Timing of Craniotomy and Associated Outcomes in Severe Blunt Traumatic Brain Injury.

INTRODUCTION/RATIONALE: Traumatic brain injuries (TBIs) are a leading cause of death among adults, resulting in approximately 214,110 TBI-related hospitalizations and 69,473 TBI-related deaths in the United States. There remains some debate regarding the optimal timing of craniotomy particularly as it relates to the use of intracranial pressure (ICP) monitoring.

OBJECTIVE

Our study aims to determine the association of time to craniotomy intervention (≤6 or >6 hr), ICP monitoring, and trauma center level on patient outcomes in blunt, severe, non-subarachnoid TBI with skull fracture.

METHODS

This retrospective study utilized the American College of Surgeons-Trauma Quality Improvement Program (ACS-TQIP) database to examine adult trauma patients (age ≥18 years, Injury Severity Score ≥15) between 2017 and 2023. The study included patients with isolated, severe, blunt, non-subarachnoid hemorrhage TBIs (Glasgow Coma Scale ≤8, Abbreviated Injury Scale ≥2) measuring ≥8 mm. Outcomes of interest were stratified by trauma center level and whether they underwent ICP monitoring.

RESULTS

A total of 3,265 adult patients with isolated, blunt, severe, non-subarachnoid TBIs were included in this analysis. Patients who had ICP monitoring and received craniotomy within 6 hr had no significant difference in odds of mortality (aOR: 0.662, 95% CI: 0.326-1.345, p = .254). Patients who received craniotomy beyond 6 hr were 2.5 times more likely to be associated with in-hospital mortality (aOR: 2.54, 95% CI: 1.19-5.39, p = .016). ICP monitoring correlated with a 1.4-day longer intensive care unit length of stay (β = 1.40, 95% CI: 0.56-2.25, p = .001) and 2.0 fewer ventilator-free days (β = -1.95, 95% CI: -3.16 to -0.74, p = .002). ICP-monitored patients had 50% lower odds of discharge to home (aOR: 0.50, 95% CI: 0.30-0.82, p = .006).

CONCLUSION

In patients with severe TBI, our findings indicate that late craniotomy had increased odds of in-hospital mortality, suggesting a benefit to craniotomy prior to 6 hr. ICP monitoring should be evaluated on a case-by-case basis in this patient population to ensure proper and effective use toward improving patient outcomes and overall prognosis.