A Literature Review of Decompressive Craniectomy for Paediatric Patients in Low-and-Middle Income Countries

Traumatic brain injury (TBI) is one of the leading causes of mortality and morbidity in children worldwide. In severe cases, high intracranial pressure (ICP) is the most frequent cause of death. When first-line medical management fails, the neurosurgical procedure of decompressive craniectomy (DC) has been proposed for controlling ICP and improving the long-term outcomes for children with severe TBI. However, the use of this procedure is controversial. The evidence from clinical trials shows some promise for the use of DC as an effective second-line treatment. However, it is limited by conflicted trial results, a lack of trials and a high risk of bias. Furthermore, most research comes from retrospective observational studies and case series. This narrative review will consider the current strength of evidence for the use of DC in both a high-income country (HIC) and low-to-middle income country (LMIC) setting and examine how we can improve study design to better assess the efficacy of this procedure and increase the clinical translatability of results to centres worldwide. Specifically, we argue for a need for further studies with higher paediatric participant numbers, multi-centre collaboration and the use of a more consistent methodology to enable comparability of results between settings.Abstract word count: 200.