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

Abstract

Purpose: The 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. Methods: Data on patients < 18 years of age treated in Germany, Austria, and Switzerland during a ten-year period were extracted from TraumaRegister DGU(R), forming a retrospective multi-centre cohort study. Descriptive and multivariable analyses were performed to compare mortality and outcomes after decompressive craniectomy and medical management. Results: 2507 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). Conclusion: DC 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.