Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury

Introduction: We compared the effect of early decompressive craniectomy (< 24 h) vs non-operative treatment on the outcome of children with refractory intracranial hypertension after severe traumatic brain injury. Material and methods: We retrospectively reviewed 12 consecutive patients treated between 1999 and 2001 for refractory intracranial hypertension after isolated severe head injury without any intracranial haematomas. In all patients, treatment included sedation, paralysis and IV mannitol under intracranial pressure monitoring. Early decompressive craniectomy was carried out in six patients (mean age: 13 years) at mean time from injury of 7 h (range: 2-18 h), whereas six patients (mean age: 11.5 years) were managed with non-operative treatment. The Marshall Grading system was used to score the severity of radiological abnormalities in CT scans. The Glasgow Outcome Scale (GOS) at 1-year follow-up was used as outcome measure. Results:The mean Marshall grade was 3 in the craniectomy group and 2 in the non-operative group. All patients in the craniectomy group survived: four patients scored 5 and two patients scored 4 on the GOS. In the non-operative group, two patients (33%) died, one of whom received late decompressive craniectomy at 9 days, while three patients scored 5 and one patient scored 3 on the GOS. Conclusion: In children who suffered severe head injury with refractory intracranial hypertension without intracranial haematoma, early decompressive craniectomy employed in the first few hours after injury before the onset of irreversible ischaemic changes may be an effective method to treat the secondary deterioration that commonly leads to death or severe neurological deficit.