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From Decompressive Craniectomy to Cranioplasty and Beyond—A Pediatric Neurosurgery Perspective

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From Decompressive Craniectomy to Cranioplasty and Beyond—A Pediatric Neurosurgery Perspective Child's Nervous System (2019) 35:1517–1524 https://doi.org/10.1007/s00381-019-04303-z ORIGINAL ARTICLE From decompressive craniectomy to cranioplasty and beyond—a pediatric neurosurgery perspective Thomas Beez1 & Christopher Munoz-Bendix 1 & Sebastian Alexander Ahmadi1 & Hans-Jakob Steiger1 & Kerim Beseoglu1 Received: 23 May 2019 /Accepted: 8 July 2019 /Published online: 20 July 2019 # Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract Purpose Decompressive craniectomy (DC) is an established neurosurgical emergency technique. Patient selection, optimal timing, and technical aspects related to DC and subsequent cranioplasty remain subjects of debate. For children, the overall degree of evidence is low, compared with randomized controlled trials (RCTs) in adults. Methods Here, we present a detailed retrospective analysis of pediatric DC, covering the primary procedure and cranioplasty. Results are analyzed and discussed in the light of modern scientific evidence, and conclusions are drawn to stimulate future research. Results The main indication for DC in children is traumatic brain injury (TBI). Primary and secondary DC is performed with similar frequency. Outcome appears to be better than that in adults, although long-term complications (especially bone flap resorption after autologous cranioplasty) are more common in children. Overt clinical signs of cerebral herniation prior to DC are predictors of poor outcome. Conclusions We conclude that DC is an important option in the armamentarium to treat life-threatening intracranial hypertension, but further research is warranted, preferentially in a multicenter prospective registry. Keywords Intracranial hypertension . Cranial reconstruction . Bone flap resorption Background compared with conservative management [4]. Another RCT (DECRA) had a lower ICP threshold (> 20 mmHg) and dem- The appeal of decompressive craniectomy (DC) as a universal onstrated lower mortality but more unfavorable outcomes af- treatment of severely raised intracranial pressure (ICP) is con- ter DC [5]. Uncertainty has also been demonstrated in clinical siderable, as it is a technically simple operation with logical reality concerning primary DC for acute subdural hematoma pathophysiological benefit: DC is providing an additional [6]. This has led to a RCT investigating the role of primary DC space for a swollen brain by opening the “closed container” (RESCUE-ASDH), but final results are pending [7]. represented by the skull [1]. However, the impacts of primary For space-occupying (malignant) ischemic supratentorial and secondary brain injury have to be taken into account, as stroke, several RCTs in adults (e.g., HAMLET, DECIMAL, well as complications and limitations of DC itself and of sub- and DESTINY I and II) demonstrated significant reduction of sequent cranioplasty [2, 3]. mortality, although DC renders a relevant proportion of pa- In adults, the RESCUEicp trial of delayed or secondary DC tients with moderately severe disability [8–11]. in patients with refractory intracranial hypertension (> In contrast, high-level evidence is unavailable for children. 25 mmHg) after severe TBI indicated lower mortality The only RCT in pediatric TBI suggested benefit of surgery without reaching statistical significance, and the surgical tech- nique differed from what pediatric neurosurgeons would now- adays consider a standard DC [12]. Data for DC in pediatric * Thomas Beez [email protected] stroke is limited to case series and anecdotal case reports [13–15]. To fill these evidence gaps, study results obtained from adult patients can only be extrapolated to children under a ca- 1 Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University, Moorenstrasse 5, veat: there are relevant differences in anatomy and physiology 40225 Düsseldorf, Germany between adults and children, as well as within the pediatric age 1518 Childs Nerv Syst (2019) 35:1517–1524 spectrum [16]. Additionally, a fixed point of outcome assess- ment as used in adults (e.g., after 12 months) might not ade- quately reflect impact of injuries or treatments on the develop- ing brain, which would require longitudinal observation. Current knowledge with regard to cranioplasty is based on low-level evidence in all age groups [17, 18]. Both autologous and alloplastic cranioplasties are associated with relevant complications. Outcome of autologous cranioplasty appears to be worse in children due to high rates of aseptic bone flap resorption. In the absence of reliable data on risk factors for failure of autologous implants, institutional protocols with re- gard to bone flap storage and timing of reimplantation vary significantly and no consensus exists. Pooling of published data is hampered by heterogeneous data elements and missing information. A recent systematic review on pediatric cranioplasty reported resorption rates between 20 and 80%, but almost 50% of publications do not explicitly state resorption rates [18]. Few studies provide long-term information reaching from craniectomy to cranioplasty, although both operations are closely related and relevant to overall morbidity and outcome. We therefore provide a detailed analysis of a well-documented single-cen- ter cohort of children undergoing DC and subsequent cranioplasty. Fig. 1 Morphometric measurements obtained in this study. a Maximum Methods fronto-occipital skull length was determined as an indicator of age- dependent skull size (red line). Maximum horizontal brain diameters were This retrospective study covering the years 2010–2018 was measured before (not shown) and after hemicraniectomy (green line) as a surrogate parameter of volume gain. b Maximum anterior-posterior (blue approved by the ethics committee (study no. 2019-415- line) and cranio-caudal (yellow line) diameters of hemicraniectomies RetroDEuA). We included patients aged less than 18 years were used to calculate the approximate decompression area at the time of DC. Radiological studies were retrieved and the following pa- rameters measured as presented in Fig. 1: maximum fronto- Results occipital skull length was determined as an indicator of age- dependent skull size. Maximum anterior-posterior (A)and Decompressive craniectomy cranio-caudal (B) diameters of hemicraniectomies were used to calculate approximate decompression areas (A × B). Fifteenchildren(meanage12years,range1–17) underwent Maximum horizontal brain diameters were measured before DC for TBI (N = 12), hemorrhage (N = 2), or ischemic stroke (C) and after (D) hemicraniectomy as surrogate parameters of (N = 1) within the study period (Table 1). We performed 9 volume gain (D − C). If bone flap resorption occurred, it was unilateral hemicraniectomies, 3 bilateral hemicraniectomies, classified according to the Oulu resorption score [19]. In the and 3 bifrontal craniectomies. Therapeutic pathways are sum- TBI subgroup, computed tomography (CT) characteristics marized in Fig. 2. The surgical aim was a large craniectomy were classified according to Rotterdam CT score [20]. with wide dural opening and expansion duroplasty, using a Outcome was categorized according to King’s Outcome xenogenic dural substitute (Tutopatch, Tutogen Medical Scale for Childhood Head Injury (KOSCHI) and GmbH, Germany). The standard procedure at our institution trichotomized into good outcome (KOSCHI 4 and 5), poor for a lateralized lesion is hemicraniectomy. Bilateral outcome (KOSCHI 2 and 3), and death (KOSCHI 1) [21]. hemicraniectomy was performed for either significant bilater- Statistical analysis was performed with GraphPad Prism al lesions (such as temporal contusions) or patients who de- (GraphPad Software, USA). Statistical significance was velop raised ICP or a new contralateral lesion after assessed using two-sided Student’s t test and bivariate corre- hemicraniectomy. Bifrontal DC was mainly performed for lation with Pearson correlation coefficient. global cerebral edema without lateralization, as reflected by Childs Nerv Syst (2019) 35:1517–1524 1519 the delayed timing of DC and absent midline shift in these patients (Table 1). Autologous bone flaps were cryoconserved at − 80 °C. The TBI subgroup comprised 12 children (7 boys, 5 girls, mean age 12 years) with mean initial GCS of 4 (range 3–7) and mydriasis prior to DC in 6 cases. Trauma mechanisms Last recorded KOSCHI at follow-up (months) 4b (120) 3a (2) 4b (96) 2 (21) 3a (2) 5a (60) 4b (18) 5a (18) 5a (14) 3a (8) 5a (84) were road traffic accidents (RTA) as a pedestrian/cyclist (N = 6), falls from large height (N = 3), RTA as a passenger (N =2),andviolence(N = 1). Median distance from the trau- ma scene to the tertiary care hospital was 19 km (range 4– 56 km). Nine patients were transported directly, and 3 patients were first admitted to secondary care hospitals and referred after initial survey and imaging. No invasive measures were performed at these hospitals. Additional injuries were present discharge in 11 children, mainly thoracic trauma. Initial CT findings were acute subdural hematoma (N = 9), traumatic SAH (N = 8), cerebral contusions (N = 6), skull fractures (N = 7), cerebral edema (N = 5), and signs of diffuse axonal injury (N =3). literated 1 (hemorrhagic shock) NA Ob Basal cisterns KOSCHI at initial Obliterated 3a Obliterated 1 (brain death) NA Obliterated 3a Obliterated 1 (brain death) NA Obliterated 3a Patent 1 (brain death) NA Obliterated 2 Obliterated 3a Obliterated 3a Patent 2 Obliterated 2 Obliterated 3a Obliterated 2 Mean midline shift was 6 mm (range 0–16) and basal cisterns
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