Clinical and tomographic criteria for neurosurgical approaches in children with severe traumatic brain injury: A systematic review

Abstract

Background: Severe traumatic brain injury (sTBI) remains a major cause of mortality and disability in children worldwide. Intracranial pressure monitoring (ICPm) and decompressive craniectomy (DC) are commonly employed in the management of pediatric sTBI, the clinical and radiological criteria guiding these interventions remain heterogeneous. Methods: A systematic review was conducted according to PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, and LILACS were searched in March 2026 for studies published within the last 10 years. Eligible studies included pediatric patients (<18 years) with severe TBI (Glasgow Coma Scale [GCS] <9) and reported quantitative clinical or tomographic criteria for neurosurgical interventions. Results: From 2,763 retrieved records, 21 studies met the inclusion criteria, including 10 focused on ICPm and 11 on DC. ICPm was primarily indicated in patients with GCS≤8 and abnormal computed tomography findings, particularly brain swelling and high Marshall scores. Intracranial hypertension thresholds varied between 15 and 20 mmHg, with some age-adjusted approaches. For DC, the most frequent radiological findings were acute subdural hematoma, midline shift, diffuse cerebral edema, and signs of herniation. Lower GCS scores and pupillary abnormalities were consistently associated with worse outcomes. While ICP-guided management and DC were associated with improved physiological control and, in some studies, better functional outcomes, consistent reductions in mortality were not demonstrated. Conclusions: Current evidence reveals substantial heterogeneity in the clinical and tomographic criteria used for ICPm and DC in pediatric sTBI. Standardized prospective multicenter studies are needed to define optimal indications and improve outcome prediction.