Editorial Comment

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Editorial Comment

The Underestimated Complication Rate of Decompressive Craniectomy in Pediatric Traumatic Brain Injury Aurelia Peraud1

Maximilians-University, Munich, Germany Neuropediatrics 2015;46:3–4.

Decompressive craniectomy for the treatment of refractory increased intracranial pressure (ICP) in pediatric traumatic brain injury is a common surgical procedure. It has been described already in the early years of neurosurgery and became popular in the 1970s. The enthusiasm subsided due to concerns with regard to clinical outcome. Since the 1990s, decompressive craniectomy experienced a renaissance, and numerous case series have been published mainly for the adult population. Several studies have now focused not only on outcome but also on the complication rate of decompressive craniectomy in pediatric traumatic brain injury.1 In comparison with adult patients, children exhibit some delicate characteristics, which may have an impact on further treatment decisions. In infants (up to the age of 1.5 years), the skull is still pliable and allows to expand to some extent due to the open cranial sutures. Thus, brain swelling may occur to a certain degree without significant elevation of the ICP. In contrast, in older children, the brain is more voluminous and has less compensatory reserve to tolerate increased ICP. With regard to brain maturation, myelinization will not be complete before the age of 18 to 24 months, thus making the brain of an infant more vulnerable and susceptible for significant damage after trauma. There is common agreement that children may benefit even more from decompressive craniectomy compared with adult patients especially with regard to long-term clinical outcome.2,3 On the other hand, decompressive craniectomy with duroplasty is a highly invasive procedure. Further surgical interventions may become necessary. Not only the reimplantation of the bone flap has to be considered, but occasionally a 

This editorial is a commentary on the article by Pechmann A, Anastasopoulos C, Korinthenberg R, van Velthoven-Wurster V, Kirschner J. Decompressive craniectomy after severe traumatic brain injury in children: complications and outcome. Neuropediatrics 2015;46(1):5–12

published online October 24, 2014

Address for correspondence Aurelia Peraud, MD, Oberärztin der Neurochirurgischen Klinik Klinikum Grosshadern Ludwig-MaximiliansUniversität Marchioninistrasse 15, D- 81377 München, Germany (e-mail: [email protected]).

ventriculo-peritoneal shunt for posttraumatic hydrocephalus or a drainage of subdural hygroma or hematoma become necessary. Other surgical complications include bone flap resorption and infection. In this issue, Pechmann et al report a cohort of 12 children who received decompressive craniectomies after traumatic brain injuries.4 The incidence of postoperative complications (up to 83%) is surprisingly high, but other reports support these findings. Bowers et al reported of a 50% rate of postimplantation bone flap resorption and described young age (

The underestimated complication rate of decompressive craniectomy in pediatric traumatic brain injury.

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