Protocol for the multicentre prospective paediatric craniectomy and cranioplasty registry (pedCCR) under the auspices of the European Society for Paediatric Neurosurgery (ESPN)

Abstract

Purpose
In the paediatric age group, the overall degree of evidence regarding decompressive craniectomy (DC) and cranioplasty is low, whereas in adults, randomised controlled trials and prospective multicentre registries are available. To improve the evidence-based treatment of children, a consensus was reached to establish a prospective registry under the auspices of the European Society for Pediatric Neurosurgery (ESPN).

Methods
This international multicentre prospective registry is aimed at collecting information on the indication, timing, technique and outcome of DC and cranioplasty in children. The registry will enrol patients ≤ 16 years of age at the time of surgery, irrespective of the underlying medical condition. The study design comprises four obligatory entry points as a core dataset, with an unlimited number of further follow-up entry points to allow documentation until adolescence or adulthood. Study centres should commit to complete data entry and long-term follow-up.

Results
Data collection will be performed via a web-based portal (homepage: www.pedccr.com ) in a central anonymised database after local ethics board approval. An ESPN steering committee will monitor the project’s progress, coordinate analyses of data and presentation of results at conferences and in publications on behalf of the study group.

Conclusion
The registry aims to define predictors for optimal medical care and patient-centred treatment outcomes. The ultimate goal of the registry is to generate results that are so relevant to be directly transferred into clinical practice to enhance treatment protocols.

Full text

Vol.:(0123456789)
1 3
https://doi.org/10.1007/s00381-022-05540-5
ORIGINAL ARTICLE
Protocol forthemulticentre prospective paediatric craniectomy
andcranioplasty registry (pedCCR) undertheauspices oftheEuropean
Society forPaediatric Neurosurgery (ESPN)
ThomasBeez1 · MartinU.Schuhmann2· PaoloFrassanito3· FedericoDiRocco4· UlrichW.Thomale5·
HansChristophBock6
Received: 1 March 2022 / Accepted: 21 April 2022
© The Author(s) 2022
Abstract
Purpose In the paediatric age group, the overall degree of evidence regarding decompressive craniectomy (DC) and cranio-
plasty is low, whereas in adults, randomised controlled trials and prospective multicentre registries are available. To improve
the evidence-based treatment of children, a consensus was reached to establish a prospective registry under the auspices of
the European Society for Pediatric Neurosurgery (ESPN).
Methods This international multicentre prospective registry is aimed at collecting information on the indication, timing,
technique and outcome of DC and cranioplasty in children. The registry will enrol patients ≤ 16years of age at the time of
surgery, irrespective of the underlying medical condition. The study design comprises four obligatory entry points as a core
dataset, with an unlimited number of further follow-up entry points to allow documentation until adolescence or adulthood.
Study centres should commit to complete data entry and long-term follow-up.
Results Data collection will be performed via a web-based portal (homepage: www. pedccr. com) in a central anonymised
database after local ethics board approval. An ESPN steering committee will monitor the project’s progress, coordinate
analyses of data and presentation of results at conferences and in publications on behalf of the study group.
Conclusion The registry aims to define predictors for optimal medical care and patient-centred treatment outcomes. The
ultimate goal of the registry is to generate results that are so relevant to be directly transferred into clinical practice to enhance
treatment protocols.
Keywords Decompressive craniectomy· Autologous cranioplasty· Allogeneic cranioplasty· Intracranial pressure· Bone
flap resorption· Functional outcome
Introduction
Decompressive craniectomy (DC) is part of the armamen-
tarium to control critically raised intracranial pressure (ICP)
occurring at different stages after severe cerebral insults [1]
: Primary DC is used to treat patients with significant space-
occupying lesions, in whom the risk of evolving brain edema
is high. Secondary or delayed DC is usually considered as
a final step if intracranial hypertension becomes refractory
to conservative measures. In addition to the implications of
primary and secondary brain injury itself, the limitations,
inherent risks and complications of DC and also of subse-
quent cranioplasty have to be taken into account.
Looking at the adult age group, several studies with high-
quality methodology have been or are being conducted: A
randomised controlled trial (RCT) investigating the role of
* Thomas Beez
thomas.beez@med.uni-duesseldorf.de
1 Department ofNeurosurgery, Medical Faculty, Heinrich-
Heine-Universität, Düsseldorf, Moorenstrasse 5,
40225Düsseldorf, Germany
2 Pediatric Neurosurgery, Universitätsklinikum Tübingen,
Tübingen, Germany
3 Pediatric Neurosurgery, Fondazione Policlinico Universitario
A. Gemelli IRCCS, Rome, Italy
4 Service de Neurochirurgie Pédiatrique, Hôpital Femme Mère
Enfant, Lyon, France
5 Pediatric Neurosurgery, Charité Universitätsmedizin Berlin,
Berlin, Germany
6 Department ofNeurosurgery, Universitätsmedizin Göttingen,
Göttingen, Germany
/ Published online: 9 May 2022
Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1 3
primary DC (RESCUE-ASDH) has finished enrolment and
the final results are not yet published(ISRCTN87370545).
Concerning secondary DC for refractory intracranial hyper-
tension (> 25mmHg) due to severe traumatic brain injury
(TBI), the RESCUEicp trial indicated a lower mortality com-
pared to conservative management [2]. The similar DECRA
trial had a lower ICP threshold (> 20mmHg) and demon-
strated reduced mortality but more unfavourable outcomes
after DC [3]. For malignant ischemic stroke, several RCTs
(including HAMLET, DECIMAL, DESTINY I and II) proved
a significant reduction of mortality, although DC renders a
relevant subgroup with moderately severe disability [4–7].
In contrast, such high-level evidence is not available in
the paediatric age group, where the large majority of previ-
ous publications are retrospective and monocentric [8–18].
For a recent review on DC in paediatric TBI, Ardissino etal.
screened 212 studies, but only 12 ultimately qualified for
systematic comparison [19]. The authors concluded that DC
reduces mortality and may improve functional outcome, but
they also highlighted significant knowledge gaps. Results for
DC in paediatric ischemic stroke are limited to case series
and anecdotal case reports [20].
Regarding cranioplasty, the level of evidence is low for
all age groups. Klieverik etal. recently screened 393 publi-
cations on paediatric cranioplasty and ultimately included
24 articles in their systematic review [21]. They concluded
that both autologous and alloplastic cranioplasty appeared
to be associated with relevant complication rates, with the
problem of aseptic bone flap resorption having a pronounced
impact on the paediatric cohort. Beyond this, no reliable
conclusions were possible and the authors emphasised the
relevance of large prospective cohort studies. To improve
the evidence base in adults, two prospective multicentre reg-
istries are actively recruiting patients
≥
18years of age in
Europe (UKCRR in the UK and GCRR in Germany, Austria
and Switzerland) [22, 23].
The recent efforts of both Ardissino etal. and Klieverik
etal. highlight the problems encountered in paediatric DC
and cranioplasty [19, 21] : The pooling of published results
is hindered by heterogeneous data elements and by miss-
ing information. Few studies provide long-term information
spanning craniectomy and cranioplasty, although both opera-
tions are closely related and relevant to the overall morbidity
and outcome of individual patients. If we attempt to fill these
evidence gaps with extrapolation of study results obtained in
the adult age group, there is a significant caveat: Highly rel-
evant differences in anatomy and physiology are described
between adults and children and even within the paediatric
age spectrum [24, 25]. Additionally, a fixed point of outcome
assessment as used in adults (in virtually all RCTs after 6
and/or 12months) does not adequately reflect the impact
of injuries and treatments on the developing child’s brain.
Children require longitudinal observation over many years
with age-adjusted outcome measures.
To this point, it should have become clear that the field of
paediatric DC and cranioplasty requires significant research
activity. However, to further justify such efforts, the rele-
vance of the field has to be taken into account as well. In
the paediatric age group, the main cause of severe acute
primary and secondary brain injury with consecutive intrac-
ranial hypertension and need for decompressive craniectomy
(and thus later cranioplasty) is TBI. Therefore, the best epi-
demiological and health-economic data is available for this
condition: 30% of all TBI cases occur in patients under the
age of 16, of which approximately 10% suffer moderate or
severe TBI [26]. The financial burden of TBI is significant,
with estimated annual costs for TBI-related hospitalisation
of children in the USA of more than $ 1 billion [27]. With
regard to medical outcomes, it is assumed that 30% of chil-
dren do not survive severe TBI despite DC [14, 28]. Among
survivors a good outcome can be expected in 60–90%
depending on the type of initial cerebral insult [28, 29]. In
addition to the sequelae of the insult itself, the risks of DC
and cranioplasty (especially CSF disorders, infections and
resorption of autologous bone flaps with the need for revi-
sion surgery) need to be taken into account [13, 30–34]. The
field is therefore highly relevant for the individual child and,
not least due to associated health-care costs, also to society.
The initial proposal for this study was presented at the
ESPN Consensus Conference 2019 in Paris. At this confer-
ence, a consensus was reached to establish a multicentric
registry under the auspices of ESPN. Achieving optimal out-
comes after severe insults to the child’s brain is of utmost
importance and the ESPN pedCCR will significantly con-
tribute towards this aim.
Aims andobjectives
After reaching consensus to establish a multicentre, prospec-
tive, registry under the auspices of ESPN, an initial interna-
tional steering committee was formed to formulate the study
goals and generate a proposal for a study protocol, which
was subsequently ratified by the ESPN board.
The primary objective of this study is a detailed system-
atic assessment of DC and cranioplasty in children (defined
as patients ≤ 16years of age at the time of surgery) with
regard to indication, timing, technique and outcomes, irre-
spective of underlying disease and with a minimum follow-
up of 24months after cranioplasty. The secondary objective
is the comparison of treatment strategies and identification
of predictors for optimal outcomes of DC and cranioplasty.
This study will generate an international multicentric, pro-
spectively collected data set to achieve these objectives.
1462 Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1 3
Such systematic and high-quality data collection and
analysis will improve the evidence base and thus medi-
cal care in several specific aspects. The concept of the
study is characterised by patient orientation: Based on a
large, prospective patient series, we aim for identifying
risk factors as well as optimal and suboptimal approaches.
This effort may ultimately reduce the complication rate,
thereby increasing patient safety and optimizing outcome.
The study protocol explicitly includes the long-term course
and health-related quality of life (using KIDSCREEN-10)
in age-dependent self or external assessment, in addition
to the King’s Outcome Scale for Childhood Head Injury
(KOSCHI) [35, 36]. The latter scale is validated for TBI,
but can be applied to other conditions similar to the Glas-
gow Outcome Scale.
A systematic analysis and comparison of different cranio-
plasty materials and techniques will deliver further knowledge
in order to optimise quality of care and cost-effectiveness in
this critical phase after TBI, as cranioplasty carries significant
short- and long-term risks in children [34]. Ultimately, based
on the data collected, revision surgery could be avoided and
implants with the best cost–benefit ratio could be identified.
Additionally, the optimal timing of cranioplasty will be ana-
lysed, as there is currently conflicting data on early versus
delayed cranial reconstruction [37–40]. A further strength of
the registry is its focus on specific technical details from a
paediatric neurosurgical perspective, which are often impos-
sible to be reconstructed retrospectively from operation notes.
Study design
This is a multicentre, prospective, registry. Patients ≤ 16
years of age at the time of surgery can be included after
informed consent as detailed below, irrespective of under-
lying disease (i.e. indication for DC). In surviving patients,
the study centres are committed to contributing data on
subsequent cranioplasty as well as a minimum follow-up of
24months after cranioplasty (Fig.1). Further follow-up until
adolescence or adulthood is encouraged.
The criteria applying for patient enrolment into the regis-
try were kept simple as a result of the low incidence of DC
in children and to actively encourage recruitment (Table1).
Based on retrospective data and an exploratory review of
the literature, we estimate an annual recruitment of 2 to 5
patients per centre. The experience of the German Cranio-
plasty Registry for adult patients (GCRR) has shown that
approximately 10 national centres can be expected to partici-
pate, depending on the size of the country [22]. Sample size
justification is based on a minimal assumption of 20 contrib-
uting centres for the ESPN pedCCR, with mean enrolment
of 3.5 patients per year. The registry could therefore have an
annual recruitment of 70 patients.
Fig. 1 Illustration of the study
design, with 4 obligatory data
entry points for a complete core
data set
Table 1 Overview of inclusion
and exclusion criteria Inclusion criteria Exclusion criteria
- Age
≤
16years at the time of surgery - Cranioplasty for conditions other
than DC (e.g. congenital skull
defects)
- Any type of underlying cerebral insult
- Informed consent obtained
- Ability to provide follow-up of at least 24months after cranio-
plasty
1463Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1 3
Data entry will be web-based and the protocol is opti-
mised towards efficiency and low resource requirements for
the contributing centres in order to encourage active and
lasting enrolment, complete data entries and sufficient fol-
low-up. A complete minimal data set for a patient surviving
after DC would include four data entry points, i.e. forms
for DC Module, Cranioplasty Module and two Routine
Follow-up Modules at 12 and 24months after cranioplasty,
respectively (Fig.1). The data elements for each module
are partially based on the National Institute of Neurologi-
cal Disorders and Stroke (NINDS) Common Data Elements
(https:// commo ndata eleme nts. ninds. gov). Additionally, sev-
eral validated scores and measures are explicitly or implic-
itly contained within the forms. The forms for each module
are outlined below:
Decompressive craniectomy module
– 48 items
– Paediatric GCS prior to DC and at discharge or day 30
after DC [41]
– Paediatric Risk of Mortality Score (PRISM) within 4h
after admission [42]
– Rotterdam CT Score [43]
– KOSCHI at discharge or day 30 after DC [35]
Cranioplasty module
– 26 items
– Paediatric GCS prior to cranioplasty and at discharge or
day 30 after cranioplasty
– KOSCHI prior to cranioplasty and at discharge or day 30
after cranioplasty
– KIDSCREEN-10 prior to cranioplasty [36]
Routine follow‑up module
– 10 items
– Paediatric GCS
– KOSCHI
– KIDSCREEN-10
– Oulo Resorption Score (if bone flap resorption observed
on imaging) [44]
Incident reporting module
– 13 items
– Paediatric GCS
– KOSCHI
– KIDSCREEN-10
– Oulo Resorption Score (if bone flap resorption observed
on imaging)
Data management andstatistical analysis
A web-based database using Filemaker® software has been
designed to allow password-protected data entry (Fig.2),
similar to the system successfully used for the TROPHY
registry [45, 46]. The central server is physically located
and professionally hosted in Europe. Data transfer between
the user and the study server is encrypted (SSL coding) to
assure data privacy. Access to the online registry applica-
tion is provided via the study homepage: www. pedccr. com.
Patients will be pseudonymised (consecutive numbers)
locally by the respective centre. The central data collection
will then be done anonymously, i.e. the central database
itself does not contain any identifying patient information
and the pseudonymisation key will be securely kept at the
local centre.
As this is a prospective registry without a limited study
period, data collection will be ongoing and no endpoints
were predefined. Regular audits will be performed to
ensure data quality and integrity. Data analysis will be
performed with descriptive statistics. Based on results
from the previous literature, the following statistical
assumptions regarding relevant clinical variables were
made: 30-day-complication rate after DC — 40%; good
outcome after DC — 50%; mortality after DC — 30% and
autologous bone flap resorption rate — 80%. With the aim
of a confidence level of 90% and an error margin of less
than
±
10%, an analysis will be carried out for N = 100
included cases. To compare the complication rate between
autologous versus allogeneic cranioplasty, an evaluation
of N = 150 cases per cranioplasty modality will be carried
out in view of the complication rates from the literature
of 33% versus 14%.
Ethics andinformed consent
The study will be carried out in accordance with the prin-
ciples of the Declaration of Helsinki in the revised version
of 2013. The study protocol has been approved by the ethi-
cal review board at Heinrich-Heine-University, Düsseldorf,
Germany (study number 2021–1653). Each centre will need
to have obtained a positive local ethics vote before begin-
ning enrolment. The study protocol and consent forms in
German and English will be available for download on the
study homepage upon user registration. Since we are includ-
ing underage subjects, the legal representatives or the carer
must provide written consent. If the minor is able to under-
stand the nature of the study, his/her written consent is also
required. An age-appropriate adapted patient information
leaflet and consent form will be provided. The individual
patient data can be deleted completely and irretrievably at
any time upon the patient’s request, without giving reasons.
1464 Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1 3
Conclusions
The lack of high-quality data and thus the low degree
of evidence on which treatment decisions can be based
with regard to DC and cranioplasty in children became
evident during the ESPN Consensus Conference 2019
in Paris. Consensus was reached to create this registry
as an important way to systematically collect real-world
experiences in the field and analyse and compare treat-
ment approaches across paediatric neurosurgical centres.
We believe that this “science of practice” approach will
achieve a high degree of internal and external validity and
answer important questions and stimulate further research.
Contribution and collaboration at all levels, including
Fig. 2 Representative screen shots of the pedCCR database — A homepage (homepage: www. pedccr. com) and B data entry form for DC
1465Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1 3
optimizing the study design, is highly appreciated to
advance this project together.
Funding Open Access funding enabled and organized by Projekt
DEAL. The study receives financial support from the European Soci-
ety for Pediatric Neurosurgery (ESPN), Geneva, Switzerland, and the
independent not-for-profit organisation ZNS – Hannelore Kohl Stiftung
für Unfallverletzte mit Schäden des Zentralen Nervensystems, Bonn,
Germany.
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article's Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
References
1. Kolias AG, Adams H, Timofeev I etal (2016) Decompressive
craniectomy following traumatic brain injury: developing the evi-
dence base. Br J Neurosurg 30:246–250. https:// doi. org/ 10. 3109/
02688 697. 2016. 11596 55
2. Hutchinson PJ, Kolias AG, Timofeev IS etal (2016) Trial of
decompressive craniectomy for traumatic intracranial hyperten-
sion. N Engl J Med 375:1119–1130. https:// doi. org/ 10. 1056/
NEJMo a1605 215
3. Cooper DJ, Rosenfeld JV, Murray L etal (2011) Decompres-
sive craniectomy in diffuse traumatic brain injury. N Engl J Med
364:1493–1502. https:// doi. org/ 10. 1056/ NEJMo a1102 077
4. Hofmeijer J, Kappelle LJ, Algra A etal (2009) Surgical decom-
pression for space-occupying cerebral infarction (the Hemi-
craniectomy After Middle Cerebral Artery infarction with
Life-threatening Edema Trial [HAMLET]): a multicentre, open,
randomised trial. Lancet Neurol 8:326–333. https:// doi. org/ 10.
1016/ S1474- 4422(09) 70047-X
5. Vahedi K, Vicaut E, Mateo J etal (2007) Sequential-design,
multicenter, randomized, controlled trial of early decompres-
sive craniectomy in malignant middle cerebral artery infarction
(DECIMAL Trial). Stroke 38:2506–2517. https:// doi. org/ 10. 1161/
STROK EAHA. 107. 485235
6. Jüttler E, Schwab S, Schmiedek P etal (2007) Decompressive
Surgery for the Treatment of Malignant Infarction of the Mid-
dle Cerebral Artery (DESTINY): a randomized, controlled trial.
Stroke 38:2518–2525. https:// doi. org/ 10. 1161/ STR OK EAHA. 107.
485649
7. Jüttler E, Unterberg A, Woitzik J etal (2014) Hemicraniectomy in
older patients with extensive middle-cerebral-artery stroke. N Engl
J Med 370:1091–1100. https:// doi. org/ 10. 1056/ NEJMo a1311 367
8. Van Der Meer C, Van Lindert E, Petru R (2012) Late decompres-
sive craniectomy as rescue treatment for refractory high intrac-
ranial pressure in children and adults.Acta Neurochir Suppl
114:305–310. https:// doi. org/ 10. 1007/ 978-3- 7091- 0956-4_ 59
9. Güresir E, Schuss P, Seifert V, Vatter H (2012) Decompressive
craniectomy in children: Single-center series and systematic
review. Neurosurgery 70:881–888. https:// doi. org/ 10. 1227/ NEU.
0b013 e3182 37a6a6
10. Figaji AA, Fieggen AG, Peter JC (2003) Early decompres-
sive craniotomy in children with severe traumatic brain injury.
Child’s Nerv Syst 19:666–673. https:// doi. org/ 10. 1007/
s00381- 003- 0804-3
11. El Hindy N, Stein KP, Hagel V etal (2014) The role of decompres-
sive craniectomy in children with severe traumatic brain injury.
Eur J Trauma Emerg Surg 40:481–487. https:// doi. org/ 10. 1007/
s00068- 013- 0337-8
12. Khan SA, Shallwani H, Shamim MS etal (2014) Predictors of
poor outcome of decompressive craniectomy in pediatric patients
with severe traumatic brain injury: a retrospective single center
study from Pakistan. Child’s Nerv Syst 30:277–281. https:// doi.
org/ 10. 1007/ s00381- 013- 2225-2
13. Kan P, Amini A, Hansen K etal (2008) Outcomes after decom-
pressive craniectomy for severe traumatic brain injury in children.
J Neurosurg Pediatr 105:337–342. https:// doi. org/ 10. 3171/ ped.
2006. 105.5. 337
14. Jagannathan J, Okonkwo DO, Dumont AS etal (2008) Outcome
following decompressive craniectomy in children with severe
traumatic brain injury: a 10-year single-center experience with
long-term follow up. J Neurosurg Pediatr 106:268–275. https://
doi. org/ 10. 3171/ ped. 2007. 106.4. 268
15. Polin RS, Ayad M, Jane JA (2003) Decompressive craniectomy in
pediatric patients. Crit Care 7:409–410. https:// doi. org/ 10. 1186/
cc2370
16. Patel N, West M, Wurster J, Tillman C (2013) Pediatric traumatic
brain injuries treated with decompressive craniectomy. Surg Neu-
rol Int 4:128. https:// doi. org/ 10. 4103/ 2152- 7806. 119055
17. Taylor A, Butt W, Rosenfeld J etal (2001) A randomized trial of
very early decompressive craniectomy in children with traumatic
brain injury and sustained intracranial hypertension. Child’s Nerv
Syst 17:154–162. https:// doi. org/ 10. 1007/ s0038 10000 410
18. Smith SE, Kirkham FJ, Deveber G etal (2011) Outcome following
decompressive craniectomy for malignant middle cerebral artery
infarction in children. Dev Med Child Neurol 53:29–33. https://
doi. org/ 10. 1111/j. 1469- 8749. 2010. 03775.x
19. Ardissino M, Tang A, Muttoni E, Tsang K (2019) Decompres-
sive craniectomy in paediatric traumatic brain injury: a systematic
review of current evidence. Child’s Nerv Syst 35:209–216. https://
doi. org/ 10. 1007/ s00381- 018- 3977-5
20. Beez T, Munoz-Bendix C, Steiger H-J, Beseoglu K (2019)
Decompressive craniectomy for acute ischemic stroke. Crit Care
23:209. https:// doi. org/ 10. 1186/ s13054- 019- 2490-x
21. Klieverik VM, Miller KJ, Singhal A etal (2019) Cranioplasty after
craniectomy in pediatric patients—a systematic review. Child’s
Nerv Syst. https:// doi. org/ 10. 1007/ s00381- 018- 4025-1
22. Giese H, Sauvigny T, Sakowitz OW etal (2015) German Cranial
Reconstruction Registry (GCRR): protocol for a prospective, mul-
ticentre, open registry. BMJ Open 5:e009273. https:// doi. org/ 10.
1136/ bmjop en- 2015- 009273
23. Kolias AG, Bulters DO, Cowie CJ etal (2014) Proposal for estab-
lishment of the UK Cranial Reconstruction Registry (UKCRR).
Br J Neurosurg 28:310–314. https:// doi. org/ 10. 3109/ 02688 697.
2013. 859657
24. Figaji AA (2017) Anatomical and physiological differences
between children and adults relevant to traumatic brain injury
and the implications for clinical assessment and care. Front Neurol
8:1–15. https:// doi. org/ 10. 3389/ fneur. 2017. 00685
1466 Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1 3
25. Frassanito P, Bianchi F, Pennisi G etal (2019) The growth of the
neurocranium: literature review and implications in cranial repair.
Childs Nerv Syst. https:// doi. org/ 10. 1007/ s00381- 019- 04193-1
26. Rickels E, von Wild K, Wenzlaff P (2010) Head injury in Ger-
many: a population-based prospective study on epidemiology,
causes, treatment and outcome of all degrees of head-injury sever-
ity in two distinct areas. Brain Inj 24:1491–1504. https:// doi. org/
10. 3109/ 02699 052. 2010. 498006
27. Schneier AJ, Shields BJ, Hostetler SG etal (2006) Incidence of
pediatric traumatic brain injury and associated hospital resource
utilization in the United States. Pediatrics 118:483–492. https://
doi. org/ 10. 1542/ peds. 2005- 2588
28. Beez T, Munoz-Bendix C, Ahmadi SA etal (2019) From decom-
pressive craniectomy to cranioplasty and beyond-a pediatric neu-
rosurgery perspective. Childs Nerv Syst 35:1517–1524. https://
doi. org/ 10. 1007/ s00381- 019- 04303-z
29. Thomale U-W, Graetz D, Vajkoczy P, Sarrafzadeh AS (2010)
Severe traumatic brain injury in children—a single center experi-
ence regarding therapy and long-term outcome. Child’s Nerv Syst
26:1563–1573. https:// doi. org/ 10. 1007/ s00381- 010- 1103-4
30. Rivara FP, Koepsell TD, Wang J etal (2011) Disability 3, 12,
and 24 months after traumatic brain injury among children and
adolescents. Pediatrics 128:e1129–e1138. https:// doi. org/ 10. 1542/
peds. 2011- 0840
31. Manfiotto M, Mottolese C, Szathmari A etal (2017) Decompres-
sive craniectomy and CSF disorders in children. Child’s Nerv Syst
33:1751–1757. https:// doi. org/ 10. 1007/ s00381- 017- 3542-7
32. Pechmann A, Anastasopoulos C, Korinthenberg R etal (2015)
Decompressive craniectomy after severe traumatic brain injury in
children: complications and outcome. Neuropediatrics 46:5–12.
https:// doi. org/ 10. 1055/s- 0034- 13937 07
33. Peraud A (2015) The underestimated complication rate of decom-
pressive craniectomy in pediatric traumatic brain injury. Neuro-
pediatrics 46:3–4. https:// doi. org/ 10. 1055/s- 0034- 13898 99
34. Frassanito P, Tamburrini G, Massimi L etal (2017) Problems of
reconstructive cranioplasty after traumatic brain injury in chil-
dren. Child’s Nerv Syst 33:1759–1768. https:// doi. org/ 10. 1007/
s00381- 017- 3541-8
35. Crouchman M, Rossiter L, Colaco T, Forsyth R (2001) A prac-
tical outcome scale for paediatric head injury. Arch Dis Child
84:120–124. https:// doi. org/ 10. 1136/ adc. 84.2. 120
36. Ravens-Sieberer U, Erhart M, Rajmil L etal (2010) Reliability,
construct and criterion validity of the KIDSCREEN-10 score:
a short measure for children and adolescents’ well-being and
health-related quality of life. Qual Life Res 19:1487–1500. https://
doi. org/ 10. 1007/ s11136- 010- 9706-5
37. Rocque BG, Agee BS, Thompson EM etal (2018) Complications
following pediatric cranioplasty after decompressive craniectomy:
a multicenter retrospective study. J Neurosurg Pediatr 22:225–232.
https:// doi. org/ 10. 3171/ 2018.3. peds1 7234
38. Morton RP, Abecassis IJ, Hanson JF etal (2018) Timing of cranio-
plasty: a 10.75-year single-center analysis of 754 patients. J Neuro-
surg 128:1648–1652. https:// doi. org/ 10. 3171/ 2016. 11. JNS16 1917
39. Malcolm JG, Rindler RS, Chu JK etal (2018) Early cranioplasty
is associated with greater neurological improvement: a systematic
review and meta-analysis. Neurosurgery 82:278–288. https:// doi.
org/ 10. 1093/ neuros/ nyx182
40. Piedra MP, Thompson EM, Selden NR etal (2012) Optimal tim-
ing of autologous cranioplasty after decompressive craniectomy
in children. J Neurosurg Pediatr 10:268–272. https:// doi. org/ 10.
3171/ 2012.6. peds1 268
41. Borgialli DA, Mahajan P, Hoyle JD etal (2016) Performance
of the pediatric Glasgow Coma Scale score in the evaluation of
children with blunt head trauma. Acad Emerg Med 23:878–884.
https:// doi. org/ 10. 1111/ acem. 13014
42. Pollack MM, Ruttimann UE, Getson PR (1988) Pediatric risk of
mortality (PRISM) score. Crit Care Med 16:1110–1116
43. Liesemer K, Riva-Cambrin J, Bennett KS etal (2014) Use of
Rotterdam CT scores for mortality risk stratification in children
with traumatic brain injury. Pediatr Crit Care Med 15:554–562.
https:// doi. org/ 10. 1097/ PCC. 00000 00000 000150
44. Korhonen TK, Salokorpi N, Ohtonen P etal (2019) Classification
of bone flap resorption after cranioplasty: a proposal for a com-
puted tomography-based scoring system. Acta Neurochir (Wien)
161:473–481. https:// doi. org/ 10. 1007/ s00701- 018- 03791-3
45. Thomale U-W, Cinalli G, Kulkarni AV etal (2019) TROPHY reg-
istry study design: a prospective, international multicenter study
for the surgical treatment of posthemorrhagic hydrocephalus in
neonates. Childs Nerv Syst 35:613–619. https:// doi. org/ 10. 1007/
s00381- 019- 04077-4
46. Thomale UW, Auer C, Spennato P etal (2021) TROPHY registry
— status report. Child’s Nerv Syst 37:3549–3554. https:// doi. org/
10. 1007/ s00381- 021- 05258-w
Publisher's Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
1467Child's Nervous System (2022) 38:1461–1467
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com