Neurocritical Care Management Challenges in Pediatric Traumatic Brain Injury: Insights from Three Illustrative Cases

Pediatric traumatic brain injury (pTBI) remains a major contributor to mortality and long-term morbidity worldwide. Management is challenging due to age-specific physiology, evolving brain maturation, and limited pediatric-specific evidence for advanced neurocritical care interventions. We report three challenging cases of severe pTBI requiring complex neurocritical care decision-making. The first case highlights the effective use of Tier-3 therapy using barbiturate-induced coma for refractory intracranial hypertension in a 3-year-old child with diffuse cerebral edema, demonstrating safe and sustained intracranial pressure control and delayed yet meaningful neurological recovery, facilitated by bispectral index-guided titration. The second case describes conservative yet vigilant management of post-extubation stridor in a 1-year-old infant with a compound skull fracture following surgical stabilization, successfully avoiding re-intubation through stepwise escalation of respiratory and pharmacologic support. The third case highlights the complexity of managing persistent intracranial hypertension after decompressive craniectomy in a 7-year-old child with concurrent acute respiratory distress syndrome, emphasizing strategies to balance lung-protective ventilation with cerebral physiology. These cases illustrate that timely, tailored neurocritical care interventions can successfully address complex challenges in pTBI, supporting meaningful recovery even in severe presentations.