In-Depth Study Analyzes Craniectomy Outcomes in Children with Traumatic Brain Injury

Newswise — Traumatic Brain Injury (TBI) is one of the leading causes of morbidity and mortality in the pediatric population. About 475,000 children ages 0-14 suffer a TBI annually. Pediatric TBI outcomes have improved over the past 30 years due to improvements in automotive engineering, as well as preventative strategies such as recreational helmets and car seat technology. Medical options for the treatment of pediatric TBI, however, have not seen similar advances in this timeframe.

TBI patients may develop increased intracranial pressure (ICP) as a result of edema (brain swelling), blood clots, subdural hematomas, or other intracerebral hemorrhages. Controlling ICP is of paramount importance when treating the severely head-injured pediatric patient. Some experts have suggested that in these patients, removing variable amounts of bone from the skull (decompressive craniectomy) early after injury can improve the ability to control ICP and improve long-term outcomes.

A few studies have described the potential benefits of performing decompressive craniectomy in the pediatric population after trauma. However, these studies have been limited by small sample size, short follow-up, as well as variable criteria used for when to operate. Researchers at the Department of Neurological Surgery at the University of Virginia Health Sciences Center analyzed the outcome of decompressive craniectomy over the last 10 years in pediatric patients with TBI.

The results of this study, Outcomes following Decompressive Craniectomy in Severe Pediatric Traumatic Brain Injury: A Single Center Experience with Long Term Follow-up, will be presented by Jay Jagannathan, MD, 3:54 to 4:06 p.m. on Tuesday, April 17, 2007, during the 75th Annual Meeting of the American Association of Neurological Surgeons in Washington, D.C. Co-authors are David O. Okonkwo, MD, PhD, Aaron S. Dumont, MD, Abbas Bahari, MD, Hazem Ahmed, MD, PhD, Daniel M. Prevedello, MD, John A. Jane, Sr., MD, PhD, and John A. Jane Jr., MD.

The rationale for decompressive craniotomy is that by removing a variable amount of bone from the skull, the brain can expand beyond the confines of the calavarium. This improves cerebral perfusion pressure and reduces not only ICP, but also midline shift and the potential for brainstem compression and herniation.

Records of 23 pediatric patients treated with decompressive craniectomy between January 1995 and April 2006 were compiled from a database of over 500 trauma patients treated at this institution during this period. Patient radiographs were examined to evaluate extent of intracranial injury and records were reviewed to determine the admission Glasgow Coma Scale (GCS), extent of systemic injuries, timing to craniectomy, and the indications for craniectomy.

"¢Nine patients suffered injury as a result of an automobile or all-terrain vehicle accident, nine patients were injured after being struck by an automobile, three patients suffered from other blunt trauma, and two patients presented as a result of a fall. "¢Mean GCS on presentation was 4.65 (Median 5; Range 3-8). The mean age at the time of craniectomy was 11.9 years (range 2-19 years)."¢Eight patients were female and 15 were male."¢All patients had abnormal presenting CAT scans with diffuse axonal injury " traumatic contusions being the most common abnormalities."¢Nineteen patients suffered from other systemic injuries, and seven patients required emergent non-intracranial operations in addition to craniectomies.

Postoperatively, functionality and independence were evaluated using the Glasgow Outcomes Scale (GOS), and a Likert patient quality of life rating scale. Surviving patients were all discharged to rehabilitation facilities following a mean hospital stay of 21 days (range 7-100). Mean follow-up was 63 months (Median 49 months, Range 11-126 months). The following outcomes were noted:

"¢Postoperative ICP control was obtained in 19 patients."¢One intraoperative death occurred, and six patients died postoperatively. Mean time-course to death was one-day postoperatively (Range 0-3 days), except for a 15-year-old male who suffered from multiple shunt and systemic infections postoperatively, and died four months post-craniectomy from overwhelming sepsis."¢Nine patients had residual neurological deficits."¢All surviving patients eventually received a cranioplasty. Seven patients received the procedure before discharge to rehabilitation, while the remainder returned for surgery."¢Five patients eventually required shunt placement to treat post-traumatic hydrocephalus."¢Of the seven patients who are now over the age of 18, three are living independently and four have or have held gainful employment post injury."¢Thirteen patients were able to resume school."¢Only three patients remain completely dependent on caregivers.

"The overall outcomes indicate a net 65 percent favorable outcome in pediatric patients following craniectomy (good recovery or moderate disability), with 9 percent of the patients having severe disability on long-term follow-up," stated Dr. Jagannathan. "While pediatric craniectomy has often been viewed as a last resort in the pediatric population, it can be an effective method of controlling ICP and providing reasonable quality of life postoperatively," concluded Dr. Jagannathan.

Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 6,800 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system, including the spinal column, spinal cord, brain and peripheral nerves.