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.

Keywords: Decompressive craniectomy; Glasgow outcome score; Intracranial pressure; Pediatric traumatic brain injury; Severe TBI.

Fig. 1

Illustration of study design and patient enrolment, comparison of the present to a historic cohort

Fig. 2

Comparison of the patients in the recent cohort (2008–2018) treated with or without decompressive craniectomy (DC vs. no DC). a Glasgow Coma Scale (GCS) at admission (p = *0.0365), b probability of survival (p = 0.2040), and c Glasgow Outcome Scale (GOS) during follow-up (favorable, GOS 4–5; non-favorable GOS 2–3), p = 0.2505 (n.s. = not significant) at 12 and 36 months

Fig. 3

Exemplary cases of two children suffering from severe TBI and treated with decompressive craniectomy. Patient 1 was a 4-year-old boy suffering from a direct hit against the skull through the mirror of a past-driving car. The child presented with GCS 3, anisocoria, and non-intact light reaction. The initial CT scan (a) showed a complex frontal skull fracture and a diffuse TBI with a 2-mm midline shift. The child was treated with unilateral decompressive hemicraniectomy, and an EVD and an ICP probe were placed (postop scan: b). ICP was critically elevated throughout the postoperative course (ICP_max. 40 mmHg), and the child presented with severe infarction and brain death at 14 days postop (C). Patient 2 is a 9-month-old boy who fell from a height and also presented with GCS 3, anisocoria, and non-intact light reaction. The CT scan (a) showed a right frontal skull fracture and a diffuse TBI without midline shift. The child was also treated with unilateral decompressive hemicraniectomy, and an EVD and an ICP-probe were placed. ICP_max. was 21 mmHg (postop scan: b). Cranioplasty with reimplantation of the formerly removed bone flap was performed 21 days postop (c) without complications. The child showed brain hypotrophy in the follow-up scans (d, 2-year follow-up) and lives with respective disabilities (GOS 4)

Fig. 4

Comparison of the patients treated with decompressive craniectomy (DC) in the recent cohort (2008–2018) compared to the historic cohort (1996–2007). a Glasgow Coma Scale (GCS) at admission (p = *0.0163), b age at admission (p = *0.0043), c outcome data with Glasgow Outcome Scale (GOS) at discharge (favorable outcome GOS 4–5, non-favorable outcome GOS 2–3, death GOS 1) compared between patients treated in the recent (2008–2018) and in the historic cohort (1996–2007) with and without decompressive craniectomy (DC)