Socioeconomic correlates of decompressive craniectomy outcomes for pediatric traumatic brain injury: a meta-epidemiological study

Introduction: Low- and middle-income countries experience high pediatric traumatic brain injury rates. A decompressive craniectomy (DC) is a viable option for patients who are unresponsive to medical management. In 2019, the AANS Joint Section for Neurotrauma developed guidelines for pediatric TBI; however, the literature regarding socioeconomic factors that influence the success rate of DC in resource-poor environments remains sparse. Identification of these barriers is important to modify appropriate guidelines for these communities. Methods: A PRISMA-adherent systematic review of four databases was performed to identify all primary articles investigating outcomes following DC in pediatric patients. Data were extracted for study features and primary outcomes including mortality and postoperative functional status. Socioeconomic epidemiological metrics, including poverty, population density, and health outcomes, were obtained from the United Nations and World Bank. A multivariable meta-regression analysis was performed to evaluate epidemiological factors influencing the pooled mortality and GOS estimates. Results: Data from 39 studies, spanning 17 unique countries were abstracted. The mean age of patients in LMIC undergoing DC was younger, mean 4.74 (sD = 2.76) vs. mean 9.37 (sD = 3.52). Factors correlated with mortality rate included Human Development Index (HDI) (B (SE) = −2.33 (1.02), p = 0.022), population density (0.798 (0.188), p < 0.001), percent of urban population (−0.02 (0.007), p = 0.006), percent of underweight population under 5 years of age (0.028 (0.011), p = 0.010), school enrollment (−0.018 (0.006), p = 0.006), LMIC status (0.83 (0.323), p = 0.010), and the number of hospital beds (−0.12 (0.039), p = 0.002). Post-operative GOS was not associated with any epidemiological covariates. Conclusion: Socioeconomic determinants predict the success rate of DC in pediatric traumatic brain injury. Population density and the number of hospital beds having the strongest correlation to mortality rate indicate that low-resource, high-volume communities suffer from worse outcomes post-DC.