• Bettina Ruf, Matthias Heckmann, Ilona Schroth, Monika Hügens-Penzel, Irwin Reiss, Arndt Borkhardt, Ludwig Gortner, and Andreas Jödicke.
• Department of Pediatrics, University Medical Centre, Justus-Liebig-University, Giessen, Germany. bettina.ruf@paediat.med.uni-giessen.de
• Crit Care. 2003 Dec 1;7(6):R133-8.

IntroductionSevere traumatic brain injury (TBI) in childhood is associated with a high mortality and morbidity. Decompressive craniectomy has regained therapeutic interest during past years; however, treatment guidelines consider it a last resort treatment strategy for use only after failure of conservative therapy.PatientsWe report on the clinical course of six children treated with decompressive craniectomy after TBI at a pediatric intensive care unit. The standard protocol of intensive care treatment included continuous intracranial pressure (ICP) monitoring, sedation and muscle relaxation, normothermia, mild hyperventilation and catecholamines to maintain an adequate cerebral perfusion pressure. Decompressive craniectomy including dura opening was initiated in cases of a sustained increase in ICP > 20 mmHg for > 30 min despite maximally intensified conservative therapy (optimized sedation and ventilation, barbiturates or mannitol).ResultsIn all cases, the ICP normalized immediately after craniectomy. At discharge, three children were without disability, two children had a mild arm-focused hemiparesis (one with a verbal impairment), and one child had a spastic hemiparesis and verbal impairment. This spastic hemiparesis improved within 6 months follow-up (no motor deficit, increased muscle tone), and all others remained unchanged.ConclusionThese observational pilot data indicate feasibility and efficacy of decompressive craniectomy in malignant ICP rise secondary to TBI. Further controlled trials are necessary to evaluate the indication and standardization of early decompressive craniectomy as a 'second tier' standard therapy in pediatric severe head injury.

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