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Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management
Ali Mansour1,2, Plamena P Powla1, Farima Fakhri1
1Department of Neurology, Division of Neurocritical Care, University of Chicago Medical Center, Chicago , Illinois , USA.
Insights
Early neurosurgery for penetrating brain injury (PBI) in civilians improves survival rates but may increase intensive care unit (ICU) length of stay (LOS). This finding highlights the trade-offs in managing severe brain trauma.
Area of Science:
- Neurosurgery
- Trauma Care
- Critical Care Medicine
Background:
- Penetrating brain injury (PBI) presents complex management challenges.
- Determining optimal timing for neurosurgical intervention is crucial for patient outcomes.
Purpose of the Study:
- To compare outcomes of early neurosurgical intervention versus no-neurosurgical intervention in civilian PBI patients.
- To analyze the impact of timely surgical management on mortality, ICU length of stay, and disposition.
Main Methods:
- Retrospective analysis of the National Trauma Data Bank (2017-2019) for PBI cases.
- Inclusion criteria: age 16-60, ICU LOS >2 days, GCS 3-12, reactive pupils; exclusion: WLT within 72 hours.
- 1:1 matching and propensity score-weighted analysis were used to compare outcomes between surgical and non-surgical groups.
Main Results:
- Early neurosurgical intervention (within 24 hours) was associated with significantly higher survival rates (OR 1.66, P < .01) in matched cohorts.
- Propensity score-weighted analysis confirmed increased odds of survival with early surgery (OR 1.8, P < .01).
- Early surgery correlated with a longer ICU length of stay (median 12 days vs 8 days, P < .05).
Conclusions:
- Early neurosurgical intervention in PBI patients is linked to reduced mortality.
- Increased ICU length of stay is a consequence of early surgical management.
- The findings support the consideration of early neurosurgical intervention for improved survival in PBI.
Background And Objectives:
To compare the outcomes of early vs no-neurosurgical intervention in civilians with penetrating brain injury (PBI).
Methods:
We collected data from the National Trauma Data Bank for PBI between 2017 and 2019. A total of 10 607 cases were identified; 1276 cases met the following criteria: age 16-60 years, an intensive care unit (ICU) length of stay (LOS) of >2 days, a Glasgow Coma Scale of 3-12, and at least one reactive pupil on presentation. Patients with withdrawal of life-sustaining treatments within 72 hours were excluded, leaving 1231 patients for analysis. Neurosurgical intervention was defined as an open-approach cranial procedure involving release, drainage, or extirpation of brain matter performed within 24 hours. Outcomes of interest were mortality, withdrawal of life-sustaining treatments, ICU LOS, and dispositional outcome.
Results:
The target population was 1231 patients (84.4% male; median [IQR] age, 29 [18] years); 267 (21.7%) died, and 364 (29.6%) had a neurosurgical intervention within the first 24 hours. 1:1 matching yielded 704 patients (352 in each arm). In the matched cohort (mortality 22.6%), 64 patients who received surgery (18.2%) died compared with 95 (27%) in the nonsurgical group. Survival was more likely in the surgical group (odds ratio [OR] 1.66, CI 1.16-2.38, P < .01; number needed to treat 11). Dispositional outcome was not different. Overlap propensity score-weighted analysis (1231 patients) resulted in higher odds of survival in the surgical group (OR 1.8, CI 1.16-2.80, P < .01). The E-value for the OR calculated from the matched data set was 2.83. Early neurosurgical intervention was associated with longer ICU LOS (median 12 days [7.0, 19.0 IQR] vs 8 days [4.0, 15.0 IQR], P < .05).
Conclusion:
Management including early neurosurgical intervention is associated with decreased mortality and increased ICU LOS in matched cohorts of PBI.
