more likely to have a KOSCHI score of 5 (good recovery) at discharge and at follow-up (OR 6.48 and 4.58 respectively) compared with non-accidental patients.

3.       KOSCHI scores of 3a, 3b, 4a and 4b (severe to moderate disability) at follow-up were more likely to be reported by non-accidental trauma patients (OR 6.48, 5.47, 2.44 and 3.62 respectively).

Josan & Sgouros

(2006)

United Kingdom

Case Series

N=12

Population: TBI; Early Treatment Group (n=6): Mean Age=13yr; Gender: Male=5, Female=1; Mean Time Post Injury=7.0 hr; Mean GCS=6.8. Non-Operative Treatment Group (n=6): Mean Age=11.5yr; Gender: Male=3, Female=3; Mean GCS=6.

Intervention: A retrospective chart review of patients who were treated between 1999 and 2001 was conducted. Two groups of patients were compared, those who underwent decompressive craniectomy (DC) and those who received non-operative treatment. Outcomes at 1yr follow-up were also analyzed.

Outcome Measure: Glasgow Outcome Scale (GOS), Intracranial Pressure (ICP) .

1.       All patients who underwent a DC maintained a mean ICP of 12.3 mmHg post-operatively.

2.       At follow-up amongst those treated with craniectomy, four patients scored a 5 (full recovery) and two patients scored 4 (required some psychological support) on the GOS (i.e., all patients have favourable outcomes).

3.       Although three patients who did not receive operative surgery scored 5 on the GOS at follow-up (50%), two died and one scored a 3 (experiences memory and cognitive problems).

Rutigliano et al.(2006)

USA

Case Series

N=6

 

Population: TBI; Mean Age=14.5yr; Time Post Injury=<24 hr; Mean GCS=8.

Intervention: Data was extracted from the Brain Trauma Foundation TBI-trac online database for patients who had undergone decompressive craniectomy.

Outcome Measure: Functional Independence Measurement (FIM).

   

1.       All patients demonstrated improvements at discharge with GCS scores all between 12 and 15.

2.       FIM ambulation scores revealed that four patients still required assistance one was dependent, and another was considered independent.

3.       There were greater levels of independence on the FIM feeding measure with three considered independent, one dependent, and two requiring assistance.

Ruf et al.

(2003)

Germany

Case Series N=6

 

Population: TBI; Mean Age=7.8yr; Gender: Male=2, Female=4; Mean Time Post Injury=2.5d; Mean GCS=4.3.

Intervention: All patients underwent decompressive craniectomy after ICP levels exceeded 20 mmHg and did not respond to treatment for >30 min. Neurological outcomes were assessed at discharge and at 6mo follow-up.

Outcome Measure: Intracranial Pressure (ICP), Somatosensory Evoked Potentials of Median Nerve (M-SEP), Complication Rate, Neurological Status.

   

1.       ICP levels normalised to <12 mmHg immediately following surgery in 5 of the 6 patients.

2.       M-SEP post-surgery results revealed that 2 patients were categorised as “normal”, one patient with mild impairment, one with moderate impairment, and 2 with severe impairment.

3.       Neurological status was judged to be “normal” in 3 (50%) of the patients at 6mo follow-up.

4.       Only 1 patient experienced complications post-surgery after developing aseptic necrosis of the replaced bone flap.