The aim of this study was to investigate the association between timing of DC and in-hospital mortality in children with sTBI in Germany. We analyzed cases < 18 years of age from the German hospital database from 2016 to 2022 with sTBI who underwent DC. Selected cases had TBI as primary discharge diagnosis (ICD-10 code: S06) identified via codes of the International-Classification of Disease, 10 th edition, German modification (ICD-10-GM). Cases, procedures and time intervals were identified via ICD codes, procedure codes, and corresponding timestamps.

We defined sTBI as an Abbreviated Injury Scale (AIS) of the head ≥ 3. Injury severity was further assessed using survival risk ratios (SRR), and for each case, the lowest SRR was used to predict the severity of the injury for each case, (single ICISS: International Classification of Injury Severity Score), as previously described [5]. The outcome of interest was in-hospital mortality. A data driven approach was used to define time categories for the time from admission to DC of 0 to < 2 h, 2 to < 3 h, and ≥ 3 h.

9,495 severe TBI cases were identified with AIS head ≥ 3 with a median age of 12 years (IQR 4–16). Of these, 598 (6.3%) cases underwent DC during their hospital stay, 236 (40%) within the first hour and 443 (75.2%) within the first 24 h of hospitalization. More that the half of the DCs (54.8%) were performed within two hours of hospital admission, with numbers declining over the first 24 h of admission (Fig. 1). 164 (27%) of DC cases died in hospital with a median time from admission to death of 2 days. These findings suggest that a substantial proportion of DCs were performed during the initial shock room management and reflected urgent clinical decisions.

a. Distribution of time within the initial 24 h from admission to decompressive craniectomy surgery. *Hours are shown as complete hours. This graph represents 75% of the patients who underwent DC surgery in the first 24 h of admission. b. Cumulative case fatality following time to DC in hours by time to death within 14 days of hospitalization after the DC surgery. *Days and hours are shown as complete days/hours