Vacuum-assisted closure of the scalp flap following malignant cerebral edema during craniotomy: pediatric case presentations and review of the literature.

Intraoperative malignant cerebral edema is a rare but life-threatening complication that can arise during a traumatic decompressive craniectomy. The swelling may be significant enough to preclude skin closure. The current standard of care is to resect sufficient edematous brain tissue to close the scalp to establish an immune-competent barrier to the intracranial space. We report two pediatric patients who developed malignant edema during craniectomy that prevented skin closure. Both patients underwent placement of a temporary vacuum-assisted closure (VAC) device, facilitating resolution of the edema without sacrifice of brain tissue before scalp closure. Case #1 sustained a fall; head computed topography (CT) revealed a left subdural hematoma (SDH) and hemispheric infarct with midline shift. A craniotomy was performed during which malignant cerebral edema developed, preventing dural closure or scalp approximation. A VAC was placed which remained for 17 days, followed by successful primary closure of the scalp. Case #2 suffered multiple injuries from inflicted trauma; head CT demonstrated a large acute SDH over the left frontal and parietal region with a midline shift to the right. Emergent craniotomy was performed, and significant cranial edema was encountered to a degree for which medical intervention was not effective enough to allow skin closure. A VAC device was placed which was removed 8 days later with primary scalp closure. No infectious complications arose in either case, and no complications were attributable to the VAC devices. A temporizing VAC to protect the intracranial space when severe malignant cerebral edema occurs during a craniectomy may be preferable to tissue resection.