Early Postoperative Complications after Decompressive Craniectomy for Pediatric Severe Traumatic Brain Injury

Background: Decompressive craniectomy (DC) is used to treat refractory intracranial hypertension after pediatric severe traumatic brain injury (sTBI), but early postoperative neurosurgical complications and their predictors—particularly intracranial pressure (ICP) burden—remain inconsistently characterized. Methods: We performed a retrospective cohort study of consecutive pediatric patients (<18 years) with sTBI (Glasgow Coma Scale [GCS] 3–8) who underwent DC at a single high-volume trauma center. Early postoperative neurosurgical complications were defined a priori as events occurring within 7 days after DC or before hospital discharge: secondary intracranial hemorrhage, central nervous system (CNS) infection, wound dehiscence, and cerebrospinal fluid (CSF) leak. Associations with injury severity, imaging, and ICP variables (mean intraoperative ICP; cumulative duration of ICP >20 mmHg before DC) were evaluated. Results: Eighty-three children were included. At least one early neurosurgical complication occurred in 33 of 83 patients (39.8%). Secondary intracranial hemorrhage occurred in 29/83 (34.9%), CNS infection in 7/83 (8.4%), wound dehiscence in 6/83 (7.2%), and CSF leak in 4/83 (4.8%). Patients with complications had significantly higher intraoperative ICP (40.5 ± 13.5 vs 28.6 ± 4.3 mmHg; p = 0.0058) and longer pre-DC duration of ICP >20 mmHg (4.1 ± 5.9 vs 1.6 ± 2.5 hours; p = 0.0296). At 6 months, 25/83 (30.1%) had died; among survivors, 28/58 (48.3%) achieved a favorable outcome (GOS 4–5), 12% in 1 group (without complications). Conclusions: Early postoperative complications after pediatric DC were common and predominantly hemorrhagic. A greater ICP burden before and during DC was associated with these events. The co-occurrence of CSF leak and CNS infection highlights the importance of dural closure strategies that minimize CSF egress and the need for vigilant postoperative surveillance.