Association between cranial surgery and mortality among patients with firearm-related traumatic brain injury resulting in subdural hematoma

Kathleen R Ran; Jiaqi Liu; Vikas N Vattipally; Richard Cook; Sruthi Ranganathan; Jacob Jo; Jowah Gorbachev; John R Williams; Jordina Rincon-Torroella; Elliott R Haut; Jose I Suarez; Judy Huang; Chetan Bettegowda; James P Byrne; Tej D Azad

doi:10.3171/2025.3.JNS242450

Association between cranial surgery and mortality among patients with firearm-related traumatic brain injury resulting in subdural hematoma

J Neurosurg. 2025 Jun 27:1-7. doi: 10.3171/2025.3.JNS242450. Online ahead of print.

Authors

Affiliations

¹ 1Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland.
² 2Georgetown University School of Medicine, Washington, DC.
³ 3Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas.
⁴ 4Department of Medicine, University of Cambridge, United Kingdom.
⁵ 5Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and.
⁶ 6Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

PMID: 40577854
DOI: 10.3171/2025.3.JNS242450

Abstract

Objective: Firearm-related penetrating traumatic brain injury (pTBI) is highly morbid and causes heterogeneous intracranial injury patterns. As guidelines and practices evolve, tailored analysis of more homogeneous pTBI cohorts is needed to inform surgical management. Therefore, the aim of this study was to test the association between cranial surgery and survival among patients with pTBI resulting in subdural hematoma (SDH).

Methods: Patients with firearm-related pTBI and resultant SDH were retrospectively identified using the American College of Surgeons Trauma Quality Program dataset (2017-2019). The study exposure of interest was cranial surgery, and the primary outcome was in-hospital mortality. Adjusted hierarchical regression models were specified to test the association between cranial surgery and in-hospital mortality. To further increase the homogeneity of the presenting injury pattern, a subgroup analysis was performed in patients with SDH and midline shift (MLS) > 5 mm.

Results: A total of 1894 patients (84% male; median age 31 years) with firearm-related pTBI and SDH were included. The hierarchical logistic regression analysis demonstrated that cranial surgery was independently associated with lower odds of in-hospital mortality (OR 0.49, 95% CI 0.34-0.71; p < 0.001), even after risk adjustment for injury characteristics and placement of an external ventricular drain or intracranial pressure monitor. In a subgroup of 535 patients who presented with SDH and MLS > 5 mm, cranial surgery had a greater protective effect against in-hospital mortality (OR 0.40, 95% CI 0.24-0.67; p < 0.001).

Conclusions: Cranial surgery was independently associated with lower in-hospital mortality among patients with firearm-related pTBI and SDH, and its protective effect was greater among patients with significant MLS. Further investigations of long-term functional outcomes are needed.

Keywords: acute subdural hematoma; craniotomy; decompressive craniectomy; firearms; penetrating head injury; trauma; traumatic brain injury.