Comparative Effectiveness of Early Neurosurgical Intervention in Civilian Penetrating Brain Injury Management

Brain Imaging Features in Patients with Gunshot Wounds to the Head

To introduce the UChicago PBI Imaging score, a novel characterization of imaging features using head computed tomography (HCT) in patients with gunshot wounds to the head (GSWH) resulting in penetrating brain injury (PBI) and to quantify the association with mortality. We retrospectively collected and analyzed data from 230 patients with GSWH admitted to our Level 1 trauma center between May 1, 2018, and October 31, 2023. HCT images obtained on hospital arrival were evaluated for predefined imaging features by two blinded readers and arbitrated, when needed, by a third. The average contribution of each radiological feature to mortality at hospital discharge was assessed using a SuperLearner ensemble model trained on ∼77% of the cohort. Each feature's contribution was scaled to ensure the additive final score per patient ranged between 0 and 100. The HCT features predicting in-hospital mortality, ranked from highest to lowest importance, were transhemispheric projectile below the level of the third ventricle (18 [16.8, 19.9]), presence of blood in the lateral ventricles (ventricles casted) (18[16.8, 19.6]), brainstem involvement (14 [12.7, 15.1]), transhemispheric projectile above the level of the third ventricle (11 [9.7, 11.6]), presence of any amount of blood in the ambient cistern (9[8.2, 10]), presence of any amount of blood in the lateral ventricles (9 [7.9, 9.8]), cerebellar involvement (9 [7.9, 9.5]), any evidence of ventricular effacement (4 [3.4, 4.6]), midline shift (MLS) >0 mm (4 [3.4, 4.4]), perforating injury (3 [2.4, 3.2]), and presence of an intracerebral hematoma (ICH) >20 mm in the largest diameter (2 [1.4, 1.9]). The UChicago PBI Imaging score showed a strong performance, achieving an area under the curve (AUC) of 0.86 (95% CI: [0.77, 0.96]) on a test set of 56 patients who were not included in model training. This indicates better prediction accuracy compared to both the Rotterdam score (AUC 0.8, 95% CI: [0.68, 0.96]) and the Marshall score (AUC 0.66, 95% CI: [0.52, 0.81]). Our model performed particularly well for patients with a Glasgow Coma Scale (GCS) score between 5 and 9. In this range, our model's performance (AUC 0.86) remained stable, while the Rotterdam and Marshall Scores showed notably lower predictive accuracy, with AUCs of 0.61 and 0.52, respectively. A dedicated evaluation of GSWH HCT reveals an association between disease burden, as quantified by unique features not native to blunt TBI imaging models, and mortality. Specifically, transhemispheric injury below the level of the third ventricle along with blood-casting bilateral ventricles and brainstem involvement was highly associated with mortality. The model is optimized for intermediate GCS scores where greater prognostic uncertainty exists. This study parallels efforts to refine TBI classification, underscoring the necessity for precise imaging-based classification in PBI to identify imaging biomarkers and ultimately enhance prognostication and targeted treatment.

Navigating the Role of Surgery in Optimizing Patient Outcomes in Traumatic Brain Injuries (TBIs): A Comprehensive Review

Traumatic brain injuries (TBIs) present with symptoms ranging from a mildly altered level of consciousness to irreversible coma and death. The most severe stage of TBIs is diffuse axonal injury and swelling affecting the whole brain. Management strategies are based on the classification of TBIs by severity and type and range from cognitive therapy sessions to complex surgeries. Neuroimaging modalities, predominantly magnetic resonance imaging, and the clinical Glasgow Coma Scale are principal indicators to diagnose and assess a patient's condition and neurological status and decide optimal treatment modality. In this review, we have summarized the indications and patient outcomes based on neurological and functional status, post-surgical complications, and mortality rates for various life-saving interventional procedures including surgery for brain contusions, intracranial hematomas and penetrating injuries, and craniectomy and ventriculostomy for elevated intracranial pressure and hydrocephalus. Cranioplasty performed for aesthetic purposes has also been explored. Overall quality evidence presented advocates surgery as needed for improved patient outcomes resulting in early recovery and decreased mortality, especially with the emergence of minimally invasive techniques. However, there is still an increased risk of certain complications like infections and bleeding and severe disabilities leading to a vegetative state with surgery. Some guidelines have been formed to provide indications for optimal management of TBI patients including surgeries, although their effectiveness in each individual case is debatable. It is imperative to explore certain key areas like the timing of the surgery and the role of intensive patient monitoring pre- and post-procedure in future studies and lay down guidelines also applicable to resource-limited areas. Also, a deeper understanding of physiological and pathological mechanisms of functional outcomes post-surgery will help clinicians predict the patient's course of recovery.

Comparative Analysis of Clinical Severity and Outcomes in Penetrating Versus Blunt Traumatic Brain Injury Propensity Matched Cohorts

Traumatic brain injury (TBI) is a global health challenge; however, penetrating brain injury (PBI) remains under-represented in evidence-based knowledge and research efforts. This study utilized data from the Trauma Quality Improvement Program (TQIP) of the National Trauma Data Bank (NTDB) to investigate outcomes of PBI as compared with clinical-severity-matched non-penetrating or blunt TBI. A total of 1765 patients with PBI were 1:1 propensity score-matched for clinical severity with blunt TBI patients. The intent of PBI was self-inflicted in 34.1% of the cases, and the mechanism was firearm-inflicted in 89.1%. Mortality was found to be significantly more common in PBI than in the severity- matched TBI cohort (33.9% vs. 14.3 %, p < 0.001) as was unfavorable outcome. Mortality was mediated by withdrawal of life-sustaining therapies (WOLST) 30% of the time, and WOLST occurred earlier (median 3 days vs. 6 days, p < 0.001) in PBI. Increased rate of mortality was observed with a Glasgow Coma Scale (GCS) of <11 in PBI as compared with <7 in blunt TBI. In conclusion, PBI patients exhibited higher mortality rates and unfavorable outcomes; one third of excess mortality was mediated by WOLST. The study also brings into question the applicability of the conventional TBI classification, based on GCS, in PBI. We emphasize the need to address the observed disparities and better understand the distinctive characteristics and mechanisms underlying PBI outcomes to improve patient care and reduce mortality.