242 Interhospital Variation in Operative Intervention for Firearm-Related Penetrating Traumatic Brain Injury and Associations With Inpatient Mortality

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INTRODUCTION: Firearm-related penetrating traumatic brain injury (pTBI) carries a high mortality risk and grim prognosis. Neurosurgical management of firearm-related pTBI is further complicated by the lack of clear consensus over indications for performing surgery, as current guidelines predominantly focus on the surgical management of blunt TBI. METHODS: We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Programs Dataset to identify adult patients presenting with firearm-related pTBI. Risk-adjusted hierarchical regression evaluated associations with cranial surgery. Hospitals were stratified into quartiles based on surgical tendency (lowest, Q1; highest, Q4). Propensity score matching was performed across quartiles, and a multivariable regression model was constructed to investigate associations between hospital quartile and inpatient mortality. Effect modification by pupillary reactivity was tested. RESULTS: Cranial surgery rates for 4,895 patients (median age, 31 years) varied widely across 309 hospitals (0–71%; median, 21%; median odds ratio, 1.33). After matching, treatment at Q4 hospitals was associated with significantly reduced odds of mortality compared to treatment at Q1 hospitals (OR, 0.61; 95% CI, 0.47–0.78). Patients presenting with one (interaction P = 0.03) or both (interaction P=0.03) unreactive pupils experienced amplified survival benefits from treatment at Q4 hospitals. CONCLUSIONS: Substantial interhospital variation exists in operative intervention for firearm-related pTBI. Hospitals with higher surgical tendency were associated with improved survival, and this effect was amplified for patients presenting with unreactive pupils. These findings suggest a need to standardize operative decision-making for patients with firearm-related pTBI, aligning with ongoing efforts by organizations such as the Brain Trauma Foundation.

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