Factors predicting the need for rescue decompressive craniectomy for refractory intracranial hypertension in pediatric traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) is a leading cause of death and disability in the pediatric population. Decompressive craniectomy (DC) is an important surgical intervention for severe TBI with refractory intracranial hypertension (IH). However, it is classically performed early for primary injuries such as acute subdural hematoma. In rare cases, delayed IH develops, requiring rescue DC. Here, we analyze a cohort of pediatric patients with severe TBI who required rescue DC (> 24 h) for predictive characteristics. METHODS: A retrospective case series through the Children's Hospital of Pittsburgh Pediatric Trauma Center's Institutional Database was performed. Inclusion criteria were severe TBI (Glasgow Coma Scale ≤ 8), age < 18 years, and DC for refractory IH > 24 h after admission. Patients who underwent surgical intervention for expanding intracranial hematomas, cosmetic reconstruction, or repair of cerebrospinal fluid leak were excluded. A descriptive analysis identified clinical factors associated with rescue DC. RESULTS: Eleven patients met the inclusion criteria. The average time to rescue DC was 3.6 ± 2.6 days. Factors associated with the need for rescue DC following TBI (Table 1) were (1) intracranial hemorrhage (11/11; 100%), (2) diffuse cerebral edema (11/11; 100%) on initial CT head, and (3) high velocity mechanism of injury (11/11; 100%). CONCLUSION: In this retrospective case series, all patients requiring DC after 24 h had a high-velocity mechanism of injury, diffuse cerebral edema and intracranial hemorrhage (in any compartment) at the time of presentation. Identifying radiographic indicators in this population could improve understanding of the need for DC.

Duke Scholars

Author Stephanie Greene Neurosurgery