Decompressive Craniectomy in Pediatric Traumatic Brain Injury: A Retrospective Cohort Study

Introduction: Decompressive craniectomy in children with traumatic brain injury (TBI) and refractory raised intracranial pressure (ICP) remains controversial. We aimed to describe the clinical and operative characteristics of children with moderate to severe TBI who underwent decompressive craniectomy, and compare outcomes with those who received medical therapy. Methods: We performed a retrospective observational cohort study on children < 16 years old with moderate to severe TBI (Glasgow Coma Scale, GCS ≤ 13 who underwent DC in 2 pediatric centers in Singapore and China between 2014 and 2017, and compared their outcomes to children who underwent medical treatment, among participating centers of the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN). We defined poor functional outcomes as moderate, severe disability, vegetative or comatose state, or mortality, using the Pediatric Cerebral Performance Category scale. We performed multivariable logistic regression to identify predictors for poor functional outcomes. Results: We analyzed 18 children who underwent DC with 214 who had medical therapy. A greater proportion of children with DC (14, 77.8%) experienced poor functional outcomes, compared to those with medical therapy (87, 41.2%, p=0.003). Children who underwent DC had fewer median 14-day ICU-free days (2.5 days, interquartile range, IQR 0.0 – 5.8 vs 8.0, IQR 0.0 – 11.0, p=0.033), median 28-day hospital-free days (0 days, IQR 0.0-3.5 vs 11.0, IQR 0.0 – 21.0, p=0.002) and 14-day mechanical ventilation-free days (6.5 days, IQR 0.0 – 12.3 vs 11.0, IQR 3.0 – 14.0, p=0.011). After accounting for age, sex, GCS, cerebral edema, uncal herniation, nonaccidental injury (NAI) and need for intubation, there was no significant association between decompressive craniectomy and poor functional outcomes (aOR 1.59, 95% CI 0.35 – 7.24, p = 0.548). Conclusions: Children with DC had severe injuries, prolonged hospital and ICU stays. Future studies are needed to understand the effectiveness of DC on children with TBI.