Case Report
Pediatr Neurosurg 2009;45:390–395
DOI: 10.1159/000260910

Received: March 25, 2009
Accepted after revision: July 20, 2009
Published online: November 26, 2009

Bilateral Decompressive Craniectomy for
Refractory Intracranial Hypertension in a
Child with Severe ITP-Related Intracerebral
Haemorrhage
Adrianna Ranger a Artur Szymczak a Douglas Fraser b Marina Salvadori c
Lawrence Jardine d
Departments of a Pediatric Neurosurgery, b Pediatric Intensive Care, and c Pediatric Infectious Diseases, and
d
Division of Pediatric Oncology, London Health Sciences Center, London, Ont., Canada

Abstract
We report a 13-month-old infant who developed acutely elevated intracranial pressure (ICP) as a result of a spontaneous intracerebral haemorrhage (ICH), secondary to idiopathic thrombocytopenic purpura (ITP). Her ICP remained se verely elevated despite aggressive medical measures, with
persistent obtundation, right hemiparesis and a dilated left
pupil. Bilateral decompressive craniectomies (DCs) were
performed, which resulted in a rapid decline in ICP. Ultimately, the patient regained consciousness and went on to complete neurological recovery. Tragically, she died of non-neurological, ITP-related complications 9 months later. In our
review, we identified no other instances of bilateral DCs reported in the management of an infant with ITP and/or an
ICH. We addressed three central questions: (1) Is there any
value of DCs in children, and especially in infants, with elevated ICP? (2) Is there any value of DCs in the setting of nontraumatic ICH? And (3) is there any rationale for the use of
bilateral versus unilateral DCs?

Introduction

Among the first decompressive craniectomies (DCs)
ever performed were those reported in the literature in
1906, when they were being used as a palliative measure
in patients with tumours of the brain [1]. By the 1970s,
DCs were being utilized in the management of elevated
intracranial pressures (ICPs) in patients who had sustained major head trauma [2, 3]. A subsequent comparison, published in 1997 by Polin et al. [4], of surgically
treated patients versus patients in a control database revealed that those who had surgery within 48 h of their
trauma and whose ICP never rose above 40 Torr experienced clearly superior outcomes compared to controls.
More recently, the surgical management of patients with
elevated ICP following brain trauma has become commonplace [5], and numerous other reports have commented on the results obtained in a variety of different
patient groups and in a variety of clinical settings. Though
the majority of patients in these reports underwent DCs
because of increased ICP resulting from head trauma [6–
11], some patients have had other reasons for elevated
ICP, including spontaneous intracerebral or subarachnoid haemorrhages from ruptured intracerebral vessels/
aneurysms [12–16], cerebral venous and dural sinus

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Adrianna Ranger
Children’s Hospital, London Health Sciences Center
800 Commissioners Road East, Room E6-315
London, ON N6A 5W9 (Canada)
Tel. +1 519 685 8107, Fax +1 519 685 8171, E-Mail aranger@uwo.ca

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Key Words
Decompressive craniectomy â´¢ Idiopathic
thrombocytopenic purpura â´¢ Intracerebral haemorrhage â´¢
Intracranial pressure, infant

thrombosis [17], bacterial and viral encephalitis and meningo-encephalitis [18–22], and intracranial hypertension during acute posttraumatic liver dysfunction [23].
As with DCs following brain trauma [24], the vast majority of the patients in these other reports were adults. In
fact, among those patients reported with spontaneous intracranial haemorrhages who had undergone DCs, all
were at least 18 years of age [12–16].
Idiopathic thrombocytopenic purpura (ITP) is a poorly understood condition that has been described worldwide and affects all ages, including children [24–27]. In
more than one epidemiological study, it has been shown
to be particularly prevalent in younger children, including infants under 2 years old [24–27]. Management varies
with the severity of platelet count depression and symptoms, but not uncommonly includes immunosuppressive
therapy and/or splenectomy. Intracranial haemorrhages
comprise a particularly severe complication in a small
percentage [27–31], and some of these patients die [28–
31]. To date, there have been no reports of decompressive
procedures having been performed on infants with ITP
or any other non-traumatic cause of elevated ICP.
Consequently, we present a 13-month-old infant who
developed acutely elevated ICP as a result of a spontaneous intracerebral haemorrhage (ICH), secondary to ITP,
whose ICP remained severely elevated despite aggressive
medical measures, and whose clinical status included being obtunded and having right hemiparesis and a dilated
left pupil. A decision was made to proceed to emergent
DC. We then review the pertinent medical literature.

Fig. 1. Non-enhanced axial CT head scan revealing left rolandic
acute ICH with midline shift.

Fig. 2. Non-enhanced axial CT head scan 6 months later showing

The Institutional Review Board has approved the publication
of this case. The patient was a 13-month-old girl who presented
to the emergency department of the Children’s Hospital, London
Health Sciences Centre, a tertiary-care university-based medical
centre. She was brought to hospital by her parents after they had
noticed that she was bleeding from her gums and had bruising
over her skin. Initial evaluations in the hospital revealed her
to be severely thrombocytopenic, with a platelet count of only
3.0 ! 109 cells/l (normal 150–400 ! 109). A subsequent work-up
initially established a diagnosis of ITP.
While in hospital for work-up and management of her ITP, she
became progressively and rapidly irritable, then drowsy, and then
hemiparetic on her right side, accompanied by a dilated left pupil.
Computed tomography (CT) revealed a 6-cm acute ICH involving the left rolandic region, accompanied by extensive surrounding oedema and a midline shift (fig. 1). Aggressive management
was initiated, which included initiation of intravenous mannitol
and placement of an external ventricular drain after platelet infusion; however, the patient continued to exhibit severely elevated

Bilateral Craniectomies in an Infant
with ITP

resolution of haemorrhage and mass effect following bilateral
DC.

ICP, on one occasion as high as 40 mm Hg. Because of this persistent elevation and her persistent obtundation, the decision was
made to perform an emergent DC with removal of initially a large
left convexity bone flap encompassing the frontal, temporal and
parietal regions and expansion duraplasty utilizing fascia lata.
ICP was immediately normalized, but within 12 h became similarly elevated and refractory to ongoing medical measures,
prompting return to the operating room for a right-sided large
convexity bone flap removal. We elected to remove large bone
flaps only, but not to evacuate the intracerebral haematoma, because of profoundly low platelet counts with risks of intra- and
postoperative bleeding. A splenectomy was considered but not
performed, due to the concern about the risk of bleeding, the desire to minimize the number of surgical interventions and the
possibility that her platelet count might recover spontaneously.

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Case Report

Discussion

The underlying purpose behind the various DC procedures is to minimize or eliminate whatever secondary
damage to the brain is caused by elevated ICP, irrespective of the primary cause of that pressure elevation. This
secondary damage is the result of a sequence of events
that can include: disruption of the normal regulation of
cerebral inflow and outflow, often resulting in cerebral
hyperaemia; increased transmural pressure in capillary
beds causing tissue hypoxia, elevated levels of CO2 and a
reduction in extravascular fluid resorption; tissue acidosis; metabolic dysfunction; microthrombus formation;
secondary inflammation, and damage to the blood-brain
barrier, all of which increase cerebral oedema and cause
further increases in ICP [32–43]. The brain of a child, and
particularly of a young child, may be particularly susceptible to these pathophysiological changes. For example,
Aldrich et al. [44] found that diffuse brain swelling was
twice as common in those under 16 years old as in adults.
Child brains also exhibit an increased propensity for
apoptosis, age-dependent parameters for cerebral blood
flow and metabolism, development-specific biomarkers,
the increased likelihood of early posttraumatic seizures,
differential sensitivity to commonly used neuro-active
medications and altered neuroplasticity during recovery
from injury [45]. On the other hand, the brain of a child
also appears to possess the greatest potential for recovery
from injury so that children with severe brain injuries
tend to have better overall outcomes than their adult
counterparts [44, 46–49].
Our patient was 13 months old when she developed
markedly and persistently elevated ICP to as high as 40
392

Pediatr Neurosurg 2009;45:390–395

mm Hg, along with a decreased level of consciousness,
hemiparesis and a dilated pupil. Bilateral DCs resulted in
the rapid normalization of pressures, almost immediate
clinical improvement and an ultimate return to good
neurological function. This case consequently raises a
few essential questions: (1) Is there any value of DCs in
children, and especially in infants, with elevated ICP? (2)
Is there any value of DCs in individuals whose elevated
ICP is the result of a non-traumatic intracranial haemorrhage? And (3) is there any rationale for the use of bilateral versus unilateral DCs?
To address the first question, only two randomized
clinical trials have been published that have compared
DCs against the non-surgical management of elevated
ICP in children, and both were performed in children
whose elevated ICP was the result of trauma [50, 51]. In
one study, recruitment was limited to children who were
over 12 months of age at the time of surgery. Fourteen
children who received standard medical management
were compared with 13 who received bitemporal DCs
within 6 h of randomization. Relative to a non-surgical
approach, surgical management resulted in a decrease in
ICP and cerebral perfusion pressure that either achieved
(p ! 0.05) or approached (p = 0.057) statistical significance, despite the small sample size. More importantly, an
overall favourable outcome was evident in 54% in the surgery versus just 14% in the control group (p = 0.046). Josan
and Sgouros [51] performed a smaller study, with 6 patients in each group, the age range in the DC group being
2–16 years, but with 5 of the 6 patients being teenagers. In
the DC group, all had pre-operative ICPs between 22 and
35 mm Hg, and all pressures were maintained below 15
mm Hg postoperatively. Moreover, at the 1-year followup, 4 of 6 exhibited full recovery, with the remaining 2
patients having a score of 4 on the Glasgow Outcome Scale
and only requiring continued psychological support. In
comparison, 2 of the 6 patients (age range 7–15 years) who
did not undergo surgical decompression died, 1 continued to have cognitive and memory deficits and a Glasgow
Outcome Scale score of 3, and 3 achieved full recovery.
Otherwise, there have been several case series and case
reports of children who had undergone DCs during the
management of traumatic brain injuries. Dam Hieu et al.
[49] reported in 1996 on their experience performing a
wide frontotemporal DC on an 8-year-old boy with ICP
as high as 90 Torr, and a unilateral frontal DC on an 8year-old girl whose ICP rose as high as 120 Torr; both
returned to school with minimal to no residual neurological deficits within about 6 months. Similarly, in 2002,
Hejazi et al. [52] reported complete recovery in 7 youths,
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Jardine

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The patient received blood products intra-operatively to maintain a safe platelet count and remained intubated and sedated for
transfer back to the paediatric critical-care unit. Following bilateral bone flap removal, ICPs were much reduced and ultimately
normalized. The patient subsequently regained full consciousness and experienced resolution of all observed neurological deficits. Six months postoperatively, she had recovered the use of her
right-sided extremities, and her neuro-imaging revealed resolution of the haemorrhage (fig. 2). Daily transfusions of platelets
were required for 4 months; however, she also went on to develop
leukopenia and anaemia so that a diagnosis of aplastic anaemia
was ultimately made. She was considered for bone marrow transplantation. Her bone flaps were never replaced, since she was
deemed too medically fragile to undergo surgery, and there was
an ongoing risk that she might develop osteomyelitis in the bone
flaps. Tragically, she died 9 months later, due to complications
related to her aplastic anaemia, which included severe sepsis and
multi-organ failure.

successful results with bifrontal DC in 2 young adult
males who had sustained rupture of the anterior communicating artery. Finally, Kim et al. [53] conducted a retrospective study in which adult patients with different neurological conditions were compared – 28 with a severe
traumatic brain injury, 24 with a large ICH and 23 patients with major cerebral infarctions. Patients with a cerebral infarct were the least likely to have a favourable
outcome.
As for the third question, addressing the issue of unilateral versus bilateral DC, no formal comparisons have
been published. In a very recent report, in which 7 infants
with non-accidental head trauma presented with cerebral
oedema, coma and unilateral hemiparesis, unilateral DC
was used, with all 7 patients surviving with reasonably
good outcomes at the follow-up [54]. Otherwise, in several series, both procedures have been used, the choice of
procedure depending upon the clinical scenario [6, 51,
55]. In still others, the surgical details provided are inadequate to determine, with certainty, which approach was
utilized. In those reports in which bilateral DCs were
used exclusively, the results appear to be comparable to
those achieved in other reports [4, 15, 16, 24, 50, 53, 56].
Three of these reports were exclusive to paediatric patients [24, 32, 50].
Returning, therefore, to the three questions posed earlier. First, is there any value of DC in children, and especially in infants, with elevated ICP? The answer is that
there have been at least 30 children and adolescents reported in whom DCs have been used to control ICP, almost exclusively related to trauma, but there have been
no clinical trials and no reports in infants as young as our
own. Second, is there any value of a DC in individuals
whose elevated ICP is the result of a non-traumatic intracranial haemorrhage? The answer here is that there have
been studies and case series, but exclusively in adults. The
results appear to show that DCs have a role in the management of intractably elevated ICP in such patients, with
some patients surviving and some even having a good
outcome, who otherwise had been expected to expire, be
severely disabled or remain vegetative. Moreover, early
decompression seems to yield a better outcome than waiting beyond 48 h. Third and finally, is there any rationale
for the use of bilateral versus unilateral DC? To date, no
comparative studies have been published. Overall, the
choice of which procedure to use seems to be based on
surgeon preference and the clinical scenario.
A final question that might be asked is whether other
options exist, besides non-surgical management and DC,
which might have been utilized in our infant. Perhaps, for

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between the ages of 5 and 14 years, who had presented
with decorticate posturing and initial ICPs between 46
and 55 mm Hg, and who underwent unilateral DC. And,
in 2005, Reithmeier et al. [24] reported complete recovery
after motor vehicle brain injury in a 10-year-old girl who
had initially responded to evacuation of a subdural haematoma, but subsequently developed markedly elevated
ICP to 60 mm Hg and coma and responded to bilateral
frontotemporal DC with additional dural enlargement.
All these results are in stark contrast to the disappointing
results reported by Venes and Collins [2] in 1975, at which
time only 1 of 7 paediatric patients had a favourable outcome, suggesting that outcomes have improved over the
years, at least in children, 5 years old and older, who sustained brain trauma.
To address the second question, with one exception,
only in adults have the results of DC been assessed in individuals with non-traumatic elevations in ICP, and the
one ‘exception’ was an 18-year-old male [12] who was one
of 73 patients with spontaneous intraparenchymal haematomas included in a single study. In that study, the only
controlled study of DC versus no DC, Dierssen et al. [12]
retrospectively compared 73 adults who had had an ICH
and underwent a DC versus 54 patients who underwent
surgical removal of the clot alone: they identified a statistically reduced rate of mortality among patients with
acute haemorrhages that required surgery within 24 h.
Overall, 33% of the patients undergoing DC died, 36%
recovered completely, 10% resumed normal social activities, but did not return to work, 16% recovered partially,
but required assistance with self-care, and 5% remained
in a vegetative state. The only outcome detail provided
regarding the 18-year-old patient is that he did not die.
Otherwise, between 1993 and 2004, Otani et al. [13] treated 110 adult patients, 35–77 years old, with grade IV or V
aneurysmal subarachnoid haemorrhage, in whom 57
with either a large ICH or a sylvian haematoma underwent DC. Final outcomes were good recovery in 14%,
moderate recovery in 23%, severe disability in 28%, vegetative state in 14% and death in 21%, though patients
with grade IV lesions appeared to do better. Schirmer et
al. [14] published the results of their DC and duroplasty
procedures on 16 adult patients, aged 28–70 years, all
with intractable intracranial hypertension after an aneurysmal subarachnoid haemorrhage. Postoperative ICP
more than halved; 69% survived and 64% were deemed,
at the long-term follow-up, to have had a good outcome.
Moreover, early decompression yielded a better outcome
than delaying beyond 48 h after the subarachnoid haemorrhage (p ! 0.01). Scozzafava et al. [15] reported on their

example, the left-sided intracerebral clot could have been
removed via a minimally invasive approach with simultaneous rapid correction of the platelet abnormality; concerns about the proximity of the motor strip could be
lessened by performing a neuronavigation-guided crani-

otomy. However, even less evidence exists supporting this
approach than for DC, and some of that evidence is unfavourable [12]. Moreover, given our child’s rapidly worsening state, we chose to be aggressive; a decision that ultimately seems to have been the correct one.

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