Severe Traumatic Brain Injury in children—paradigm of decompressive craniectomy compared to a historic cohort

Abstract

Purpose Traumatic brain injury (TBI) is one of the leading causes of death and disability in children. Medical therapy remains limited, and decompressive craniectomy (DC) is an established rescue therapy in case of elevated intracranial pressure (ICP). Much discussion deals with clinical outcome after severe TBI treated with DC, while data on the pediatric population is rare. We report our experience of treating severe TBI in two different treatment setups at the same academic institution. Methods Forty-eight patients (≤ 16 years) were hospitalized with severe TBI (GCS ≤ 8 points) between 2008 and 2018 in a pediatric intensive care unit (ICU) at a specialized tertiary pediatric care center. Data on treatment, clinical status, and outcome was retrospectively analyzed. Outcome data included Glasgow Outcome Scale (GOS) at 3-, 12-, and 36-month follow-up. Data was compared to a historic cohort with 53 pediatric severe TBI patients treated at the same institution in a neurointensive care unit between 1996 and 2007. Ethical approval was granted (EA2/076/21). Results Between 2008 and 2018, 11 patients were treated with DC. Compared to the historic cohort, patients were younger and GCS was worse, while in-hospital mortality and clinical outcome remained similar. A trend towards more aggressive EVD placement and the internal paradigm change for treatment in a specialized pediatric ICU was observed. Conclusions In children with severe TBI treated over two decades, clinical outcome was comparable and mostly favorable in two different treatment setups. Consequent therapy is warranted to maintain the positive potential for favorable outcome in children with severe TBI.

WITHDRAWN: The Impact of Decompressive Craniectomy on the Prognosis of Pediatric Patients with Moderate-to-Severe Traumatic Brain Injury: A Retrospective Matched Case-Control Study

“…Our rate of poor outcomes (PCPC 3-5 and death) was 53.2%, which is relatively high compared to similar studies and could be attributed to the different evaluation criteria. Additionally, the median age of our study participants in the DC and non-DC groups was 5.0 and 3.8 years old, respectively, younger than the mostly 5-13-year-old patients in similar studies [9][10][11][12][13][14][15][16][17][18][19] . An epidemiological review also revealed that the average age of pediatric TBI patients in China is 3.2 years old, which is younger than in most countries 1 .…”

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience

“…With regard to second-tier interventions, a high percentage of 67% of those patients who underwent decompressive craniectomy had a favorable functional outcome. This is in accordance to recent studies both in children and adults showing that patients with refractory IC-HTN can achieve a good neurologic outcome after secondary decompressive craniectomy [ 36 , 41 , 42 , 43 ], while current reports highlight the importance of early and aggressive treatment algorithms, especially for pediatric TBI patients, who have higher recovery rates compared to adults [ 13 ]. However, other detailed reviews in adults highlight the significantly reduced mortality, but also the increased proportions of severely disabled patients in the decompressive craniectomy group of patients, when compared to conservatively treated medical groups.…”

“…The pediatric scalp is relatively heavier and highly vascularized, leading to higher risk of lethal blood loss. Moreover, due to higher plasticity and deformity, fewer mass lesions but more white matter shear lesions may occur, while anatomic differences in myelination are pronounced during progressing development, accounting for different absorption of traumatic forces in younger children [ 13 , 14 ]. The most significant secondary complication following sTBI is the emergence of cerebral edema, and because of the developing biological processes of autoregulation for restoring brain blood supply, the vulnerability of children to cerebral hyperemia and intracranial hypertension seems to be critical [ 15 ].…”

Evaluation of decompressive craniectomy in mice after severe traumatic brain injury

“…Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide (1)(2)(3). It accounts for an estimated 37% of all injury-related deaths in the EU and 30.5% in the USA, and the mortality is estimated to be ∼13 cases per 100,000 people in China (4,5).…”