Decompressive craniectomy in children and adolescents with severe traumatic brain injury: a systematic review.

Abstract

Introduction/Background: Decompressive craniectomy (DC) is a neurosurgical technique employed in pediatric patients with severe traumatic brain injury (sTBI). However, consensus remains lacking regarding the specific criteria for its indication. The objective of this study is to synthesize data concerning the clinical and CT scan criteria for performing DC in children and adolescents with sTBI. Methodology: This systematic review analyzed scientific studies indexed in the MEDLINE database via the PubMed platform. The search included studies published between 2015 and 2025 that involved children and adolescents (under 18 years of age) with sTBI treated with DC. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD420251159406). Results: Eighteen manuscripts describing the clinical and tomographic criteria for DC indication were included. In a combined sample of 916 children, pupillary abnormalities (162/343; 47.2%) were identified as a primary clinical factor guiding surgical decisions. CT imaging revealed post-traumatic intracranial mass lesions associated with midline shift (MLS), further justifying the procedure. Invasive intracranial pressure monitoring (ICPm) was utilized in 48.6% (386/794) of cases, and the overall mortality rate was 24% (220/916). Conclusion: In children and adolescents victims of sTBI, pupillary abnormalities coupled with CT evidence of acute intracranial lesions, mass effect, and MLS are key indicators for DC, whether or not invasive ICPm is employed.