Concussion Surgery

Eric jackson dtl

Morgan Edwards had almost completed her Saturday afternoon ATV ride when she collided with her brother on a dirt bike near her home in Aberdeen, Md. When her head hit his chest, her helmet popped off—then she somersaulted and her head hit the road. While her brother suffered lacerations from sliding on the road, Morgan started exhibiting some of the classic signs of a serious concussion—anger, confusion, dizziness and vomiting.

“Morgan was like Mike Tyson—she was very combative,” says her mother, Linda Edwards. “In the ambulance she started throwing up, so they called for a medivac helicopter and flew her here.”

“Here” is the Johns Hopkins Children’s Center where pediatric trauma surgeons and the pediatric neurocritical care team of intensivists, neurologists, neuroradiologists and neurosurgeons, among other specialists, care for children with traumatic brain injury. In cases like Morgan’s, they immediately look for signs of bleeding or swelling in the brain, keeping a close eye on the patient’s intracranial pressure (ICP) and medically managing the patient to keep ICP levels down. That includes elevating the head of the patient’s bed to reduce gravitational pressure on the brain, sedating the patient as agitation and pain can also increase brain pressure, and boosting salt levels to limit edema caused by the sheer force of the brain striking the skull during the trauma.

“It’s counter-intuitive but increasing serum sodium improves the efficiency of blood flow in the brain, thereby shrinking the diameter of blood vessels in the brain and lowering pressures,” says pediatric intensivist Courtney Robertson. “This also creates a higher osmolarity in the body so fluid is pulled across the blood brain barrier to the body and away from the brain, a secondary way to lower pressure.”

Despite these steps, Morgan’s intracranial pressure continued to rise into Saturday night. Also, around 11 p.m. she began to have seizures, a sign of severe brain trauma. Following their evidence-based protocol, the neurocritical care team took another step and infused the young patient with pentobarbital, inducing a coma-like state.

“We’re medically putting their brain to sleep, which lowers the metabolic needs and demands of the brain,” says Robertson. “The brain responds accordingly by lowering the amount of blood flow that it needs, which lowers the intracranial pressure.”

Still Morgan’s ICP continued to climb into Sunday morning, alarming Robertson and the team. Intracranial pressures are expected to rise in cases like Morgan’s—but not so rapidly.

“We think of the peak of swelling as three days out, not one or two days, yet already she was in trouble,” says Robertson. “And within a day we had run through the gamut of all the medical management tiers we can offer.”

It was time to consider another option.

Pediatric neurosurgeon Eric Jackson, who had been tracking the teen’s condition since admission, recommended removing part of her skull to maintain blood flow and oxygen to the brain and minimize swelling and pressure. Without the procedure, called a decompressive craniectomy, Morgan’s brain would likely continue to swell and—with nowhere to go beyond the rigid confines of the cranium—put her at risk of brain herniation, which can lead to a massive stroke and fatal damage to the brainstem, which controls breathing and blood flow.

Nonetheless, the procedure is not without risks. A 2007 report showed 65 percent of pediatric trauma patients had favorable outcomes five years after decompressive craniectomy (Journal of Neurosurgery Pediatrics 106(4):268-275), but a 2011 study found the surgery was associated with worse functional outcomes than best medical care (NEJM 364(16):1493-502). Because of such risks, Hopkins pediatric neurosurgeons view the procedure as an option of last resort.

“There’s a lot of literature on the complications and long-term problems when you take the bone off, so it really is something we tend to do as a lifesaving procedure,” says Jackson.

This is where perhaps the greatest value of the pediatric neurocritical care team comes into play—multiple disciplines weighing in on the patient’s status to devise optimal treatment. In this case, all were in agreement—surgery was the only remaining answer for Morgan’s intractable intracranial pressure. Jackson explained the recommendation and risks to Morgan’s mom.

“Her pressure was skyrocketing because her brain was swelling and there was no place for it to go,” says Morgan’s mom. “They had to relieve the pressure. They ran out of options medically, so it was his turn.”

On Sunday afternoon, Jackson removed a bone flap from the left side of Morgan’s skull, carefully avoiding the superior sagittal sinus that runs along the midline of the brain. He also made the flap large—with too small a flap, Jackson says, the remaining bone may pinch vessels of the protruding brain, resulting in ischemia.

Following the surgery, Morgan’s ICP declined to single-digit levels. The next day, however, it spiked again, prompting Jackson to return to the OR to place a drain in the ventricles of Morgan’s brain to remove cerebral spinal fluid (CSF) and lower pressures. Because his patient’s ventricles were small and vulnerable to increased swelling, Jackson also removed more bone from the front and back of her skull. It worked. The teen’s ICP numbers dropped to manageable levels.

Still, Morgan was not out of the woods. As she underwent neuro-rehabilitation at neighboring Kennedy Krieger Institute, the pediatric neurocritical care team monitored her closely for signs of complications from the surgery. One risk was post-traumatic hydrocephalus, which can occur when bone is removed and the body doesn’t properly reabsorb CSF. Also, meningitis or brain abscess can occur after decompressive craniectomy. And the bone flap, sitting in a freezer for a period of time, becomes a foreign body that can get infected.

Because of such risks, Jackson likes to put the bone back in as soon as the patient has recovered from the trauma, brain swelling has subsided and intracranial pressures have returned to normal, which can be as long as six months. For Morgan, who was discharged in late May, the wait was six weeks. It’s been a journey, says Morgan’s mom, who adds that she was “amazed” by her daughter’s care: “From the minute Morgan arrived, her care here was awesome. I’ve said it before, ‘If you have to be injured or sick, we live in the perfect area.’ There’s no better place. And Dr. Jackson? I just love him. If we have a thousand questions, he’ll stand there and answer a thousand questions.”

The pediatric neurocritical care team works in one 20-bed section of the pediatric intensive care unit (PICU), which enhances communication, coordination and collaborative relationships among staff.

“Instead of the neurosurgeon being split among three teams and 40 beds in the PICU, they’re seeing the same folks over and over again,” says Robertson. “There’s an education value, too, as residents and fellows rotating on the team can really think continuously about neurovascular physiology.”