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

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To the Editor: As French military neurosurgeons, we read with great interest a recent study by Vattipally et al1 who investigated the odds for emergency cranial neurosurgical intervention for ballistic penetrating traumatic brain injury (bTBI) depending on the hospital of admission on a national scale in the United States. Their striking results showed that there was notable variation (13%-36%, P < .001) across US neurosurgery centers in the operative rate for bTBI, even though patients were comparable at baseline regarding age, admission Glasgow Coma Scale (GCS) score, pupillary status, injury severity score, midline shift on computed tomography scan, and health insurance coverage. This calls for further investigation. MANAGEMENT OF PENETRATING NEUROSURGICAL CRANIAL EMERGENCY IN LEVEL-1 TRAUMA CENTERS First, which facilities among the 309 participating hospitals were considered level-1 trauma centers? Indeed, neurosurgery and resuscitation teams in level-1 trauma centers are specifically trained to care for severe trauma patients such as those included in this study,2,3 displaying a median Injury Severity Score of 25. It would be helpful to know whether there was a higher proportion of level-1 trauma centers among facilities more prone for surgery, called “quartile 4 hospitals.” ORGANIZATION OF THE ON-CALL 24/7 NEUROSURGICAL SHIFT In the same way, was there a 24/7 on-call senior neurosurgeon available? Indeed, emergency life-saving neurosurgical management may be highly conditioned by the on-site presence of a permanently available senior neurosurgeon,4-6 who deals with a constantly increasing number of requests for assessing the emergency character of neurosurgical cases and for performing emergency surgeries, with a 300% increase in emergency neurosurgical activity over the past 10 years.7 Was the regional referral neurosurgical center systematically reached for patients admitted in local hospitals without permanent on-site neurosurgical shift? It seems rather surprising that the rate of interfacility transfer was the same (19%, P = .352) between quartile 1 and quartile 4 hospitals, even though the final operative rate was almost 3 times higher in quartile 4 hospitals. This observation is reinforced by the fact that interhospital transfer stands as a major item for predicting the mortality rate for civilian penetrating TBI in the SPIN score.8 EXAMPLE OF THE ON-CALL 24/7 NEUROSURGICAL SHIFT IN VAR REGION IN SOUTH FRANCE In our region called “Var” in South France comprising 1 000 000 inhabitants, since 2004 we have implemented the “ROR Paca” telemedicine network, allowing clinicians from the 7 local hospitals to reach the 24/7 on-call senior neurosurgeon in the level-1 trauma center Military Teaching Hospital, providing online request with computed tomography scan or MRI features along with clinical information. Since the launch of this network, we have answered to more than 35 000 demands, with a constantly increasing yearly number of requests (1000/y in 2004, 1500/y in 2015, 2500/y in 2025) and approximately 20% of emergency interhospital transfer (Figure).FIGURE.: Organization of the 24/7 on-call neurosurgery shift between the 7 local hospitals and the level-1 trauma center Military Teaching Hospital of Var region in the South France for a population of 1 000 000 people usually and 2 000 000 people during summer holidays. Figure 1 was created specifically for this submission by Nathan BEUCLER, MD.VECTOR ANALYSIS OF PROJECTILE’S TRAJECTORY AND KIM’S “ZONA FATALIS” In this paper, we did not recall seeing projectile's trajectory analysis.1 Since Kim's pioneer work that described the ballistic “zone fatalis” back in 2005,9 it is now well-known that intracranial projectile's trajectory stands as one of the main factors of bTBI-associated mortality.10,11 Hence, specific trajectories, such as frontal-to-contralateral, parietal, bitemporal crossing the midbrain, biventricular, or transcallosal, are generally associated with dismal prognosis from the beginning.12 It seems surprising that the authors chose to focus on factors relevant to blunt TBI such as extra-axial or intra-axial hematoma, instead of analyzing projectile's trajectory which seems highly more relevant bTBI. WARTIME BALLISTIC PENETRATING CRANIOCEREBRAL INJURY EXPERIENCE OF MILITARY NEUROSURGEONS Depending on the country's Military Health Services, emergency neurosurgical care in forward field surgical teams may be performed by neurosurgeons or by non-neurosurgeons trained to damage-control cranial neurosurgery.13 In France, we have experience in providing remote assistance to non-neurosurgeons performing wartime damage-control cranial neurosurgical procedures in strained resources setting,14 even though the physical presence of the neurosurgeon remains ideal whenever possible15,16 to decrease mortality.17 Hence, were there more Military hospitals in quartile 4 hospitals group? Indeed, the wartime operational experience18 of military neurosurgical teams can be helpful for managing civilian bTBI in the mainland10,11,19 but also for providing remote telemedicine assistance for non-neurosurgeons or neurosurgical teams less accustomed to bTBI.14 UP-TO-DATE GUIDELINES FOR PENETRATING TRAUMATIC BRAIN INJURY FROM THE FRENCH SOCIETY OF NEUROSURGERY This gives us the opportunity to present the recent bTBI guidelines by the French Society of Neurosurgery,20,21 which were closely followed by their American counterpart.22 The French chapter regarding penetrating TBI suggests emergency neurosurgical management for all patients with admission GCS ≥5, and for patients with GCS<5 but without bilateral fixed dilated pupils or pejorative radiologic criteria, based on multidisciplinary discussion and taking into account the SPIN score8 or the Maritzburg score.20,23 CONCLUSION In a world where we may encounter wartime bTBI in the mainland more frequently,24 this study calls for a more in-depth analysis of the regional organization of the neurosurgical framework in the United States, the training of civilian neurosurgeons to wartime cranial neurosurgery by their fellow Military colleagues, and last the update of American guidelines regarding acute neurosurgical indication for bTBI.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.