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.