Decompressive craniectomy: The potential association with long-term functional outcomes in children with traumatic brain injury

Background: Traumatic brain injury (TBI) is the leading cause of death and disability in pediatric patients. However, TBI management widely varies due to a lack of high-quality evidence in pediatric population. We aimed to determine the association of decompressive craniectomy (DC) on long-term functional independence in pediatric TBI. We hypothesize that the use of DC would not be associated with improved functional independence after discharge. Methods: This is a retrospective cohort study using the Federal Interagency Traumatic Brain Injury Research (FITBIR) Informatics System, a national database of TBI studies. The Approaches and Decisions in Acute Pediatric TBI (ADAPT) Trial was selected for its international patient population from 2014 to 2017. Patients (age ≤18 y) with TBI, Glasgow Coma Scale (GCS) ≤8, and insertion of an intracranial pressure monitor were categorized into the DC and no-DC groups. The primary outcome was Glasgow Outcome Scale-Extended Pediatric Version (GOS-E Peds) at a follow-up visit ≥6 months postdischarge. A secondary analysis included all patients admitted for the management of TBI to examine the association between DC and in-hospital mortality. Results: We included 686 TBI patients followed up ≥6 months postdischarge or recorded mortality. Of those, 213 (31.0%) patients received DC. The median GCS on presentation was 5. The median GOS-E at follow-up was 5. In a multivariate regression model, the use of DC was not associated with good functional recovery defined as GOS-E Peds <5 (odds ratio [OR]: 0.64, 95% CI: 0.39–1.05, p =0.077). In a secondary analysis, DC was not associated with in-hospital mortality (OR: 1.02, 95% CI: 0.60–1.74, p =0.95). Conclusion: The results of this study suggest that DC is not significantly associated with favorable functional outcomes >6 months postdischarge or decreased in-hospital mortality. Future research is warranted to further delineate the indication for DC in the pediatric TBI population. LEVEL OF EVIDENCE: Prognostic/epidemiological study; Level IV.