The presence of traumatic brain injury (TBI) is a critical determinant of post-traumatic mortality and morbidity. Not only is TBI one of the leading causes of death among severely injured patients, but it also substantially impacts long-term outcomes following severe trauma. Neurocritical care has a profound effect on outcomes following brain injury; nevertheless, its application in preclinical studies remains infrequent. This review therefore discusses strategies to improve the translational relevance of experimental TBI research, including the integration of neurocritical care principles in animal models. The review further addresses the impact of observation periods after injury and the selection of appropriate animal models (large vs. small animal models). In addition, commonly used injury induction methods—including controlled cortical impact (CCI), fluid percussion injury (FPI), weight-drop models, and blast injury paradigms—are discussed in terms of their reproducibility and clinical relevance. Finally, the review explores whether age, comorbidities, and sex influence TBI outcomes—and, if so, how these variables should be incorporated into experimental designs to improve translational fidelity.

Background: Decompressive craniectomy (DC) is a life-saving intervention for refractory intracranial pressure (ICP). While outcomes in adults are well documented, pediatric data, especially concerning pupillomotor dysfunction, remain limited. Anisocoria is generally considered a marker of severe neurological compromise, but its clinical relevance in children undergoing DC has not been adequately studied. Methods: We retrospectively reviewed 25 pediatric patients treated with DC between 2004 and 2024. Demographic, radiological and clinical data included age, sex, hospital stay, operative time, etiology, side of craniectomy, preoperative midline (ML) shift, Marshall score, Rotterdam score, Glasgow Coma Scale (GCS) and pupillary status before surgery. Functional outcomes were assessed using the pediatric version of the Glasgow Outcome Scale Extended (pGOS-E) at discharge, after 3 months, 1, 2 and 4 years. Results: The majority of patients were school-aged children with a median age of 10 (range 0–17) years. Traumatic brain injury accounted for 16 cases and represented the leading etiology for DC. Pupillomotor dysfunction (anisocoria or bilateral fixed pupillary dilatation) was observed in 15 of 25 patients, 47% of whom died during hospitalization, demonstrating a significant association with in-hospital mortality (p = 0.02). However, survivors with primary pupillomotor dysfunction demonstrated a favorable recovery at 12 months with a median pGOS-E of 6 (range 4–8), indicating moderate disability. A preoperative ML-shift > 5 mm was not associated with lower pGOS-E scores during follow-up (p > 0.05). Bone flap autolysis was observed in 12 out of 14 children (86%) receiving autologous cranioplasty, and 8 (57%) patients required revision surgery with synthetic material. Conclusions: In pediatric patients, pupillomotor dysfunction is associated with higher early mortality but does not reliably exclude favorable long-term outcomes. Compared with adult cohorts, children appear to have a greater potential for neurological recovery, suggesting that severe initial clinical findings alone should not preclude timely surgical intervention.