J Korean Neurosurg Soc.  2012 Feb;51(2):86-90. 10.3340/jkns.2012.51.2.86.

Decompressive Hemicraniectomy and Duroplasty in Toddlers and Preschool Children with Refractory Intracranial Hypertension after Unilateral Hemispheric Stroke

• Lee SK
• Kim SD
• Kim SH
• Lim DJ
• Park JY

• KMID: 1441415
• DOI: http://doi.org/10.3340/jkns.2012.51.2.86

Abstract

OBJECTIVE
Life-threatening hemispheric stroke is associated with a high mortality and morbidity. Decompressive hemicraniectomy has been regarded as an effective treatment option for refractory intracranial hypertension. Here, we reported the clinical course of 5 children with decompressive craniectomy and duroplasty after non-traumatic refractory intracranial hypertension.
METHODS
Four toddlers and one preschool-girl were included in this study; there were 3 boys and 2 girls with a mean age of 34.6 months (range 17-80). Decompressive craniectomy including duroplasty was performed in cases of dilatation of pupil size after intensified standard medical therapy had proven insufficient. All children had a Pediatric Glasgow Coma Scale score <8 at pre-operation state. The mean time-point of craniectomy after stroke attack was 12 hours (range 4-19).
RESULTS
During the long-term follow-up period (mean 47.6 months), no children died. One year later, when we checked their Glasgow Outcome Scale scores, only one toddler received a score of 4 (moderate disability). But the others had good recoveries although they had minor physical or mental deficits. According to the Pediatric Cerebral Performance Category Scale, 4 children received a score of 2 (mild disability).
CONCLUSION
Despite our small cases, we suggest that decompressive hemicraniectomy and duroplasty is an acceptable and life-saving treatment for refractory intracranial hypertension after unilateral hemispheric stroke in toddlers and preschool children.

Keyword

Decompressive craniectomy; Stroke; Pediatric; Outcome

MeSH Terms

Child
Child, Preschool
Decompressive Craniectomy
Dilatation
Follow-Up Studies
Glasgow Coma Scale
Glasgow Outcome Scale
Humans
Intracranial Hypertension
Pupil
Stroke

Figure

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  Fig. 1 A : Non enhanced brain CT revealed an acute right-sided middle cerebral artery territory infarct with mass effect manifested as right lateral ventricular compression, attenuation of the basal cisterns and right convexity sulci effacement. Because of midline shift due to severe brain parenchymal swelling, posterior horn of lateral ventricle was not seen. And hemorrhagic transformation was also noted at same side area. B and C : DWI MRI scan of his brain revealed that lesion was appropriate for acute cerebral infarction with hemorrhagic transformation with significant mid-line shift. CT : computed tomography, DWI : diffusion weighted image, MRI : magnetic resonance imaging.

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  Fig. 2 Brain CT at the time of post-operative 7 days revealed sustained brain swelling with decompressive craniectomy, but midline shift did not noted anymore.

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  Fig. 3 Three years later, there was encephalomalasic change in right-sided middle cerebral artery territory. The bone flap was secured.

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