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17-11-2011 | Surgery | Article

Decompressive craniectomy could benefit children with brain swelling


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MedWire News: Decompressive craniectomy may improve outcomes in children with brain swelling, regardless of the underlying cause, say researchers.

Decompressive craniectomy is considered a life-saving procedure in adults with elevated intracranial pressure (ICP) due to conditions such as trauma, intracranial bleeding, and cerebral ischemia.

There has so far been just one randomized trial of decompressive craniectomy in children, and this trial took 7 years to recruit just 27 patients. It found that decompressive craniectomy was associated with a nonsignificant increase in the rate of favorable outcomes.

"However, craniectomy was performed by removal of small bitemporal bone flaps rather than a large craniectomy and with no attempt to open the dura," say Erdem Güresir (Johann Wolfgang Goethe-University, Frankfurt, Germany) and team.

"Because studies analyzing the expansion after [decompressive craniectomy] have shown that a large craniectomy with dural opening is necessary to maximize the benefit of [decompressive craniectomy], one can speculate that outcomes might have been better with a more definitive decompression."

For their study, Güresir et al therefore focused on cases involving large decompressive craniectomy with dural opening. They identified 34 such patients (aged 0-18 years) from the records of their own institution and a further 138 from the literature.

Overall, 62% of patients had a favorable outcome, the team reports in the journal Neurosurgery.

The underlying cause of high ICP did not appear to influence the impact of decompressive craniectomy, with favorable outcomes achieved in 69% of 36 patients with traumatic brain injury and 60% of 136 who underwent decompressive craniectomy for other reasons.

Clinical signs of herniation were recorded for 100 children. The presence and severity of herniation tended to be related to outcome, albeit nonsignificantly, with 73% of patients with no signs of herniation achieving a favorable outcome, compared with 60% of those with unilaterally dilated pupils and 45% of those with bilaterally dilated pupils.

But overall the rate of favorable outcomes in children with herniation was high, compared with in previous studies. The researchers suggest that this could be due partly to publication bias, with unfavorable results being less likely to be published than favorable ones.

"Hence, careful individual decision making is needed for each patient when signs of cerebral herniation are present, especially when they [have] persisted for a long time," concludes the team.

By Eleanor McDermid

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