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 Copyright © 2009 S. Karger AG, Basel © 2009 S. Karger AG, Basel 1016–2291/09/0455–0390$26.00/0 Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/pne 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 Downloaded by: Claude Moore Health Sciences Lib - Univ of Virginia 128.143.23.241 - 9/27/2013 5:40:18 PM Key Words Decompressive craniectomy ⴢ Idiopathic thrombocytopenic purpura ⴢ Intracerebral haemorrhage ⴢ 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. Pediatr Neurosurg 2009;45:390–395 391 Downloaded by: Claude Moore Health Sciences Lib - Univ of Virginia 128.143.23.241 - 9/27/2013 5:40:18 PM 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, Ranger /Szymczak /Fraser /Salvadori / Jardine Downloaded by: Claude Moore Health Sciences Lib - Univ of Virginia 128.143.23.241 - 9/27/2013 5:40:18 PM 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 Bilateral Craniectomies in an Infant with ITP Pediatr Neurosurg 2009;45:390–395 393 Downloaded by: Claude Moore Health Sciences Lib - Univ of Virginia 128.143.23.241 - 9/27/2013 5:40:18 PM 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. 1 Spiller WG, Frazier CH: Cerebral decompression: palliative operations in the treatment of tumors of the brain, based on the observation of fourteen cases. 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