# Timing of decompressive craniectomy and short-term outcomes in pediatric severe traumatic brain injury: a nationwide observational study in Germany

## TL;DR

This study examines when decompressive craniectomy is performed in children with severe brain injuries and how timing affects recovery and survival.

## Contribution

The study provides new insights into the impact of early versus late decompressive craniectomy timing on pediatric severe traumatic brain injury outcomes.

## Key findings

- Early decompressive craniectomy was associated with higher odds of in-hospital mortality.
- Survivors who underwent early decompressive craniectomy had shorter mechanical ventilation and hospital stays.
- Sensitivity analyses confirmed the association between early timing and improved recovery metrics in survivors.

## Abstract

Decompressive craniectomy (DC) is a critical intervention for managing severe traumatic brain injury (sTBI) in children when medical therapy fails, but the optimal timing remains unclear. This study evaluated the association between different DC timing and short-term outcomes in pediatric sTBI in Germany. A retrospective cohort study of the German national hospital discharge database was conducted for cases < 18 years undergoing DC following sTBI were extracted from 2016 to 2022. Time from admission to DC were calculated as complete hours and data were compared between early (time to DC ≤ 2 h) and late DC (> 2 h). Hierarchical logistic regression models evaluated the association of DC timing with in-hospital mortality, functional outcomes (Pediatric Complex Chronic Conditions (PCCC) ≥ 2)), poor outcome (composite outcome of death or PCCC ≥ 2), length of hospital stay, days on mechanical ventilation (MV) and coding of seizures. Among 13,492,821 children hospitalized, 9,495 had sTBI. DC was performed in 598 cases and half of surgeries were performed within the first two hours after admission. Higher odds of death (adjusted odds ratio [OR] 2.89; 95% confidence interval [95%CI] 1.43–5.85) were observed in the early versus late DC groups. However, in survivors, early DC was linked to shorter durations MV and hospital stay. Sensitivity analyses across multiple thresholds of DC timing confirmed mortality and MV findings. Early DC in pediatric sTBI was primarily performed as an urgent intervention in critical injured patients, yet survivors showed faster recovery with few MV days and hospital stay.

The online version contains supplementary material available at 10.1038/s41598-026-35837-3.