Aggressive operative neurosurgical management in patients with extra-axial mass lesion and Glasgow Coma Scale of 3 is associated with survival benefit: A propensity matched analysis.
BACKGROUND
Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI).


METHODS
We conducted a five-year, multicenter retrospective cohort study of patients with an ED GCS 3 and a positive head CT identified by ICD-9CM diagnosis codes. Two populations were examined: (1) patients with extra-axial mass lesion (subdural or epidural haematoma), (2) patients without mass lesion (subarachnoid and intraparenchymal haemorrhage including contusion, other intracerebral haemorrhage or intracranial injury including diffuse axonal injury). In patients with extra-axial mass lesion, propensity score techniques were used to match patients 1:1 by CRANI, and the following outcomes were analysed with conditional logistic regression: survival, favourable hospital disposition to home or rehabilitation, and development of complications.


RESULTS
There were 541 patients with TBI and GCS3; 19% had a CRANI, 83% were initiated within 4h. In those with mass lesion, 27% (91/338) had a CRANI; after matching, a significant survival benefit was observed with CRANI vs. without CRANI (65% vs. 34% survival, OR: 3.9 (1.6-10.5) p<0.001). There was borderline increased odds of favourable disposition (43% vs. 26%, OR: 2.4 (0.99-6.3, p=0.052) with CRANI vs. without CRANI, and no difference in developing a complication (58% vs. 48%, OR: 1.5 (0.7-3.4), p=0.30).


CONCLUSIONS
Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.
Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States. Electronic address: ksalottolo@ampiopharma.com.
Kristin
K
Salottolo
Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States. Electronic address: matt.carrick@acutesurgical.com.
Matthew
M
Carrick
Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Intermountain Neurosurgery, 11700 W. 2nd Place, Lakewood, CO 80228, United States. Electronic address: stewartlevy@centura.org.
A Stewart
AS
Levy
Trauma Services Department, Medical Center of Plano, 3901 W. 15th St, Plano, TX 75075, United States. Electronic address: brentandang@me.com.
Brent C
BC
Morgan
Trauma Services Department, St. Anthony Hospital, 11600 West 2nd Place, Lakewood, CO 80228, United States. Electronic address: charleswmains@centura.org.
Charles W
CW
Mains
Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Swedish Medical Center, 499 E. Hampden Ave, Englewood, CO 80113, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States. Electronic address: sue.slone@healthonecares.com.
Denetta S
DS
Slone
Department of Trauma Research, Medical Center of Plano, 3901 West 15th Street, Plano, TX 75075, United States; Department of Trauma Research, Swedish Medical Center, 501 E. Hampden Ave, Englewood, CO 80113, United States; Department of Trauma Research, St. Anthony Hospital, 11600 W. 2nd Place, Lakewood, CO 80228, United States; Trauma Services Department, Rocky Vista University, 8401 S. Chambers Rd, Parker, CO 80134, United States. Electronic address: dbaror@ampiopharma.com.
David
D
Bar-Or
D001930:Brain Injuries / Q000401:mortality / Q000601:surgery*; D003399:Craniotomy / Q000401:mortality*; D004636:Emergency Service, Hospital; D015600:Glasgow Coma Scale; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D019586:Intracranial Hypertension / Q000401:mortality / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods / Q000401:mortality; D011379:Prognosis; D057216:Propensity Score; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome
Craniotomy; Glasgow Coma Score; Mortality; Traumatic brain injury