A 13-month-old Haitian boy presented to Project Medishare field hospital in Port-au-Prince, with a 4-day history of traumatic brain injury (TBI). A cement block fell through the roof of his "sheet" tent, striking him on the right side of the head. He initially lost consciousness, and once he was more alert, was noted to be hemiplegic. The family did not seek immediate medical attention, but when he became increasingly sleepy and irritable, they brought him to the hospital.
On examination, the child exhibited left hemiplegia, prominent scalp veins, a bulging fontanelle, irritability, and a depressed level of consciousness. Computed tomography (CT) scanning was unavailable at the field hospital, and a decision for urgent surgical intervention was made based on the patient's history of neurological deterioration and observed signs of increased ICP.
General anesthesia was induced, and then the patient positioned supine for a typical trauma flap craniotomy/craniectomy procedure. A reverse question mark scalp incision was utilized and a myocutaneous flap elevated, revealing a large frontoparietotemporal linear depressed skull fracture with active herniation of cortical tissue from the fracture line [Figure 2]. Multiple burr holes were placed with a Hudson Brace, and then a Gigli saw was used to perform a craniectomy in three large pieces, roughly corresponding to the frontal bone, parietal bone, and squamous temporal bone.
A large dural rent was extended to create a stellate dural opening. Epidural hemostasis was achieved using bipolar cautery and Surgicel (Ethicon, Cincinnati, OH, USA). Evacuation of a small intraparenchymal hematoma and brain elevation out of the large craniectomy defect resulted in significant brain relaxation. After hemostasis was ensured, the stellate dural flaps were laid on the brain surface and the entire defect was covered with a thin layer of Fibrillar hemostatic agent (Ethicon) [Figure 3a]. The three bone flaps were then placed on the surface of the dura/fibrillar cushion in approximate anatomic position [Figure 3b]. Because of the expansion of the brain out of the craniectomy and the requisite increase in surface area, there were gaps of 5-10 mm between each of the flaps. The bone flaps were not affixed in any way to the skull or to each other, but were fairly adherent in their positions. The scalp was then reapproximated under mild tension in a standard fashion.
After surgery, the patient remained intubated, but was extubated on postoperative day 1. He was transferred out of the pediatric ICU after several days. He was alert and feeding well immediately, and was noted to have movement of the left hand and lower extremity by postoperative day 6. The incision site remained intact without swelling or defect. The patient had excellent cosmetic outcomes and neurological recovery, and was discharged on postoperative day 10 [Figure 4]. Due to the unique nature of this case and the post-disaster condition in Haiti, long-term clinical or radiographic follow-up was not available.