Mortality and outcomes after decompressive craniectomy in children with severe traumatic brain injury

Abstract

PurposeThe effect of decompressive craniectomy (DC) on mortality and outcomes in children with elevated intracranial pressure after severe head trauma is strongly debated and high-quality evidence is lacking. This study was conducted to determine whether DC in children with severe head trauma is associated with a decrease in mortality or poor outcomes at discharge from the intensive care unit.MethodsData on patients < 18 years of age treated in Germany, Austria, and Switzerland during a ten-year period were extracted from TraumaRegister DGU®, forming a retrospective multi-centre cohort study. Descriptive and multivariable analyses were performed to compare mortality and outcomes after decompressive craniectomy and medical management.Results2507 patients were included, of which 402 underwent decompressive craniectomy. Mortality was 20.6 % in children undergoing DC compared to 13.7 % after medical management. Observed and predicted mortality after DC and medical management matched in all subgroups except in children between six and 17 years of age, where mortality after DC was lower than predicted. Poor outcome was observed in 27.6 % of DC patients vs. 16.1 % receiving medical management. Logistic regression revealed slightly negative effects of DC on mortality (odds ratio 1.20, not significant) and outcomes (odds ratio 1.56 (95% confidence interval 1.01-2.40).ConclusionDC did not decrease overall mortality or rates of poor outcome. However, children above six years of age may benefit from DC. High quality prospective studies are urgently needed.

Impact of Intracranial Hypertension on Outcome of Severe Traumatic Brain Injury Pediatric Patients: A 15-Year Single Center Experience

“…With regard to second-tier interventions, a high percentage of 67% of those patients who underwent decompressive craniectomy had a favorable functional outcome. This is in accordance to recent studies both in children and adults showing that patients with refractory IC-HTN can achieve a good neurologic outcome after secondary decompressive craniectomy [ 36 , 41 , 42 , 43 ], while current reports highlight the importance of early and aggressive treatment algorithms, especially for pediatric TBI patients, who have higher recovery rates compared to adults [ 13 ]. However, other detailed reviews in adults highlight the significantly reduced mortality, but also the increased proportions of severely disabled patients in the decompressive craniectomy group of patients, when compared to conservatively treated medical groups.…”

Decompressive Craniectomy in Pediatric Traumatic Brain Injury: A Retrospective Cohort Study

“…8,16,25 We did not find a difference in mortality between children who underwent DC compared with those who did not, similar to another multicenter study of 2,507 children. 13 After adjusting for severity, we did not find an independent association between DC and poor outcomes. Our study adds to the current literature, with others similarly reporting no difference between the DC and non-DC groups.…”

“…Other studies have similarly compared the outcomes of children who underwent DC with those who only underwent medical therapy. 10,11,13,21 This article is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. 22 The checklist is included in the ►Supplementary Tables (available in the online version only).…”

“…Other studies have similarly compared the outcomes of children who underwent DC with those who only underwent medical therapy. 10 11 13 21…”

“…7 There is a lack of consensus regarding the benefit of DC over medical management, with some studies reporting better or comparable clinical outcomes, 10,11 and others reporting worse outcomes. 12,13 The only randomized controlled trial (RCT) on outcomes of early DC in a pediatric population conducted in 2001 found that functional outcome and quality of life may be better than in children treated medically without DC. 14 Among studies reporting DC in children with TBI, there remains great variability in surgical techniques and timing of surgery.…”