Effect of time to craniotomy on outcomes in patients with severe traumatic brain injury: A nationwide cohort study using the Japan Trauma Data Bank.

Abstract

Traumatic brain injury (TBI) is a major cause of mortality worldwide. The goals of TBI management include prevention of secondary brain injury by reducing pathological increase in intracranial pressure. Craniotomy is an effective intervention for relieving refractory increased intracranial pressure. Therefore, we aimed to clarify the association between time from hospital arrival to craniotomy and outcomes in patients with severe TBI using data from a nationwide trauma registry. We identified patients who underwent craniotomy owing to severe blunt TBI (Glasgow Coma Scale score ≤ 8 and Abbreviated Injury Scale score 4 or 5 for the head region) between 2019 and 2023 from the Japan Trauma Data Bank. Exclusion criteria were transfer from another hospital, extracranial surgery, time from arrival to craniotomy > 8 h, or missing data regarding time to surgery or in-hospital mortality. Patients were categorized into the early (≤ 4 h) or delayed (> 4 h) surgery groups based on the time to craniotomy. The primary outcome was in-hospital mortality. Secondary outcomes included probability of favorable neurological outcomes (Glasgow Outcome Scale score 4 or 5), discharge to home rate, length of hospital stay, length of intensive care unit (ICU) stay, and duration of mechanical ventilation. Multivariable logistic regression analysis was performed to adjust for potential confounders. Among the 1058 eligible patients, 960 (90.7%) and 98 (9.3%) underwent early and delayed craniotomy, respectively. In-hospital mortality was not significantly different between the groups even after adjusting for confounders. Furthermore, probability of favorable neurological outcomes, discharge to home rate, length of hospital stay, length of ICU stay, and duration of mechanical ventilation were not significantly different between the groups. A generalized additive model revealed no significant non-linear association between time to craniotomy and in-hospital mortality. Short-term outcomes in patients with severe TBI were not significantly associated with time from hospital arrival to craniotomy. This finding highlights the importance of flexible, individualized clinical decision-making in patients with TBI. Further studies are warranted to identify specific patient subgroups that may benefit from early craniotomies.