Beuriat P A, Javouhey E, Szathmari A, Courtil-Tesseydre S, Desgranges F P, Grassiot B, Hequet O, Mottolese C
Pediatric Neurosurgical Unit Neurological Hospital Pierre Wertheimer, Lyon, France -
J Neurosurg Sci. 2015 Dec;59(4):405-28. Epub 2015 Mar 10.
Decompressive craniotomy (DC) in children is a life-saving procedure for the treatment of refractory intracranial hypertension related to traumatic, ischemic and infectious lesions. Different surgical procedures have been proposed including uni or bilateral hemicraniectomy, bi-frontal, bi-temporal, or bi-parietal craniotomies. DC can avoid the cascade of events related to tissue hypoxia, brain perfusion reduction, hypotension and the evolution of brain edema that can be responsible for brain herniation. The monitoring of intracranial pressure (ICP) is very important to take a decision as well as the value of Trans cranial Doppler (TCD). Repeated TCD in the intensive care unit give important information about the decrease of the cerebral perfusion pressure (CPP) and facilitates the decision making. The important question is about how long time we have to wait before to perform the DC. Three conditions can be distinguished: 1) ICP stable and TCD with good parameters: the decision can be postponed; 2) ICP>20 mmHg with good TCD and without clinical signs of deterioration: the decision can be postponed; 3) ICP>20 mmHg with altered CPP and degraded TCD value and clinical signs of brain herniation: the surgical procedure is indicated. The decision of a ventricular drainage can also be discussed but in cases of slit ventricles it is preferable to realize a DC to avoid the problems of multiple taps without finding the ventricular system. In some very specific situations, DC has to be contraindicated. The first one is a prolonged cardiopulmonary arrest with a no-flow longer than 15 minutes and irreversible lesions on the TCD or on the CT-scan. The second most common situation is a patient with GCS of 3 on admission associated with bilaterally fixed dilated pupils. In this case TCD is very useful to document the decrease or the absence of diastolic flux that indicates a very poor cerebral perfusion. In case of severe polytraumatism with multiorgan failure, especially in very severe hemorrhagic shock with incontrollable coagulopathy, the realization of DC is definitely hazardous with y a high risk of cardiac arrest during the surgical procedure. The decision to realize a hemicraniectomy or a bi-frontal craniotomy is related to the presence or not of associated traumatic lesions as hemorrhagic contusions or a sub-dural or extradural hematoma. In cases of diffuse cerebral edema the bi-frontal bone flap is indicated. In all cases a closure of the dura mater with a large dural patch has to be performed avoiding compression of the nervous system. Our results showed a mortality rate of 18%. Eighty percent of the survivors have a good quality of life but only 43% in a scholar age could attend a normal program. Patients treated with DC need a long follow-up and an important rehabilitation program to improve their quality of life. Our report shows that DC in children is effective to control the post-traumatic intracranial hypertension but a long follow-up is recommended to access the sequels and quality of life of these patients.
儿童减压性颅骨切除术（DC）是一种挽救生命的手术，用于治疗与创伤性、缺血性和感染性病变相关的难治性颅内高压。已经提出了不同的手术方法，包括单侧或双侧颅骨切除术、双额、双颞或双顶骨开颅术。DC可以避免与组织缺氧、脑灌注减少、低血压以及可能导致脑疝的脑水肿进展相关的一系列事件。颅内压（ICP）监测对于做出决策非常重要，经颅多普勒（TCD）的数值也是如此。在重症监护病房重复进行TCD可以提供有关脑灌注压（CPP）降低的重要信息，并有助于决策。重要的问题是在进行DC之前我们要等待多长时间。可以区分三种情况：1）ICP稳定且TCD参数良好：可以推迟决策；2）ICP>20 mmHg，TCD良好且无临床恶化迹象：可以推迟决策；3）ICP>20 mmHg，CPP改变，TCD值下降且有脑疝临床迹象：建议进行手术。也可以讨论脑室引流的决策，但在裂隙脑室的情况下，最好进行DC以避免多次穿刺找不到脑室系统的问题。在一些非常特殊的情况下，DC必须列为禁忌。第一种情况是长时间心肺骤停，无血流时间超过15分钟，TCD或CT扫描有不可逆病变。第二种最常见的情况是入院时格拉斯哥昏迷评分（GCS）为3分且双侧瞳孔固定散大的患者。在这种情况下，TCD对于记录舒张期血流减少或消失非常有用，这表明脑灌注非常差。在严重多发伤伴多器官功能衰竭的情况下，尤其是在严重失血性休克伴无法控制的凝血病时，进行DC肯定是危险的，手术过程中有很高的心脏骤停风险。决定进行半颅骨切除术或双额开颅术与是否存在相关创伤性病变有关，如出血性挫伤或硬膜下或硬膜外血肿。在弥漫性脑水肿的情况下，建议采用双额骨瓣。在所有情况下，都必须用大的硬脑膜补片进行硬脑膜缝合，避免压迫神经系统。我们的结果显示死亡率为18%。80%的幸存者生活质量良好，但学龄期患者中只有43%能够参加正常课程。接受DC治疗的患者需要长期随访和重要的康复计划来提高他们的生活质量。我们的报告表明，儿童DC对于控制创伤后颅内高压是有效的，但建议进行长期随访以了解这些患者的后遗症和生活质量。
