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« Outcome following decompressive craniectomy in children with severe traumatic brain injury:
a 10-year single-center experience with long-ter m follow-up »
Jagannathan J, Okonkwo O and al
J Neurosurg: Pediatrics 106: 268-275, 2007
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Introduction
Importance du contrôle de la PIC +++ dans la prise en charge du TC grave de l'enfant
=> ↑autonomie
↓incapacités
STRATEGIES THERAPEUTIQUES:Sédation-hypnotiquesCuraresAgents osmotiques (Mannitol)HyperventilationVentriculostomie
CRANIECTOMIE
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Physiopathologie craniectomie
� Ablation d'un volet osseux => expansion cérébrale => amélioration des pressions cérébrales
=> ↓ PIC ↓ effet de masse (déviation de la ligne
médiane) ↓ compression et engagement
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Objectifs
� Indications chirurgicales� Suivi évolution à 2 ans des enfants traités par
craniectomie dans le cadre d’un TC grave
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Matériel et méthodes
� Etude�Rétrospective�Monocentrique (Charlottesville)�Janvier 1995-Avril 2006
� Population étudiée�Enfants atteints d’un TC grave et traités par
craniectomie�Analyse rétrospective de données recueillies
prospectivement et issues d’une base de données>500 patients pris en charge pour TC pendant cette période
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Protocole de prise en charge
INDICATION CHIRURGICALE� Evaluation clinique de tout patient pris en charge pour
TC� Si GSC<8 ou suspicion de trauma cérébral :
� TDM cérébral� Bilan sanguin (NFS, coagulation, iono, transaminases,
lipases, groupe, RAI)� Intervention chirurgicale en urgence si lésion avec
effet de masse� Monitorage de la PIC pour les autres patients ou si
impossibilité se surveiller examen neuro� CRANIECTOMIE si PIC réfractaire>20 mmHg malgrè
ttt médical optimal
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� Craniectomie :� Unilatérale (cf TDM) si lésion avec effet de
masse� Bifrontale si absence de lésion focalisée
� Suivi :� Équipe multidiscipinaire ( pédiatres,
neurochirurgiens, médecine physique et réadaptation, neuropsychiatres)
� Evaluation à 2 ans
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Données recueillies
Mécanisme du traumatismeGCS initialEtendue des lésions cérébrales (TDM)Lésions extra-crâniennes, nécessité d’interventions chirurgicalesDélai craniectomieIndication craniectomiePIC post-opératoireDurée hospitalisationEvolution à long-terme: à 2 ans
GOS [Glasgow Outcome Scale ]QOL [Quality Of Life]: score de Likert (activités quotidiennes,
fonctions comportementales, émotives, cognitives et aptitudes physiques)
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23 patients traités par craniectomie� 8 filles/15 garçons� Age moyen: 11,9 ans
� Mécanisme lésionnel� Accident voiture (9)� AVP piéton (9)� Chute (2)� Autre (3)
� GSC à l’admission: 4,65 [3-8]
Résultats
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Résultats
� Imagerie cérébrale� TDM pathologique à l’admission� Lésions les plus observées
� Lésions axonales diffuses (91%)� Contusion/hémorragie intraparenchymateuse� Fracture
� Autres lésions� 82% (19) patients
� 53%: orthopédie� 32%: lésions abdominales
� 7 chirurgies
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Résultats
� Monitorage PIC� Délai: 7h (1-8h)� PIC moyenne initiale: 18mmHg (11-33)� PIC moyenne craniectomie: 30mmHg (20-66)
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Résultats
� Craniectomie� Délai: 68h (24-192)� Indications:
� 78%: PIC réfractaire, échec ttt médical� 13%: Aggravation clinique brutale
� Intervention:� 65%: bifrontale� 35%: unilatérale� 100%:PIC
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Evolution
� Décès : 34%� 1 per-opératoire� 6 post-opératoire
� Hospitalisation� Durée moyenne: 21 jours (1-100)� Sortie hôpital: 89% (17), 16 survivants
� Suivi à long terme� 62 mois en moyenne (11-126)� GOS moyen à 2 ans: 4,2� Scolarisation: 13/16 (76%)� Dépendance: 3/16
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Evolution
� A long terme� Ttt médical
� 69%: anti-dépresseurs et anti-convulsivants
� Déficit neuro: 59%� Hémiparésie� Trouble du langage� Trouble de la vision
� Obésité: 13%
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Analyses statistiques
� Taux mortalité : significativement + élevé si:� Atteinte vasculaire associée� Craniectomie secondaire à une aggravation
neuro clinique� PIC post-op>20mmHg
� Evolution à long terme : significativement + favorable si:� Lésions axonales diffuses isolées sur TDM
initial
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Conclusion
� Physiopathologie PIC: méconnue mais 2 profils évolutifs qui suggèrent 2 mécanismes:� Altération immédiate de la régulation
� Hyperhémie et œdème� Efficacité du ttt médical� Craniectomie retardée
� Ischémie et hypoxie� Craniectomie précoce
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Conclusion
� Série importante� Evolution favorable après craniectomie à
court et à long terme des enfants pris en charge pour TC grave� 65% favorable� 82% survivants scolarisés� Importance GOS, QOL
� Nécessité prise en charge multidisciplinaire
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Conclusion
� Protocole: craniectomie si PIC>20mmHg� PIC moy craniectomie=30mmHg
� Délai craniectomie plus importants, taux de survie identiques� Délai moyen craniectomie: 4,6 jours chez
patients décédés vs 3 jours chez survivants