ORIGINAL ARTICLES Surgical treatment for ‘brain compartment syndrome’ in children with severe head injury A A Figaji, A G Fieggen, A Argent, J C Peter Objectives. Traumatic brain injury accounts for a high Outcome measures. Computed tomography (CT) scanning, ICP percentage of deaths in children. Raised intracranial pressure control, clinical outcome. (ICP) due to brain swelling within the closed compartment of Results. Despite the very poor clinical condition of these the skull leads to death or severe neurological disability if not children preoperatively, aggressive management of the raised effectively treated. We report our experience with 12 children pressure resulted in unexpectedly good outcomes. who presented with cerebral herniation due to traumatic brain Conclusion. Aggressive surgical measures to decrease ICP in swelling in whom decompressive craniectomy was used as an the emergency situation can be of considerable benefit; the emergency. key concepts are selection of appropriate patients and early Design. Prospective, observational. intervention. Setting. Red Cross Children’s Hospital. S Afr Med J 2006; 96: 969-975. Subjects. Children with severe traumatic brain injury and cerebral swelling. Compartment syndrome of the limbs or the abdomen is sustained at the moment of impact, it is now recognised that a well-known entity in general surgical and orthopaedic avoidance or early treatment of secondary insults can make a practice, characterised by an increase of pressure within dramatic difference to outcome in individual patients.2 Of these a musculofascial compartment leading to progressive secondary insults, raised ICP is the most widely recognised. neurovascular dysfunction. Although it has not been described Space-occupying traumatic haematomas causing raised as such, raised pressure within the intracranial compartment is ICP are readily removed via emergency craniotomy, thereby arguably the most dramatic example of the same pathological relieving pressure on the brain. However, when the aetiology principle, given the rigidity of the cranium and the importance of raised ICP is swelling of the brain itself, the management of its contents. When increasing intracranial volume exceeds becomes much more challenging. Medical treatment remains the compensatory capacity of the brain, the ensuing rise of suboptimal and despite the promise of pharmacological intracranial pressure (ICP) leads to brain herniation and research to interrupt the biochemical cascades that occur in cerebral ischaemia. If no intervention is forthcoming, severe severe brain trauma, nothing has been developed as yet that neurological injury or death is inevitable as a consequence of prevents the development of traumatic brain swelling in what is, in essence, a ‘brain compartment syndrome’. humans. In South Africa, traumatic brain injury (TBI) is common Decompressive craniectomy has been used in various and probably represents an under-appreciated reality in our forms, and for various indications, to manage the problem of society. Traumatic injury accounts for most deaths in children increased pressure within the intracranial compartment. The 1 in the 5 - 15-year-old age group. Motor vehicle accidents, rationale for the operation is intuitive – the removal of a section falls and assaults are common causes of injury in children of the cranium enlarges the available space for brain swelling and it is usually the severity of the head injury sustained that and reduces the contained pressure therein, thereby preventing determines the eventual outcome. Of those who survive severe cerebral herniation and allowing blood flow to return to the TBI, many are left neurologically disabled, placing a significant brain. Yet despite the apparent simplicity of the principle, it has burden on the immediate family and State resources. Although remained controversial primarily because of concern regarding there is little one can do once the primary injury has been its effectiveness. However, careful analysis of the reported data reveals likely reasons for the lack of demonstrable benefit in Divisions of Paediatric Neurourgery and Paediatric Critical Care, School of Child the earlier literature on the subject. and Adolescent Health, University of Cape Town, and Red Cross War Memorial Children’s Hospital, Rondebosch, Cape Town In our experience with severe traumatic brain injury (TBI) 969 A A Figaji, MB ChB, Dip Obstet, FCS (Neurosurgery), MMed in children, the use of decompressive craniectomy in carefully A G Fieggen, BSc, MB ChB, MSc, FCS (Neurosurgery) selected patients with brain swelling has produced dramatic A Argent, MB BCh, OCH, MMed, FCP ICP control in patients thought to be herniating. Given the J C Peter, MB ChB, FRCS (Neurosurgery) severity of the clinical problem, the outcome in this series is surprisingly favourable. In this study we update our early Corresponding author: A Figaji (afi[email protected]) September 2006, Vol. 96, No. 9 SAMJ ORIGINAL ARTICLES results3 with a larger number of patients and long-term patients who had both pre- and postoperative ICP monitoring. follow-up. Based on our experience and increasing numbers This was calculated from the difference between the mean of favourable reports from other centres, we believe that the preoperative ICP readings averaged over 5 hours and the mean key to the optimal use of the procedure is the identification of postoperative ICP over 10 hours. The first 6 hours of readings suitable patients, early intervention and the adequate technical in the postoperative period were excluded from analysis to performance of the operation. avoid the potential confounding effect of general anaesthesia in lowering ICP. A longer period for analysis of postoperative Methods and materials readings was chosen to take into account possible later rises in ICP. Patients were identified from a prospectively collected database of decompressive craniectomy operations performed Outcome for traumatic brain swelling (without haematomas) from September 1999 to September 2005. Collected data included Follow-up for survivors was conducted prospectively at the (among others): mechanism of injury, initial clinical assessment, neurosurgical clinic with a minimum follow-up period of 1 radiological findings, ICP readings, neurological deterioration, year; the median duration of follow-up was 35 months (range extracranial injury, timing of the operation, technical details 1 - 6 years). All survivors had a favourable outcome: 6 patients of the operation, change in postoperative ICP readings and had a Glasgow Outcome Score (1 to 5) of 4, and 5 patients radiological findings, and clinical outcome. Outcome was had a score of 5. One patient developed bone flap sepsis after reported based on clinical assessment at the last neurosurgical the bone had been replaced, which required removal of the clinic visit and school reports. Craniectomy usually entailed flap. Another demonstrated slight subsidence of the flap at removing a large part of the hemicranium ipsilateral to the follow-up. Asymptomatic subdural hygromas were observed side of most severe swelling, although in three cases bifrontal in 2 patients. Long-term behavioural disturbances and mild craniectomy was done where both hemispheres were equally cognitive deficits were relatively common (Table I). swollen. Expansion of the dura was achieved by the insertion of a dural graft. Discussion The use of decompressive craniectomy for the relief of Results intracranial hypertension was originally described by Kocher Twelve patients had decompressive craniectomy performed for in 1905. Since then, its use in trauma has been surrounded post-traumatic brain swelling. All had radiological evidence by controversy. The debate is largely centred on the issue of of brain swelling with obliteration of the basal cisterns on whether it is of clinical benefit in TBI, and therefore, whether preoperative computed tomography (CT) imaging. In 11 its use justifies the additional effort and risk that the operation patients there had been a documented secondary deterioration may entail. There are also concerns about potential adverse in neurological status or refractory rise in ICP that prompted consequences of cranial decompression, such as the possibility the decision to operate (Table I). The combination of the of increasing cerebral oedema beneath the bone flap, which radiological appearance of obliterated perimesencephalic may further exacerbate the problem of raised ICP and cisternal spaces, the clinical signs and acute secondary compromise tissue perfusion. deterioration was consistent with cerebral herniation. One patient had previously had an extradural haematoma taken Exacerbation of cerebral oedema out via craniotomy, after which he recovered but went on In theory, brain tissue that is compressed may develop to develop secondary deterioration with brain swelling. All increased oedema when the transmural hydrostatic pressure of these patients underwent surgery within 12 hours of this gradient is reduced by craniectomy, thereby favouring deterioration. In the one exception, there was no secondary enhanced vasogenic oedema.4 Of the experimental data deterioration – the decision to operate was made on the reported, the results from Hatashita et al.5 are of particular grounds of the poor clinical condition at the outset, swollen interest. These investigators studied 4 groups of cats – 1 brain on CT, and elevated ICP. This was the only patient who control group and 3 treatment groups which were subjected