Decompressive craniectomy in pediatric patients with traumatic brain injury: an up to date comprehensive review.

introductionTraumatic brain injury (TBI) is a leading cause of morbidity and mortality among children worldwide. Decompressive craniectomy (DC) is considered a life-saving option for refractory intracranial hypertension, yet its role, timing, and long-term outcomes in the pediatric population remain controversial.

methodWe conducted a systematic review in accordance with PRISMA guidelines, searching PubMed and Scopus up to 2025. Eligible studies included pediatric patients (< 18 years) with TBI who underwent DC and reported outcomes. Data were extracted on patient characteristics, timing and type of surgery, and clinical outcomes. Methodological quality was assessed using a modified Newcastle-Ottawa Scale. Pooled analyses were performed for mortality and functional recovery.

resultsA total of 33 studies, comprising 666 pediatric patients, were included. Most studies were observational, with one randomized controlled trial. The mean age ranged from 1.6 to 16 years, and initial Glasgow Coma Scale scores from 3 to 10. Hemidecompression was the most common surgical approach. The pooled favorable outcome rate was 66.1% (95% CI 55.4-76.0), while pooled mortality was 18.9% (95% CI 13.6-24.8). Favorable outcomes were more frequent in patients with higher initial GCS (> 6) and in larger cohorts.

conclusionDC remains a critical intervention for severe pediatric TBI, offering survival with meaningful recovery in nearly two-thirds of cases. However, significant heterogeneity exists, underscoring the need for standardized reporting and well-designed multicenter trials to optimize patient selection and timing.