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Published on: August 16, 2019
Surgical Versus Medical Management for Severe Pediatric Traumatic Brain Injury: A Systematic Review and Meta-Analysis
Leonardo Di Cosmo1, Jad El Choueiri1, Francesca Pellicanò1
1Department of Biomedical Sciences, Humanitas University, Milan, Italy.
Insights
Decompressive craniectomy (DC) offers no clear survival or functional benefits for pediatric severe traumatic brain injury (TBI) compared to medical management (MM). However, DC is linked to significantly longer intensive care unit and hospital stays in these children.
Area of Science:
- Neurosurgery
- Pediatric Critical Care
- Trauma Surgery
Background:
- Severe pediatric traumatic brain injury (TBI) necessitates interventions to manage intracranial pressure.
- Decompressive craniectomy (DC) is a surgical option, but its efficacy in children is debated.
- Existing evidence comparing DC to medical management (MM) in pediatric TBI is limited and conflicting.
Purpose of the Study:
- To conduct a meta-analysis evaluating the comparative outcomes of DC versus MM in pediatric patients with severe TBI.
- To synthesize current evidence to inform clinical decision-making and guideline development.
Main Methods:
- Systematic literature search following PRISMA guidelines up to October 2025.
- Inclusion of randomized controlled trials and observational studies comparing DC and MM in patients under 18 with severe TBI.
- Application of random-effects models for meta-analysis of clinical outcomes.
Main Results:
- Analysis included 553 patients undergoing DC and 2336 patients receiving MM.
- No significant difference in favorable functional outcomes (Glasgow Outcome Scale) or mortality was found between DC and MM groups.
- DC was associated with significantly longer intensive care unit (ICU) stays (mean difference 6.2 days) and a trend towards longer hospital stays.
Conclusions:
- Decompressive craniectomy (DC) does not demonstrate clear survival or functional advantages over medical management (MM) in pediatric severe TBI.
- DC is associated with increased length of ICU and hospital stays.
- Further high-quality, prospective, multicenter studies are essential to validate these findings and establish pediatric-specific guidelines.
Background And Objectives:
Decompressive craniectomy (DC) is used to control intracranial pressure in severe pediatric traumatic brain injury (TBI), although evidence of its benefit in pediatric patients remains conflicted. To address this, this meta-analysis evaluates the outcomes of DC vs medical management (MM) in pediatric severe TBI.
Methods:
Following PRISMA guidelines, databases were searched through October 2025 for studies comparing DC and MM in patients younger than 18 years with severe TBI. Randomized control trials and prospective and retrospective studies reporting at least one clinical outcome were included. Random-effects models were applied, with relative risks used for dichotomous outcomes and mean differences for continuous outcomes.
Results:
Our analysis included 553 DC and 2336 MM patients, with 1 randomized trial and 10 observational studies. Pooled analyses showed no significant difference in good functional outcomes between DC and MM, whether based on the Glasgow Outcome Scale or study-specific definitions or mortality (1.06, 95% CI 0.69-1.64; P = .78). Subgroup analyses of Glasgow Outcome Scale scores at discharge and 30 days corroborated these findings. DC was associated with a significantly longer intensive care unit stay (mean differences, 6.2 days, 95% CI 4.4-8.0; P < .001) and a similar trend toward longer hospital stay (mean differences, 4.0 days, 95% CI -0.6 to 8.7; P = .09), which became significant on sensitivity analysis. Reported complication rates, when reported, were low and comparable across groups.
Conclusion:
In children with severe TBI, DC does not appear to provide clear survival or functional advantages over MM and is significantly associated with longer intensive care unit and hospital stays. However, these findings should be interpreted with caution as the current literature mainly composed of small and heterogeneous retrospective studies. Further large, prospective, multicenter studies are needed to confirm these findings, refine surgical indications, and establish pediatric-specific management guidelines.
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