Outcomes following surgical intervention for acute hemorrhage in severe traumatic brain injury: a review of the National Trauma Data Bank.

OBJECTIVE: Severe traumatic brain injury (TBI) is a public health issue posing significant morbidity and mortality to afflicted patients. While the effect of time to surgery as the primary factor for survival has been extensively studied, long-term dispositional outcomes following intracranial hemorrhage evacuation have not been well described in the literature. Therefore, the aim of this study was to elicit potential prognostic factors in patients presenting with severe TBI that may have a significant impact on discharge disposition. METHODS: The authors searched the National Trauma Data Bank (NTDB) for patients included between 2010 and 2019, solely focusing on those with a Glasgow Coma Scale score ≤ 8, signifying severe TBI, and with associated intracranial hemorrhage treated via surgical intervention. Numerous characteristics were analyzed, including demographics (age, sex, race, ethnicity, payment status), discharge disposition, time to surgery, pupillary response, midline shift (> 5 mm), and postoperative inpatient complications and comorbidities. Disposition included routine discharge to home, discharge to home with home health services (HHSs), discharge to acute inpatient rehabilitation (AIR), discharge to a skilled nursing facility (SNF)/long-term acute care hospital (LTACH), and death. RESULTS: The authors analyzed data on 7308 patients, 69.6% of whom were White and 11.2% of whom were Black. More young Black and Hispanic patients had severe TBI events than their matched elders, whereas more elderly White patients had severe TBI events than their matched younger counterparts. The most common disposition across all ages was SNF/LTACH. Septuagenarians and octogenarians were 12.1 and 21 times more likely, respectively, to die following a severe TBI than their younger counterparts (p < 0.001). Patients aged 18-29 were 1.7 times more likely to be discharged with HHSs (p < 0.001). Minority race/ethnicity groups were less likely to be discharged to AIR. As age increased, a patient's intensive care unit stay increased by 15 days (p < 0.001) and total hospital length of stay increased by 25 days (p < 0.001). CONCLUSIONS: Neurosurgical evacuation of intracranial hemorrhage in severe TBI has variable long-term morbidity. Utilizing the largest collection of trauma data within the United States, the authors present quantitative evidence on discharge disposition. Understanding these tangible points can help neurosurgeons present potential outcomes to patients, promote preventative care, and generate tangible conversations with patients and their family members.

Nontraumatic Subarachnoid Hemorrhage and Ruptured Intracranial Aneurysm: Recognition and Evaluation.

Subarachnoid hemorrhage caused by a ruptured intracranial aneurysm is a neurosurgical emergency with a mortality rate of approximately 50%. Prompt identification and treatment of aneurysmal subarachnoid hemorrhage are paramount to reduce mortality, long-term morbidity, and health care burden for survivors. The prevalence of intracranial aneurysms is 2% to 6% of the global population, many of which are found incidentally during workup for an unrelated condition. Screening is not recommended for the general population and should be reserved for patients who have at least one family member with a history of intracranial aneurysm or subarachnoid hemorrhage or when there is a high index of suspicion for those with certain medical conditions associated with an increased incidence of intracranial aneurysms. Physicians who treat patients with headache should be aware of the spectrum of clinical presentation of aneurysmal subarachnoid hemorrhage because not all patients present with the classic thunderclap headache. The Ottawa Subarachnoid Hemorrhage Rule is a validated clinical decision tool to help determine which patients with a sudden, acute headache require imaging with noncontrast computed tomography. Based on the results of initial computed tomography and duration of symptoms, the patient may require a lumbar puncture or additional imaging to confirm the diagnosis. Prompt diagnosis of an aneurysmal subarachnoid hemorrhage is essential to patients receiving definitive treatment.

Answering Our Nation's Call: A Solution for Military Neurosurgery Wartime Readiness Through Civilian Collaboration.

Military-civilian partnerships have built the foundation for US neurosurgery as we see it today. Each conflict throughout history has led to expansion within the field of neurosurgery, benefiting civilian patients and those in uniform. Despite the field's growth during wartime, military neurosurgical case volume declines during peacetime, and as a result, important knowledge gained is at risk of being lost. The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship. Because of this peacetime, the surgical case volume and experience of the military neurosurgeon are declining rapidly. In addition to providing a history of military-civilian partnerships in neurosurgery, we have analyzed the declining case volume trends at a single military treatment facility with neurosurgical capabilities. We compared the case volume of a military neurosurgeon at a civilian partnered location with their previous volume at a military treatment facility and analyzed current trends in wartime readiness by Neurosurgery Knowledge, Skills and Abilities metrics. We believe that military civilian partnerships hold the key to scaffolding the experience to maintain the wartime readiness in the military neurosurgical community.

Direct enhancement of readiness for wartime critical specialties by civilian-military partnerships for neurosurgical care: residency training and beyond.

Military neurosurgery has played an integral role in the development and innovation of neurosurgery and neurocritical care in treating battlefield injuries. It is of paramount importance to continue to train and prepare the next generation of military neurosurgeons. For the Army, this is currently primarily achieved through the military neurosurgery residency at the National Capital Consortium and through full-time out-service positions at the Veterans Affairs-Department of Defense partnerships with the University of Florida, the University of Texas-San Antonio, and Baylor University. The authors describe the application process for military neurosurgery residency and highlight the training imparted to residents in a busy academic and level I trauma center at the University of Florida, with a focus on how case variety and volume at this particular civilian-partnered institution produces neurosurgeons who are prepared for the complexities of the battlefield. Further emphasis is also placed on collaboration for research as well as continuing education to maintain the skills of nondeployed neurosurgeons. With ongoing uncertainty regarding future conflict, it is critical to preserve and expand these civilian-military partnerships to maintain a standard level of readiness in order to face the unknown with the confidence befitting a military neurosurgeon.