Volume 259, December 2025, 109210Author links open overlay panel, , , , , , , , Highlights•

TBI in pediatric patients is associated with significant morbidity and mortality.

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Decompressive craniectomy (DC) is weakly recommended in certain circumstances.

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There are significant deficits in the literature regarding DC in pediatric patients.

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This study is a meta-analysis aiming to address these deficits.

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No differences in outcomes were identified between medical management and DC.

AbstractObjective

Traumatic brain injury (TBI) in pediatric patients is associated with significant mortality. Management ranges from conservative treatment to decompressive craniectomy (DC). Current guidelines weakly recommend DC in pediatric patients experiencing neurologic deterioration, herniation, or refractory intracranial hypertension. There are significant deficits in the literature regarding the benefits and optimal timing of DC for pediatric TBI. The objective of this review is to address these gaps via the largest meta-analysis on this subject to date.

Methods

Several electronic databases were searched for articles investigating the utility of DC for patients under 18 years of age suffering from TBI. The primary outcome measures evaluated included in-hospital mortality and Glasgow Outcomes Scale (GOS) scores. Risk of bias was assessed using the Newcastle-Ottawa Scale and Egger’s test. Fixed- or random-effects models were employed based on study heterogeneity. A meta-regression was performed for the pooled main effect.

Results

39 studies with 1332 patients were included for aggregate meta-analysis. No significant difference in mortality or GOS between patients managed with DC versus medical management was observed in this cohort. The results of the multivariable meta-regression in this cohort demonstrated younger age and midline shift greater than 5 mm (MLS) were associated with increased mortality. Intraparenchymal hemorrhage, subarachnoid hemorrhage, high ICP at presentation, delayed DC > 5 days, and unilateral DC were associated with unfavorable neurological outcomes.

Conclusion

No significant difference in outcomes was identified between DC versus medical management for severe TBI. Several patient factors were identified that are significantly associated with unfavorable outcomes after DC.

Introduction

Traumatic brain injury (TBI) is a prevalent childhood condition associated with severe morbidity and mortality [1]. Severe TBI increases intracranial pressure (ICP), which can be life-threatening and cause significant brain injury if not properly treated [1]. Optimal management of TBI is complex and may include medical management and surgical intervention with a decompressive craniectomy (DC) [1], [2]. DCs lower elevated ICP by allowing the brain to expand without being compressed by the cranium [2]. They involve removing part of the skull and replacing it after the swelling has decreased [2].

The indications for DC in pediatric patients are complex and controversial. DC has been shown to improve outcomes in adult patients with TBI, particularly in those with large cerebral contusions or brain edema unresponsive to medical management [2]. However, there are risks associated with the procedure, including infection, blood loss, persistent neurologic dysfunction, and scarring [2]. Also, the long-term effects in pediatric patients of removing part of the skull and replacing it with an artificial flap are not fully understood [3]. The decision to perform the procedure is based on careful consideration of the benefits and risks. Factors such as the child's age, the severity of the TBI, and the presence of comorbidities must be considered [4]. In 2019, the AANS Joint Section for Neurotrauma guidelines for Pediatric TBI suggested DC for neurologic deterioration, herniation, or intracranial hypertension refractory to medical management [4]. In those guidelines, several notable deficits in the literature regarding the benefit and timing of decompressive surgery were described [4]. Since then, no rigorous analysis of the literature has been performed to address these deficits.

The present study aims to address these deficits via a meta-analysis featuring the largest number of studies to date on DC for pediatric TBI. Complex meta-analysis and meta-regression methodologies were used to analyze individual patient data (IPD) and assess management strategies and outcomes. This review aims to enable neurosurgeons to better assess the efficacy and limitations of DC in TBI and provide guidelines based on the best available evidence.

Section snippetsSearch strategy and selection criteria

A Preferred Reporting in Systematic Reviews and Meta-Analysis (PRISMA)-adherent search was performed on PubMed/MEDLINE, Scopus, and Web of Knowledge on December 26th, 2022, for all clinical articles investigating the utility of DC for pediatric patients with severe TBI. This review was not previously registered, though an a priori protocol was prepared. The search terms employed were: (decompressive craniectomy) AND (pediatr*) AND (traumatic brain injury). Articles were included if they were

Search results

From a total of 444 records, 40 full studies were included for complete analysis. Fig. 1 presents the flow of evidence. 19 studies with 178 patients were included for IPD analysis, whereas 39 studies with 1332 patients were included for pooled aggregative analysis. Some studies featured both aggregate and individual patient data. Table S2 presents the features of all included studies.

DC vs. medical management for severe TBI

An aggregated meta-analysis was performed to compare medical management with DC for two outcomes – mortality and

Discussion

TBI leaves more than 61 % of affected pediatric patients with moderate to severe disability [9]. TBI also accounts for an estimated 3000 deaths in patients aged 0–14 years [9]. TBI in pediatric patients is an emergency that may present unique challenges due to their underdeveloped anatomy and physiology [10]. A serious complication is refractory ICP, for which management ranges from conservative treatment (monitoring, hyperventilation, and osmotherapy) to DC. Although guidelines exist for DC in

Conclusions

There is considerable uncertainty regarding the indications and timing of DC for pediatric TBI. The present study aimed to address this uncertainty with the largest meta-analysis of DC for TBI in pediatric patients. No significant differences in outcomes were observed between pediatric patients with severe TBI who were managed medically and those who were managed with DC. Additionally, several patient factors were identified that are associated with outcomes following DC, with mixed results

CRediT authorship contribution statement

Ankitha Iyer: Writing – review & editing, Supervision, Conceptualization. Umaru Barrie: Writing – review & editing, Supervision. Cesar Ramirez: Writing – original draft, Investigation, Formal analysis, Data curation, Conceptualization. Brandon Hoglund: Writing – review & editing, Writing – original draft, Project administration. Anant Naik: Writing – review & editing, Writing – original draft, Supervision, Project administration, Formal analysis, Data curation. Paul M. Arnold: Writing – review

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