Pediatric Bone Flap Resorption Rates after Decompressive Craniectomy for Severe Traumatic Brain Injury

Keywords: cranioplasty, craniectomy, children, traumatic brain injury, outcome

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     Moyamoya is an important cause of stroke in the pediatric population. Revascularization surgery such as pial synangiosis is effective in augmenting cerebral blood flow and preventing stroke in children with moyamoya.
     The pattern of cerebral perfusion and relative contribution of middle meningeal artery (MMA) and superficial temporal artery (STA) after pial synangiosis are unclear.
     We found that 50.9% (27/53) of our sample patients experienced BFR. The average sample age was 6.25 years (+/- 4.73 yrs).
     From 2009-2010, post-operative cerebral angiograms with superselective injections from the STA and MCA were performed for 10 consecutive patients with moyamoya who had undergone pial synangiosis 1 year prior. All records for this cohort were retrospectively reviewed. Patterns of revascularization were defined as STA dominant, co-dominant, MMA dominant, or neither.
     The mean time to AC was 2.06 months (SD 2.27) and the mean time for BFR was 9.52 months (SD 7.64). Fifteen patients (28.3%) required permanent csf diversion with a ventriculoperitoneal shunt. Comminuted skull fractures were found in 30.2% of patients (16/53). 17% (9/53) had a wound infection. Univariate comparisons were made between a number of baseline variables and outcome of BFR. Significant associations were observed with comminuted skull fracture (p=.006), presence of infection (p=.02), hydrocephalus developing after AC (p= 0.01), & the presence of a permanent VPS (p=0.01). 81% (13/16) of patients with comminuted skull fractures, 80% (12/15) requiring permanent VPS, 88.9% (8/9) with post-operative infection, and & 90% (9/10) with hydrocephalus after AC had BFR. None of the other factors showed a significant association with BFR. We then used multivariate analysis to develop a predictive model (logistic regression, forward, conditional). The variables entered were comminuted skull fractures, permanent VPS, and age <2.5. Comminuted skull fractures (O.R. 10.94, CI (1.19, 100.7), p=0.03), permanent VPS (O.R. 34.4, CI (2.56, 4626), p=0.007), and age < 2.5 years old (O.R. 36.1, CI (3.07, 474.5), p=0.005) were all found to be significant risk factors for BFR.
     This is a retrospective study.
     Both STA and MMA provide significant revascularization after pial synangiosis for children with moyamoya.
     Implications for surgical technique will be discussed.


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