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.