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Decompressive craniectomy following traumatic brain injury in pediatric patients: An aggregative and individual
Anant Naik1, Cesar Ramirez2, Brandon Hoglund1
1Department of Neurosurgery, University of Minnesota Twin Cities, Minneapolis, MN, USA.
Insights
Decompressive craniectomy (DC) showed no significant difference in mortality or outcomes compared to medical management for pediatric traumatic brain injury (TBI). However, factors like younger age and midline shift impact mortality risk in TBI patients.
Area of Science:
- Neurosurgery
- Pediatric Critical Care
- Trauma Surgery
Background:
- Traumatic brain injury (TBI) in children carries high mortality rates.
- Current guidelines offer weak recommendations for decompressive craniectomy (DC) in pediatric TBI.
- Evidence on the benefits and optimal timing of DC for pediatric TBI is limited.
Purpose of the Study:
- To conduct the largest meta-analysis to date on the utility of DC for pediatric TBI.
- To address gaps in the literature regarding the benefits and timing of DC in pediatric TBI management.
- To evaluate the impact of DC on mortality and neurological outcomes in pediatric TBI patients.
Main Methods:
- A comprehensive search of electronic databases was performed for studies on DC in pediatric TBI patients (<18 years).
- Primary outcomes included in-hospital mortality and Glasgow Outcomes Scale (GOS) scores.
- Risk of bias was assessed, and fixed- or random-effects models were used for meta-analysis and meta-regression.
Main Results:
- The meta-analysis included 39 studies with 1332 patients.
- No significant difference in mortality or GOS was found between DC and medical management groups.
- Factors associated with increased mortality included younger age and midline shift >5 mm; unfavorable outcomes were linked to intraparenchymal hemorrhage, subarachnoid hemorrhage, high ICP, delayed DC (>5 days), and unilateral DC.
Conclusions:
- Decompressive craniectomy (DC) does not significantly alter outcomes compared to medical management for severe pediatric TBI.
- Specific patient factors, including age, injury characteristics, and timing of intervention, are significantly associated with outcomes after DC for TBI.
Objective:
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.
