%0 Journal Article
%T Decompressive craniectomy in pediatric patients
%A Richard S Polin
%A Michael Ayad
%A John A Jane
%J Critical Care
%D 2003
%I BioMed Central
%R 10.1186/cc2370
%X The modern concept of decompression for traumatic brain injury (TBI) was introduced by Harvey Cushing before World War I [1,2]. The rationale was entirely intuitive. The Monro-Kellie hypothesis dictates that the amount of space within the skull is constant; therefore, when the pressure is raised death occurs by herniation when the capacity for adjustment by fluid shifts from the cerebrospinal fluid and vascular compartments are already maximized. Increasing the skull size by removing bone and opening the dura delays or prevents these limits from being reached. However, in the 90 years since Cushing made these observations, medical, radiographic, and surgical advances in the management of TBI have obviated the need for an aggressive surgical approach in all but a minority of cases.In spite of the ability to control intracranial pressure (ICP) elevation in most cases with removal of mass lesions, osmotic diuretics, ventricular drainage, sedative/hypnotic agents, and prevention of hypercapnea, occasional cases occur in which ICP elevation accelerates in spite of maximal conservative medical therapy, and then so-called heroic measures are employed. These currently include barbiturate coma, hypothermia, and decompressive craniectomy. These are considered at the 'option' level in the American Association of Neurological Surgeons criteria for management of severe brain injury [3] because no large randomized trial has proven their efficacy. In the pediatric population, Ruf and colleagues [4] as well as Taylor and associates [5] have addressed the issue of using decompressive craniectomy as a more formal part of a head injury protocol before going to other 'option' therapies once ICP elevation is affirmed.There are many different approaches grouped under the term 'craniectomy'. Bifrontal decompressive craniectomy is an aggressive approach described by Kjellberg and Prieto [6] before the era of modern neuroimaging with computed tomography. Venes and Collins [7] described this
%K craniectomy
%K intracranial pressure monitoring
%K intracranial pressure
%K traumatic brain injury
%U http://ccforum.com/content/7/6/409