- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
Edward A. M. Duckworth
Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
DOI:10.4103/2152-7806.89855Copyright: © 2011 Trinh VT. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Trinh VT, M. Duckworth EA. In situ free-floating craniectomy for traumatic cerebral decompression in an infant: A field hospital solution. Surg Neurol Int 14-Nov-2011;2:157
How to cite this URL: Trinh VT, M. Duckworth EA. In situ free-floating craniectomy for traumatic cerebral decompression in an infant: A field hospital solution. Surg Neurol Int 14-Nov-2011;2:157. Available from: http://sni.wpengine.com/surgicalint_articles/in-situ-free-floating-craniectomy-for-traumatic-cerebral-decompression-in-an-infant-a-field-hospital-solution/
Background:Despite refinements in neurotrauma care, the morbidity and mortality of severe traumatic brain injury (TBI) in pediatric patients remains high. We report a novel approach to the surgical management of increased intracranial pressure in severe TBI utilizing an in situ free-floating craniectomy technique, which was originally devised as a creative solution to the unique challenges in a Haitian field hospital following the 2010 earthquake.
Case Description:A 13-month-old Haitian boy presented to Project Medishare field hospital in Port-au-Prince with left hemiplegia, a bulging fontanelle, and increasing lethargy following a traumatic head injury 4 days prior. An urgent craniectomy was performed based on clinical grounds (no brain imaging was available). A standard trauma flap incision was made, followed by a hemicraniectomy and expansion duraplasty. A small hematoma was evacuated. Frontal, temporal, and parietal bone flaps were placed on the dura in approximation to their normal anatomical configuration, but not affixed, leaving space for further brain edema, and the scalp was closed. The child experienced favorable peri-operative and early postoperative results.
Conclusion:In situ free-floating craniectomy, while devised as a creative solution to limited resources in a natural disaster zone, may offer advantages over more traditional techniques.
Keywords: Craniectomy, free-floating craniectomy, intracranial pressure, traumatic brain injury
The management of posttraumatic malignant intracranial pressure (ICP) is vexing. In infants, malignant ICP presents as a significant therapeutic challenge. The open space within the cranial vault is already limited, and thus volume increases are poorly tolerated.[
In this report, we present our experience with a novel surgical technique for cerebral decompression in an infant. Our technique was developed in a post-disaster field hospital in the wake of Haiti's 2010 earthquake, where resources for bone storage were limited, there was an uncertainty that cranioplasty could or would ever by accomplished, and wound infections were common [
A 13-month-old Haitian boy presented to Project Medishare field hospital in Port-au-Prince, with a 4-day history of traumatic brain injury (TBI). A cement block fell through the roof of his “sheet” tent, striking him on the right side of the head. He initially lost consciousness, and once he was more alert, was noted to be hemiplegic. The family did not seek immediate medical attention, but when he became increasingly sleepy and irritable, they brought him to the hospital.
On examination, the child exhibited left hemiplegia, prominent scalp veins, a bulging fontanelle, irritability, and a depressed level of consciousness. Computed tomography (CT) scanning was unavailable at the field hospital, and a decision for urgent surgical intervention was made based on the patient's history of neurological deterioration and observed signs of increased ICP.
General anesthesia was induced, and then the patient positioned supine for a typical trauma flap craniotomy/craniectomy procedure. A reverse question mark scalp incision was utilized and a myocutaneous flap elevated, revealing a large frontoparietotemporal linear depressed skull fracture with active herniation of cortical tissue from the fracture line [
A large dural rent was extended to create a stellate dural opening. Epidural hemostasis was achieved using bipolar cautery and Surgicel (Ethicon, Cincinnati, OH, USA). Evacuation of a small intraparenchymal hematoma and brain elevation out of the large craniectomy defect resulted in significant brain relaxation. After hemostasis was ensured, the stellate dural flaps were laid on the brain surface and the entire defect was covered with a thin layer of Fibrillar hemostatic agent (Ethicon) [
Technique of in situfree-floating craniectomy bone flaps positioned 5-10 mm apart on the surface of the Fibrillar cushion. Bone flaps were not affixed to each other or to the skull or underlying dura, and were designed to permit mobility for outward expansion in case of further traumatic edema
After surgery, the patient remained intubated, but was extubated on postoperative day 1. He was transferred out of the pediatric ICU after several days. He was alert and feeding well immediately, and was noted to have movement of the left hand and lower extremity by postoperative day 6. The incision site remained intact without swelling or defect. The patient had excellent cosmetic outcomes and neurological recovery, and was discharged on postoperative day 10 [
Traditional decompressive craniectomy
Studies in adult and pediatric patient populations have shown the beneficial effects of decompressive craniectomy in severe TBI. Yet, craniectomy carries with it inherent morbidity and requires special accommodations. Bone flap storage requires a strict sterile environment, a bone bank freezer[
Alternatives to traditional decompressive craniectomy
Several investigators have developed alternative techniques to address these concerns. To the best of our knowledge, only two described techniques simultaneously eliminate the need for secondary storage of the bone flap and a second operation for the cranioplasty/bone flap replacement. Schmidt et al.[
Ahn et al.[
Parallels with craniosynostosis treatment
While the pathophysiology of craniosynostosis and TBI are distinct, parallels can be drawn between our technique of free-floating bone flaps and craniectomy techniques for synostosis. Both disease processes can result in increased ICP. Craniosynostosis is the premature and abnormal fusion of one or more of the six suture lines that form the living skull.[
Risks of leptomeningeal cyst, role of the dura
One might suggest that our technique could lead to a leptomeningeal cyst or growing skull fracture, a rare (0.01%) late complication of traumatic skull fractures[
Risk of bone depression
One limitation of our technique may be the risk of bone depression if the gaps between the free bone flaps are too wide.[
We report our experience with a new technique developed in a distressed operating environment: in situ free-floating craniectomy for treatment of severe TBI in infants. The procedure allows mobile bone flaps to float outward during the acute phase of injury [
We would like to thank Sangwon Yeo for his illustration.
1. Açikgöz B, Ozcan OE, Erbengi A, Bertan V, Ruacan S, Açikgöz HG. Histopathologie and microdensitometric analysis of craniotomy bone flaps preserved between abdominal fat and muscle. Surg Neurol. 1986. 26: 557-61
2. Adamo MA, Drazin D, Waldman JB. Decompressive craniectomy and postoperative complication management in infants and toddlers with severe traumatic brain injuries. J Neurosurg Pediatrics. 2009. 3: 334-9
3. Agrawal D, Steinbok P, Cochrane DD. Reformation of the sagittal suture following surgery for isolated sagittal craniosynostosis. J Neurosurg. 2006. 105: 115-7
4. Ahn DH, Kim DW, Kang SD. In situ floating resin cranioplasty for cerebral decompression. J Korean Neurosurg Soc. 2009. 46: 417-20
5. Clayman MA, Murad GJ, Steele MH, Seagle MB, Pincus DW. History of craniosynostosis surgery and the evolution of minimally invasive endoscopic techniques: The University of Florida experience. Ann Plast Surg. 2007. 58: 285-7
6. Gladstone HB, McDermott MW, Cooke DD. Implants for cranioplasty. Otolaryngol Clin North Am. 1995. 2: 381-400
7. Gosain AK, Santoro TD, Song LS, Capel CC, Sudhakar PV, Matloub HS. Osteogenesis in calvarial defects: Contribution of the dura, the pericranium, and the surrounding bone in adult versus infant animals. Plast Reconstr Surg. 2003. 112: 515-27
8. Hancock DO. The fate of replaced bone flaps. J Neurosurg. 1963. 20: 983-4
9. Hejazi N, Witzmann A, Fae P. Unilateral decompressive craniectomy for children with severe brain injury: Report of seven cases and review of the relevant literature. Eur J Pediatr. 2002. 161: 99-104
10. Khandelwal S, Sharma GL, Gopal S, Sakhi P. Growing skull fractures/leptomeningeal cyst. Indian J Radiol Imaging. 2002. 12: 485-6
11. Kreuz FP, Hyatt GW, Turner TC, Bassett AL. The preservation and clinical use of freeze-dried bone. J Bone Joint Surg Am. 1951. 33A: 863-72
12. Münch E, Horn P, Schürer L, Piepgras A, Paul T, Schmiedek P. Management of severe traumatic brain injury by decompressive craniectomy. Neurosurgery. 2000. 47: 315-22
13. Schmidt JH, Reyes BJ, Fischer R, Flaherty S. Use of hinge craniotomy for cerebral decompression. J Neurosurg. 2007. 107: 678-82
14. Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus. 2009. 26: E7-
15. Taveras J, Ransohoff J. Leptomeningeal cysts of the brain following trauma with erosion of the skull: A study of seven cases treated by surgery. J Neurosurg. 1953. 10: 233-41