Emergency neurosurgery for traumatic brain injury by general surgeons at local hospitals in Sweden: a viable option when time is brain

Abstract

Background: Timing of surgical evacuation of mass lesions in traumatic brain injury (TBI) is crucial. However, due to geographical variations, transportation time to the nearest neurosurgical department may be long. To save time, general surgeons at a local hospital may perform the operation, despite more limited experience in neurosurgical techniques. This study aimed to determine whether patient outcomes differed between those who had undergone emergency neurosurgery at local hospitals by general surgeons vs. at university hospitals by neurosurgeons.

Methods: A nationwide observational study was performed using data from the Swedish Trauma Registry (SweTrau) between 2018 and 2022. A total of 565 TBI patients (local hospitals, n = 21; university hospitals, n = 544) who underwent intracranial hematoma evacuation within 8 h after arrival at the hospital were included. Data on demography, admission variables, traumatic injuries, and outcome (Glasgow Outcome Scale [GOS]) at discharge were evaluated. Favourable vs. unfavourable outcomes were defined as GOS scores of 4-5 vs. 1-3.

Results: Compared with those treated at university hospitals, patients treated with intracranial hematoma evacuation at local hospitals had lower median Glasgow Coma Scale (GCS) scores (8 vs. 12, p < 0.001), higher rate of acute subdural hematomas (86% vs. 77%, p < 0.001), and lower rate of contusions (14% vs. 53%, p = 0.01). Being operated on at a local hospital was independently associated with higher mortality (p = 0.03) but with a similar rate of favourable outcome (p = 0.74) in multiple logistic regressions after adjustment for demographic and injury-related variables.

Conclusions: Although a slightly greater proportion of patients who underwent emergency neurosurgery at local hospitals died, there was no difference in the rate of favourable outcome. Thus, in patients with impending brain herniation, when time is of the essence, evacuation of traumatic intracranial bleeding by general surgeons at local hospitals remains a highly viable option.

Keywords: Craniotomy; Intracranial bleeding; Neurosurgery; Outcome; Traumatic brain injury.

Fig. 1

Flow chart of patient inclusion In this study, 5914 patients in the SweTrau register treated for TBI (ICD-10 codes S06.0 to S06.9) at any ICU in Sweden from the 1st of January 2018 to the 31st of December 2022 were eligible for inclusion, while those 5184 who were treated conservatively were excluded (Fig. 1). Furthermore, 165 patients were excluded: 110 with no data on time between arrival at hospital and surgery, 22 patients who underwent craniotomy more than 8 h post-arrival, and 33 without data on the treating hospital. Thus, the final study population included 565 TBI patients treated with craniotomy within 8 h post-arrival, 544 of them being operated on at a university hospital by neurosurgeons and 21 patients operated on at a local hospital by general surgeons without special neurosurgical training ICD = International Classification of Diseases. ICU = Intensive Care Unit. TBI = Traumatic Brain Injury

Fig. 2

Map of Sweden divided into its six healthcare regions This map illustrates that surgical evacuation of traumatic intracranial bleedings was more often performed at local hospitals amongst regions with bigger geographical areas (e.g., Uppsala/Örebro, Linköping, and North Region) in comparison to more densely populated ones (Stockholm-Gotland, Western Region (VGR), and South Region) UH = University Hospital. LH = Local Hospital. TBI = Traumatic Brain Injury

Fig. 3

GOS distribution following TBI with craniotomy within 8 h – local vs. university hospital Distribution according to GOS at discharge for the population of patients operated at a local hospital by general surgeons in less than 8 h post-arrival (left) and the population that underwent craniotomy in less than 8 h post-arrival at a university hospital by neurosurgeons (right) for TBI. The patients treated at local hospitals exhibited a higher mortality, but there was no difference in the rate of favourable. outcome or median GOS at discharge as compared with those treated at a university hospital GOS = Glasgow Outcome Scale. TBI = Traumatic Brain Injury