Bilateral Frontoparietotemporal Craniectomy for Traumatic Brain Injury: A Case Report

Abstract

There is no conclusive agreement on the optimal approach to managing severe traumatic brain injury. This article details the methodology and outcomes of bilateral frontoparietotemporal decompression surgery performed on a three-year-old patient with severe traumatic brain injury. As the patient had fixed dilated pupils, GCS (Glasgow coma scale) 4, and marked edema in the frontal and parietal regions, the Kjellberg approach was modified, and decompression including part of the parietal bone was performed. The patient was intubated and sedated in the intensive care unit for one week postoperatively. After extubation, the patient had reactive pupils and a GCS of 13. The patient underwent a cranioplasty two months after the trauma, combining the bone grafts placed in the abdomen. The patient was followed for three days after cranioplasty and discharged with a GCS:15 and intact motor examination.

Keywords: decompressive craniectomy; kjellberg procedure; pediatric surgery; severe head trauma; surgical case reports; traumatic brain injury.

Figure 1. a. Computed tomography image at the time of admission, showing acute subdural haematoma in the left frontotemporal region (red arrow), contusion in the bilateral frontal region (white arrow), and traumatic subarachnoid haemorrhage in the right temporal region (blue arrow). b. Imaging after bilateral frontotemporoparietal decompression. c. Tomography image after cranioplasty with bones removed from the abdomen two months after trauma. d. T2-weighted magnetic resonance imaging six months after trauma. There is a significant subdural effusion on the left.

Figure 2. 3D animation of postoperative brain CT.

Figure 3. Surgical supine position and proposed incision line. Coronal suture (red arrow) and midline sagittal suture (white arrow). A bicoronal incision was planned to be behind the hairline. The head was supported with surgical drapes under the shoulder, and a slight extension of the head was performed.

Figure 4. a. Skin subcutaneous scalpel incision was made, and the skin was folded towards the frontal base and parietal, leaving the galea on the cranium. b. The galea was peeled off the periosteum, and the frontal base was removed to be used for duraplasty (white arrow), and coronary suture (black arrow) and sagittal suture (blue arrow) are visible.

Figure 5. a. Burr holes were planned 1.5 cm lateral to the sagittal suture, both anterior and posterior to the coronary suture. Two anterior burr holes were planned 1 cm anterior to the coronary suture (upper black arrow), and two posterior burr holes were planned 4 cm posterior to the coronary suture (lower black arrow). b. All burr hole sites were connected epidurally, and the skull cap was removed with the last cut across the superior sagittal sinus. c. The bone graft was removed bilaterally. The superior sagittal sinus is pointed (blue arrow).

Figure 6. a. After bilateral opening of the dura mater, the superior sagittal sinus was ligated 2 cm anterior to the coronary suture and cut after coagulation with bipolar (black arrow), and the falx was cut 2 cm deeper at the same level. b. Duraplasty with a frontal-based galeal graft was initially used for duraplasty.