Decompressive craniectomy in pediatric patients with traumatic brain injury with intractable elevated intracranial pressure

Background: Care of pediatric traumatic brain injury (TBI) has placed emphasis on maximizing cerebral perfusion to prevent ischemia and reperfusion injury. A subset of patients with TBI will continue to have refractory intracranial pressure (ICP) elevation despite aggressive therapy including ventriculostomy, pentobarbital coma, hypertonic saline, and diuretics. Decompressive craniectomy (DC) is a controversial treatment of severe TBI. It is our hypothesis that DC can enhance survival and minimize secondary brain injury in this patient subset. Methods: Patients younger than 20 years treated at a level I regional trauma center between November 2001 and November 2004, who met inclusion criteria for the Brain Trauma Foundation TBI-trac clinical database were included. All patients with a mechanism of injury consistent with TBI and Glasgow Coma Scale score of less than 9 for at least 6 hours after resuscitation and who did not die in the emergency department are entered into a clinical database. Patients who arrived at the study hospital more than 24 hours after injury are excluded. Results: There were 30 patients with TBI identified. The mean Glasgow Coma Scale score at presentation was 8 with a range of 3 to 13. Six patients underwent DC for intractable elevated ICP. Of 6 patient's postoperative ICP, 5 were less than 20 mm Hg. One patient required a return to the operating room where further débridement of brain was performed. All patients who received a DC survived and were discharged to a TBI rehabilitation facility. Conclusion: Although this is a small sample, DC should be considered in patients with TBI with refractory elevated ICP. Long-term follow-up of this patient population should consist of neuropsychiatric evaluation in conjunction with measurement of social function.