Decompressive craniectomy for severe traumatic brain injury in children: analysis of long-term neuropsychological impairment and review of the literature
The effectiveness of decompressive craniectomy (DC) in the context of neurocritical care in adult patients has been recently under debate. The aim of our study was to evaluate the impact of decompressive craniectomy in severe traumatic brain injury (TBI) in children, focusing on short and long-term neurological and neuropsychological outcomes.
Retrospective review of the medical records of children admitted at a level I trauma center, between January 2012 and December 2015, submitted to DC due to severe TBI. Additionally, an extensive review of literature on this subject was carried out.
Sixteen patients underwent DC for TBI at our institution during the evaluated period. 62.5% were males and the mean age was 12 years. Road traffic accident (RTA) was the main mechanism of trauma (62.5%). Average Glasgow Coma Scale (GCS) at admission was 5.2, whereas 75% of the patients presented with pathological pupillary reaction. Initial computed tomography (CT) showed skull fractures in 62.5% and acute subdural hemorrhage (ASH) in 56.3% of the patients. The mean intracranial pressure (ICP) was 27.2 mmHg prior to surgery, and the mean time window between admission and DC was 36.3 h. Unilateral DC was performed in 68.8% of the cases. The average Glasgow Outcome Scale (GOS) at 6-month follow-up was 3.7, whereas 70% of the survivors presented good recovery (GOS 4–5). Abnormal pupillary reaction at hospital admission increased 3-fold the risk of long-term neuropsychological disturbances. Follow-up evaluation revealed cognitive abnormality in 55.6% of the patients. The overall mortality at 6-month follow-up was 37.5%.
The present study indicates towards a potential benefit of DC in children with severe TBI; nevertheless, our data demonstrated a high incidence of neuropsychological impairment in the long-term follow-up. Psychological and cognitive assessment should be computed in prognosis evaluation in future prospective studies.
KeywordsDecompressive craniectomy Traumatic brain injury Children Psychological evaluation
Compliance with ethical standards
Conflict of interest
The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
- 3.TBI Data and Statistics | Concussion | Traumatic brain injury | CDC Injury Center. https://www.cdc.gov/traumaticbraininjury/data/index.html. Accessed 23 Aug 2018
- 6.Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ (2016) Trial of decompressive craniectomy for traumatic intracranial hypertension. N Engl J Med 375:1119–1130. https://doi.org/10.1056/NEJMoa1605215 CrossRefGoogle Scholar
- 7.Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, Kossmann T, Ponsford J, Seppelt I, Reilly P, Wolfe R, DECRA Trial Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group (2011) Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 364:1493–1502. https://doi.org/10.1056/NEJMoa1102077 CrossRefGoogle Scholar
- 10.Marshall LF, Marshall SB, Klauber MR et al (1992) The diagnosis of head injury requires a classification based on computed axial tomography. J Neurotrauma 9(Suppl 1):S287–S292Google Scholar
- 11.Morrissey K, Fairbrother H (2016) Severe traumatic brain injury in children: an evidence-based review of emergency department management. Pediatr Emerg Med Pract 13:1–28Google Scholar
- 12.Pinto PS, Poretti A, Meoded A, Tekes A, Huisman TAGM (2012) The unique features of traumatic brain injury in children. Review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications and their imaging findings--part 1. J Neuroimaging Off J Am Soc Neuroimaging 22:e1–e17. https://doi.org/10.1111/j.1552-6569.2011.00688.x CrossRefGoogle Scholar
- 13.Jankovic J, Mazziotta JC, Pomeroy SL, Daroff RB (2015) Bradley’s neurology in clinical practice, 2-volume set, 7th edn. Elsevier, LondonGoogle Scholar
- 14.Youmans JR, Winn HR (2011) Youmans neurological surgery. Elsevier - Health Sciences Division, St. LouisGoogle Scholar
- 15.Badri S, Chen J, Barber J, Temkin NR, Dikmen SS, Chesnut RM, Deem S, Yanez ND, Treggiari MM (2012) Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med 38:1800–1809. https://doi.org/10.1007/s00134-012-2655-4 CrossRefGoogle Scholar
- 17.Hutchinson PJ, Kolias AG, Timofeev IS et al (2016) Trial of decompressive craniectomy for traumatic intracranial hypertension. In: https://doi.org/10.1056/NEJMoa1605215. https://www.nejm.org/doi/10.1056/NEJMoa1605215?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov. Accessed 23 Aug 2018
- 20.Fulkerson DH, White IK, Rees JM, Baumanis MM, Smith JL, Ackerman LL, Boaz JC, Luerssen TG (2015) Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr 16:410–419. https://doi.org/10.3171/2015.3.PEDS14679 CrossRefGoogle Scholar
- 21.Taylor A, Butt W, Rosenfeld J, Shann F, Ditchfield M, Lewis E, Klug G, Wallace D, Henning R, Tibballs J (2001) A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension. Childs Nerv Syst ChNS Off J Int Soc Pediatr Neurosurg 17:154–162. https://doi.org/10.1007/s003810000410 CrossRefGoogle Scholar
- 22.Kachmar AG, Irving SY, Connolly CA, Curley MAQ (2018) A systematic review of risk factors associated with cognitive impairment after pediatric critical illness. Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc 19:e164–e171. https://doi.org/10.1097/PCC.0000000000001430 Google Scholar
- 25.Andruszkow H, Deniz E, Urner J, Probst C, Grün O, Lohse R, Frink M, Krettek C, Zeckey C, Hildebrand F (2014) Physical and psychological long-term outcome after traumatic brain injury in children and adult patients. Health Qual Life Outcomes 12:26. https://doi.org/10.1186/1477-7525-12-26 CrossRefGoogle Scholar
- 26.Fletcher JM, Miner ME, Ewing-Cobbs L (1987) Age and recovery from head injury in children: developmental issues. In: Levin HS, Grafman J, Eisenberg HM (eds) Neurobehavioral recovery from head injury. Oxford University Press, New York, pp 279–291Google Scholar
- 27.Resch C, Anderson VA, Beauchamp MH, Crossley L, Hearps SJC, van Heugten CM, Hurks PPM, Ryan NP, Catroppa C (2019) Age-dependent differences in the impact of paediatric traumatic brain injury on executive functions: a prospective study using susceptibility-weighted imaging. Neuropsychologia 124:236–245. https://doi.org/10.1016/j.neuropsychologia.2018.12.004 CrossRefGoogle Scholar
- 28.Krasny-Pacini A, Chevignard M, Lancien S, Escolano S, Laurent-Vannier A, de Agostini M, Meyer P (2017) Executive function after severe childhood traumatic brain injury - age-at-injury vulnerability periods: the TGE prospective longitudinal study. Ann Phys Rehabil Med 60:74–82. https://doi.org/10.1016/j.rehab.2016.06.001 CrossRefGoogle Scholar
- 29.Max JE, Wilde EA, Bigler ED, MacLeod M, Vasquez AC, Schmidt AT, Chapman SB, Hotz G, Yang TT, Levin HS (2012) Psychiatric disorders after pediatric traumatic brain injury: a prospective, longitudinal, controlled study. J Neuropsychiatr Clin Neurosci 24:427–436. https://doi.org/10.1176/appi.neuropsych.12060149 CrossRefGoogle Scholar
- 30.Max JE, Wilde EA, Bigler ED, Thompson WK, MacLeod M, Vasquez AC, Merkley TL, Hunter JV, Chu ZD, Yallampalli R, Hotz G, Chapman SB, Yang TT, Levin HS (2012) Neuroimaging correlates of novel psychiatric disorders after pediatric traumatic brain injury. J Am Acad Child Adolesc Psychiatry 51:1208–1217. https://doi.org/10.1016/j.jaac.2012.08.026 CrossRefGoogle Scholar