CT-Defined Injury Patterns and 90-Day Functional Status After Operative Pediatric Traumatic Brain Injury

Background/Objectives: Children who require surgery after traumatic brain injury (TBI) represent a heterogeneous population. We compared 90-day functional status between epidural hematoma (EDH)-predominant injuries and injuries containing acute subdural hematoma (SDH) and/or cerebral contusion, and examined whether quantitative CT measures added useful context. Methods: We retrospectively studied 53 patients aged 1–18 years who underwent cranial surgery for acute TBI between June 2020 and June 2026. The primary comparison included 41 patients aged ≤ 16 years; 40 (97.6%) had assigned 90-day Glasgow Outcome Scale—Extended Pediatric Revision (GOS-E Peds) status. Preoperative CT scans were reviewed using a predefined protocol. Results: SDH/contusion-associated patients had lower admission GCS (median 10 vs. 15) and higher Rotterdam CT scores (3 vs. 1). Good recovery (GOS-E Peds 1–2) at 90 days occurred in 9/13 (69.2%) SDH/contusion-associated patients and 25/27 (92.6%) EDH-predominant patients. The corresponding exact odds ratio for absence of good recovery was 5.28 (95% CI 0.63–68.02; p = 0.075), with an absolute risk difference of +23.4 percentage points (95% CI −0.8 to 50.8). Adjustment for admission GCS attenuated the association (OR 2.57, 95% CI 0.37–19.09). Continuous midline shift was similar between the CT-pattern groups and was not associated with 90-day status. Conclusions: CT-defined injury patterns identified children with different initial injury burdens, but the 90-day association was imprecise and partly tracked admission neurological severity. CT anatomy should therefore be interpreted together with the clinical examination rather than used as a stand-alone prognostic classifier.