REPEATED DECOMPRESSIVE CRANIECTOMY AFTER HEAD-INJURY IN CHILDREN - 2 SUCCESSFUL CASES AS RESULT OF IMPROVED NEUROMONITORING

BACKGROUND Decompressive craniectomy in the treatment of posttraumatic brain swelling is not generally accepted. Until now the efficacy of o perative decompressive craniectomy in posttraumatic brain swelling of children appeared more promising. However, the criteria for such proce dures remain unclearly defined. METHODS We present two children who ha d repeated decompressive craniectomy following head injury, in order t o control intracranial pressure (ICP) sufficiently. Our indications fo r performing a decompressive craniectomy in the presence of conservati vely uncontrollable raised ICP are: (1) Patient is between the ages of 3 and 35 years. (2) An initial Glasgow Coma Scale (GCS) ranging betwe en 4 and 8. (3) Three criteria have to be fulfilled at the same time: The cerebral perfusion pressure (CPP) has to drop to values of less th an 60 mm Hg. it is impossible to control the ICP values (up to 45 mm H g) conservatively. The diastolic velocity of the transcranial doppler sonography (TCD) has to decrease until only a systolic flow pattern is obtained. (4) No other mass lesion should be detected on cranial comp uted tomography (CCT) that could account for the rise in pressure. In both cases we performed bifrontal decompressive craniectomies. RESULTS Both patients survived. Seven months after the accident, patient No. 1 was oriented and could walk on her own with a mild right-side hemipa resis. Patient No. 2 could attend school 12 months postinjury. Both pa tients developed hygromas after the craniectomy. A shunt operation, ho wever, was not necessary.CONCLUSIONS ICP monitoring, together with CCT examination, simultaneous recording of TCD, and systemic parameters, will reveal a patient at risk at a time when impending damage due to u ncontrollable ICP may still be prevented. The simultaneous assessment of cerebral blood flow by transcranial doppler (TCD), in this situatio n, proves most valuable. It improves the guidelines of patient selecti on for decompressive craniectomy, in the presence of conservatively un controllable ICP.