Outcome of children with severe traumatic brain injury who are treated with decompressive craniectomy.

OBJECT Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) is controversial. The authors sought to determine if DC improves the outcome of children with severe TBI. METHODS In a retrospective, case-control study, medical records of all patients admitted to the pediatric ICU between May 1998 and May 2008 with severe TBI and treated with DC were identified and matched to patients who were treated medically without DC. Medical records were reviewed for patients' demographic data and baseline characteristics. RESULTS During the study period, 17 patients with severe TBI treated with DC at a median of 2 hours (interquartile range [IQR] 1-14 hours) after admission were identified and matched to 17 contemporary controls. On admission, there were no differences between DC and control patients regarding age (10.2 ± 5.9 years vs 12.4 ± 5.4 years, respectively [mean ± SD]), sex, weight, Glasgow Coma Scale score (median 5 [IQR 3-7] vs 4 [IQR 3-6], respectively; p = 0.14), or the highest intracranial pressure (median 42 [IQR 22-54] vs 30 [IQR 21-36], respectively; p = 0.77). However, CT findings were significant for a higher rate of herniation and cerebral edema among patients with DC versus controls (7/17 vs 2/17, respectively, had herniation [p = 0.05] and 14/17 vs 6/17, respectively, had cerebral edema [p = 0.006]). Overall there were no significant differences in survival between patients with DC and controls (71% [12/17] vs 82% [14/17], respectively; p = 0.34). However, among survivors, at 4 years (IQR 1-6 years) after the TBI, 42% (5/12) of the DC patients had mild disability or a Glasgow Outcome Scale score of 5 vs none (0/14) of the controls (p = 0.012). CONCLUSIONS In this retrospective, small case-control study, the authors have shown that early DC in pediatric patients with severe TBI improves outcome in survivors. Future prospective randomized controlled studies are needed to confirm these findings.

Cervicomedullary junction compression caused by vertebral artery dolichoectasia and requiring surgical treatment. Case report.

A case of progressive brainstem syndrome secondary to vertebral artery (VA) dolichoectasia is reported. The patient presented with partial bilateral abduction paralysis, which progressed to quadriparesis, ataxia, and areflexia. The initial diagnosis was stroke, but because of the patient's deterioration, a diagnosis of Miller-Fisher syndrome was made. Neuroimages obtained at that time revealed an ectatic left VA with minimal cervicomedullary compression. The patient continued to deteriorate despite medical management. Follow-up imaging demonstrated worsened cervicomedullary compression. An emergency posterior fossa neurovascular decompression was performed using a Gore-Tex sling and resulted in mild neurological improvement. This case emphasizes that early recognition and surgical intervention to prevent progressive neurological sequelae are crucial in symptomatic VA dolichoectasia.