Predictors of Posttraumatic Hydrocephalus in Operated Pediatric Traumatic Brain Injury: A Decade of Experience from a Thai Trauma Center

Abstract Posttraumatic hydrocephalus (PTH) is a serious complication of traumatic brain injury (TBI) that may adversely affect neurological outcomes if not recognized and treated promptly. Although several clinical and surgical risk factors have been reported, evidence in pediatric populations, particularly from low- and middle-income countries, remains limited. This study aimed to identify the clinical and surgical factors associated with PTH in pediatric TBI patients at a level 2 trauma center in Thailand. This retrospective study enrolled 282 pediatric patients with TBI who underwent neurosurgical procedures (craniotomy or craniectomy) between 2015 and 2024. Descriptive statistics, chi-square tests, Mann–Whitney U tests, and binary logistic regression were used to evaluate the associations between clinical variables and PTH. Subgroup analyses were conducted based on the Glasgow Coma Scale, subarachnoid hemorrhage grade, duration of mechanical ventilation, and length of hospitalization. Kaplan–Meier survival analysis was used to compare the time to development of PTH across key risk factors. The incidence of PTH was 5.7% (16/282). Craniectomy was a strong independent predictor of PTH (adjusted odds ratio [aOR] = 7.33, 95% confidence interval [CI]: 1.19–45.03, p = 0.031). Subdural hematoma (SDH; aOR = 9.62, 95% CI: 2.63–35.26, p < 0.001) and mechanical ventilation for >96 hours (aOR = 12.09, 95% CI: 2.55–57.28, p = 0.002) were also significantly associated with PTH. Among ventilated patients, prolonged hospitalization was associated with PTH only in those requiring mechanical ventilation for >96 hours (p < 0.001). Survival analysis demonstrated a significantly delayed onset of PTH in patients requiring mechanical ventilation for >96 hours (mean, 296.2 days) compared with those ventilated for ≤96 hours (mean, 26.5 days; log-rank p = 0.049). Subgroup analysis confirmed the craniectomy–PTH association in both the mild and severe TBI groups (p < 0.001). Among the PTH cases, the median time to diagnosis was 112 days (interquartile range, 33–293 days). Age group and time to cranioplasty were not significantly associated with PTH. Craniectomy, SDH, and prolonged mechanical ventilation are key predictors of PTH in pediatric TBI patients. The delayed onset of PTH among patients requiring prolonged mechanical ventilation highlights the need for long-term surveillance in high-risk pediatric TBI patients.