Outcomes and prognostic factors of decompressive craniectomy and cranioplasty in pediatric severe traumatic brain injury

Abstract

Background
Decompressive craniectomy (DC) is a commonly used procedure for treating adults with refractory intracranial pressure (ICP). However, its application in pediatric severe traumatic brain injury (TBI) is debatable. We conducted a study to evaluate the effectiveness of DC in controlling refractory ICP in severe TBI, prognosis of the outcome, and the optimal timing for cranioplasty.


Patient and methods
This is a retrospective observational study that represent presentation, management, and complications of 32 pediatric patients with severe TBI managed with DC and cranioplasty over the past 4 years.


Results
The included cases comprised 20 male patients (62.5%) and 12 female patients (37.5%), with a mean age at presentation of 8.78 ± 3.774 years (range 1–16 years). Road traffic accidents were the most common mode of trauma (56.3%), and the mean presenting Glasgow Coma Scale (GCS) score was 6.84 (range 4–8). All patients underwent DC within the first 48 hours after trauma. 22 patients (68.8%) were discharged, and the postoperative mortality rate was 31.2%. Mortality significantly correlated with the Injury Severity Score (ISS), while successful discharge was related to the motor component of the GCS. 14 patients underwent cranioplasty, with no difference in the complication rate between the early and late groups. Increased bone resorption and syndrome of the trephined were noticed in the late group.


Conclusion
DC is an approach to managing refractory ICP in severe TBI if performed within 48 hours after trauma. The post-DC mortality rate is correlated with ISS. Preliminary observations suggest once brain swelling and intracranial pathologies are resolved to avoid increased bone resorption and syndrome of the trephined.