Intracranial pressure monitoring among children with severe traumatic brain injury

OBJECT Well-designed studies linking intracranial pressure (ICP) monitoring with improved outcomes among children with severe traumatic brain injury (TBI) are lacking. The main objective of this study was to examine the relationship between ICP monitoring in children and in-hospital mortality following severe TBI. METHODS An observational study was conducted using data derived from 153 adult or mixed (adult and pediatric) trauma centers participating in the American College of Surgeons (ACS) Trauma Quality Improvement Program (TQIP) and 29 pediatric trauma centers participating in the pediatric pilot TQIP between 2010 and 2012. Random-intercept multilevel modeling was used to examine the association between ICP monitoring and in-hospital mortality among children with severe TBI ≤16 years of age after adjusting for important confounders. This association was evaluated at the patient level and at the hospital level. In a sensitivity analysis, this association was reexamined in a propensity-matched cohort. RESULTS A total of 1705 children with severe TBI were included in the study cohort. The overall in-hospital mortality was 14.3% of patients (n = 243), whereas the mortality of the 273 patients (16%) who underwent invasive ICP monitoring was 11% (n = 30). After adjusting for patient- and hospital-level characteristics, ICP monitoring was associated with lower in-hospital mortality (adjusted OR 0.50; 95% CI 0.30–0.85; p = 0.01). It is possible that patients who were managed with ICP monitoring were selected because of an anticipated favorable or unfavorable outcome. To further address this potential selection bias, the analysis was repeated with the hospital-specific rate of ICP monitoring use as the exposure. The adjusted OR for death of children treated at high ICP–use hospitals was 0.49 compared with those treated at low ICP-use hospitals (95% CI 0.31–0.78; p = 0.003). Variations in ICP monitoring use accounted for 15.9% of the interhospital variation in mortality among children with severe TBI. Similar results were obtained after analyzing the data using propensity score-matching methods. CONCLUSIONS In this observational study, ICP monitoring use was associated with lower hospital mortality at both the patient and hospital levels. However, the contribution of variable ICP monitoring rates to interhospital variation in pediatric TBI mortality was modest.

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Relationship between Intracranial Pressure Monitoring and Outcomes in Severe Traumatic Brain Injury Patients

Anaesthesia and Intensive Care ◽

10.1177/0310057x1103900610 ◽

2011 ◽

Vol 39 (6) ◽

pp. 1043-1050 ◽

Cited By ~ 22

Author(s):

S. Haddad ◽

A. S. Aldawood ◽

A. Alferayan ◽

N. A. Russell ◽

H. M. Tamim ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Mechanical Ventilation ◽

Intracranial Pressure ◽

Hospital Mortality ◽

Icp Monitoring ◽

Icu Mortality ◽

Ventilation Duration ◽

Mechanical Ventilation Duration ◽

Significant Difference ◽

Severe Tbi

Intracranial pressure (ICP) monitoring is recommended in patients with a severe traumatic brain injury (TBI) and an abnormal computed tomography (CT) scan. However, there is contradicting evidence about whether ICP monitoring improves outcome. The purpose of this study was to examine the relationship between ICP monitoring and outcomes in patients with severe TBI. From February 2001 to December 2008, a total of 477 consecutive adult (>18 years) patients with severe TBI were included retrospectively in the study. Patients who underwent ICP monitoring (n=52) were compared with those who did not (n=425). The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, mechanical ventilation duration, the need for tracheostomy, and ICU and hospital length of stay (LOS). After adjustment for multiple potential confounding factors, ICP monitoring was not associated with significant difference in hospital or ICU mortality (odds ratio [OR]=1.71, 95% confidence interval [CI]=0.79 to 3.70, P=0.17; OR=1.01, 95% CI=0.41 to 2.45, P=0.99, respectively). ICP monitoring was associated with a significant increase in mechanical ventilation duration (coefficient=5.66, 95% CI=3.45 to 7.88, P <0.0001), need for tracheostomy (OR=2.02, 95% CI=1.02 to 4.03, P=0.04), and ICU LOS (coefficient=5.62, 95% CI=3.27 to 7.98, P <0.0001), with no significant difference in hospital LOS (coefficient=8.32, 95% CI=-82.6 to 99.25, P=0.86). Stratified by the Glasgow Coma Scale score, ICP monitoring was associated with a significant increase in hospital mortality in the group of patients with Glasgow Coma Scale 7 to 8 (adjusted OR=12.89, 95% CI=3.14 to 52.95, P=0.0004). In patients with severe TBI, ICP monitoring was not associated with reduced hospital mortality, however, with a significant increase in mechanical ventilation duration, need for tracheostomy, and ICU LOS.

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Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring

Journal of Neurosurgery ◽

10.3171/2012.7.jns111816 ◽

2012 ◽

Vol 117 (4) ◽

pp. 729-734 ◽

Cited By ~ 103

Author(s):

Arash Farahvar ◽

Linda M. Gerber ◽

Ya-Lin Chiu ◽

Nancy Carney ◽

Roger Härtl ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Intracranial Hypertension ◽

Severe Traumatic Brain Injury ◽

Lower Mortality ◽

Icp Monitoring ◽

Improvement Program ◽

Severe Tbi ◽

Gcs Score

Object Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score <9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and 2009. This database also contains information on known independent early prognostic indicators of mortality, including age, admission GCS score, pupillary status, CT scanning findings, and hypotension. Results Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. Conclusions In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring.

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Patients Who Benefit from Intracranial Pressure Monitoring without Cerebrospinal Fluid Drainage After Severe Traumatic Brain Injury

Neurosurgery ◽

10.1093/neuros/nyy247 ◽

2018 ◽

Vol 85 (2) ◽

pp. 231-239 ◽

Cited By ~ 4

Author(s):

Abhijit Lele ◽

Nithya Kannan ◽

Monica S Vavilala ◽

Deepak Sharma ◽

Mahmud Mossa-Basha ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Cerebrospinal Fluid ◽

Intracranial Pressure ◽

Confidence Interval ◽

Hospital Mortality ◽

Intraventricular Hemorrhage ◽

Cerebrospinal Fluid Drainage ◽

Icp Monitoring ◽

Pressure Monitoring ◽

Severe Tbi

AbstractBACKGROUNDIndia has a high traumatic brain injury (TBI) burden and intracranial pressure monitoring (ICP) remains controversial but some patients may benefit.OBJECTIVETo examine the association between ICP monitor placement and outcomes, and identify Indian patients with severe TBI who benefit from ICP monitoringMETHODSWe conducted a secondary analysis of a prospective cohort study at a level 1 Indian trauma center. Patients over 18 yr with severe TBI (admission Glasgow coma scale score < 8) who received tracheal intubation for at-least 48 h were examined. Propensity-based analysis using inverse probability weighting approach was used to examine ICP monitor placement within 72 h of admission and outcomes. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) score at discharge, 3, 6, and 12 mo. Death, vegetative, or major impairment defined unfavorable outcome.RESULTSThe 200 patients averaged 36 [18 to 85] yr of age and average injury severity score of 31.4 [2 to 73]. ICP monitors were placed in 126 (63%) patients. Patients with ICP monitor placement experienced lower in-hospital mortality (adjusted relative risk [aRR]; 0.50 [0.29, 0.87]) than patients without ICP monitoring. However, there was no benefit at 3, 6, and 12 mo. With ICP monitor placement, absence of cerebral edema (aRR 0.54, 95% confidence interval 0.35-0.84), and absence of intraventricular hemorrhage (aRR 0.52, 95% confidence interval 0.33-0.82) were associated with reduced unfavorable outcomes.CONCLUSIONICP monitor placement without cerebrospinal fluid drainage within 72 h of admission was associated with reduced in-patient mortality. Patients with severe TBI but without cerebral edema and without intraventricular hemorrhage may benefit from ICP monitoring.

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Intracranial Pressure Monitoring in Severe Traumatic Brain Injury – Results of a Canadian Survey

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100052252 ◽

2000 ◽

Vol 27 (2) ◽

pp. 143-147 ◽

Cited By ~ 22

Author(s):

Ramesh Sahjpaul ◽

Murray Girotti

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Prospective Trial ◽

Icp Monitoring ◽

Pressure Monitoring ◽

Level Of Confidence ◽

Routine Monitoring ◽

Severe Tbi ◽

High Level

ABSTRACT:Objective:The purpose of this study was to obtain information from Canadian neurosurgeons regarding their opinions on, and utilization of, intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI).Methods:A brief survey was sent to practicing Canadian neurosurgeons questioning them about their utilization of, and confidence in, intracranial pressure monitoring in the management of patients with severe TBI.Results:One hundred and ninety-six surveys were mailed. There were 103 responses for a response rate of 52.6%. The vast majority of responding neurosurgeons (98.1%) utilized ICP monitoring in the management of patients with severe TBI, with most (63.4%) using it in more than 75% of their patients, 14.9% using it in 50-75% of patients, 14.9% in 25-50% of patients, and 6.9% using it in less than 25% of patients. The level of confidence that routine monitoring improves outcome from severe TBI ranged from 23.3% having a low level of confidence, 56.3% having an intermediate level of confidence, to 20.4% having a high level of confidence. Most respondents (78.6%) felt that some form of prospective trial evaluating the role of ICP monitoring in improving outcome from severe TBI was warranted; 17.4% felt such a trial was not warranted and 3.9% were uncertain.Conclusions:While ICP monitoring has gained almost universal acceptance among responding Canadian neurosurgeons, their level of confidence that routine monitoring improves outcome from severe TBI was quite variable, with only 20.4% of respondents having a high level of confidence. Over 75% of respondents felt that some form of prospective trial evaluating the utility of ICP monitoring is warranted. This information is being used in consideration of a prospective trial addressing this issue.

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Intracranial Pressure Monitors in Traumatic Brain Injury: A Systematic Review

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100015286 ◽

2012 ◽

Vol 39 (5) ◽

pp. 571-576 ◽

Cited By ~ 29

Author(s):

Asher A. Mendelson ◽

Chris Gillis ◽

William R. Henderson ◽

Juan J. Ronco ◽

Vinay Dhingra ◽

...

Keyword(s):

Systematic Review ◽

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Observational Studies ◽

Pooled Analysis ◽

Point Estimate ◽

Icp Monitoring ◽

Study Heterogeneity ◽

Severe Tbi

We conducted a systematic review to examine the relationship between intracranial pressure monitors (ICP) monitors and mortality in traumatic brain injury (TBI). We systematically searched for articles that met the following criteria: (1) adults patients, (2) TBI, (3) use of an ICP monitor, (4) point estimate for mortality with ICP monitoring (5) adjustment for potential confounders. Six observational studies were identified with 11,371 patients. There was marked between-study heterogeneity that precluded a pooled analysis. Patients with ICP monitors had different clinical characteristics and received more ICP targeted therapy in the ICU. Four studies found no significant relationship between ICP monitoring and survival, while the other two studies demonstrated conflicting results. Significant confounding by indication in observational studies limits the examination of isolated TBI interventions. More research should focus on interventions that affect TBI careplan systems. Further research is needed to identify which subset of severe TBI patients may benefit from ICP monitoring.

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National Variability in Intracranial Pressure Monitoring and Craniotomy for Children With Moderate to Severe Traumatic Brain Injury

Neurosurgery ◽

10.1227/neu.0000000000000097 ◽

2013 ◽

Vol 73 (5) ◽

pp. 746-752 ◽

Cited By ~ 21

Author(s):

William Van Cleve ◽

Mary A. Kernic ◽

Richard G. Ellenbogen ◽

Jin Wang ◽

Douglas F. Zatzick ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Care Delivery ◽

Pediatric Trauma ◽

Intracranial Pressure Monitoring ◽

Trauma Centers ◽

Older Children ◽

Pressure Monitoring ◽

Hospital Variation

Abstract BACKGROUND: Traumatic brain injury (TBI) is a significant cause of mortality and disability in children. Intracranial pressure monitoring (ICPM) and craniotomy/craniectomy (CRANI) may affect outcomes. Sources of variability in the use of these interventions remain incompletely understood. OBJECTIVE: To analyze sources of variability in the use of ICPM and CRANI. METHODS: Retrospective cross-sectional study of patients with moderate/severe pediatric TBI with the use of data submitted to the American College of Surgeons National Trauma Databank. RESULTS: We analyzed data from 7140 children at 156 US hospitals during 7 continuous years. Of the children, 27.4% had ICPM, whereas 11.7% had a CRANI. Infants had lower rates of ICPM and CRANI than older children. A lower rate of ICPM was observed among children hospitalized at combined pediatric/adult trauma centers than among children treated at adult-only trauma centers (relative risk = 0.80; 95% confidence interval 0.66-0.97). For ICPM and CRANI, 18.5% and 11.6%, respectively, of residual model variance was explained by between-hospital variation in care delivery, but almost no correlation was observed between within-hospital tendency toward performing these procedures. CONCLUSION: Infants received less ICPM than older children, and children hospitalized at pediatric trauma centers received less ICPM than children at adult-only trauma centers. In addition, significant between-hospital variability existed in the delivery of ICPM and CRANI to children with moderate-severe TBI.

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Prognostic Impact of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1675365 ◽

2018 ◽

Vol 37 (04) ◽

pp. 291-296

Author(s):

Bárbara Borchardt ◽

Luanna Freitas ◽

Ademar Filho ◽

Áurea da Rosa ◽

Milena Gabe ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Severe Traumatic Brain Injury ◽

Total Sample ◽

Common Finding ◽

Prognostic Impact ◽

Icp Monitoring ◽

Severe Tbi ◽

Improvement In Survival

Objectives The aim of the present study was to analyze the prognostic impact of intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (TBI). Methods An observational, retrospective and quantitative study was performed. The sample consisted of 246 patients diagnosed with severe TBI, from January 2009 to August 2017. Results Out of the total sample, 43.56% of the patients were submitted to ICP monitoring. The mean time of use of the catheter was 1.7 days. In both groups, males were the most affected, and the majority of the patients were < 50 years old. Automobile accident was the main etiology of TBI. In the initial clinical evaluation, mydriatic pupils were related to death and normal pupil reaction at hospital discharge. The monitored group performed a larger number of computed tomography (CT) scans, with a mean of 2.6 examinations, with cerebral edema being the most common finding. Regarding the prognosis, those who used a catheter for ICP monitoring had a 47% reduction in the chance of death when compared with those who did not use the catheter. The stay duration both in the hospital and in the intensive care units was higher in patients who underwent ICP monitoring; periods > 30 days were related to meningitis, especially in those who used the catheter. Conclusion Patients who used a catheter for ICP monitoring had a significant improvement in survival.

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Hypertonic saline reduces cumulative and daily intracranial pressure burdens after severe traumatic brain injury

Journal of Neurosurgery ◽

10.3171/2014.10.jns132545 ◽

2015 ◽

Vol 122 (1) ◽

pp. 202-210 ◽

Cited By ~ 61

Author(s):

Halinder S. Mangat ◽

Ya-Lin Chiu ◽

Linda M. Gerber ◽

Marjan Alimi ◽

Jamshid Ghajar ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Intracranial Pressure ◽

Mortality Rate ◽

Hypertonic Saline ◽

New York State ◽

Mortality Rates ◽

Icp Monitoring ◽

Severe Tbi ◽

The Mean

OBJECT Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. METHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. RESULTS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). CONCLUSIONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.

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Hospital volume-outcome relationship in severe traumatic brain injury: stratified analysis by level of trauma center

Journal of Neurosurgery ◽

10.3171/2020.1.jns192115 ◽

2020 ◽

pp. 1-13 ◽

Cited By ~ 1

Author(s):

Sung Huang Laurent Tsai ◽

Anshit Goyal ◽

Mohammed Ali Alvi ◽

Panagiotis Kerezoudis ◽

Yagiz Ugur Yolcu ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Hospital Mortality ◽

Trauma Center ◽

Hospital Volume ◽

Trauma Centers ◽

Total Hospital ◽

Outcome Relationship ◽

Severe Tbi ◽

Volume Outcome

OBJECTIVEThe nature of the volume-outcome relationship in cases with severe traumatic brain injury (TBI) remains unclear, with considerable interhospital variation in patient outcomes. The objective of this study was to understand the state of the volume-outcome relationship at different levels of trauma centers in the United States.METHODSThe authors queried the National Trauma Data Bank for the years 2007–2014 for patients with severe TBI. Case volumes for each level of trauma center organized into quintiles (Q1–Q5) served as the primary predictor. Analyzed outcomes included in-hospital mortality, total hospital length of stay (LOS), and intensive care unit (ICU) stay. Multivariable regression models were performed for in-hospital mortality, overall complications, and total hospital and ICU LOSs to adjust for possible confounders. The analysis was stratified by level designation of the trauma center. Statistical significance was established at p < 0.001 to avoid a type I error due to a large sample size.RESULTSA total of 122,445 patients were included. Adjusted analysis did not demonstrate a significant relationship between increasing hospital volume of severe TBI cases and in-hospital mortality, complications, and nonhome hospital discharge disposition among level I–IV trauma centers. However, among level II trauma centers, hospital LOS was longer for the highest volume quintile (adjusted mean difference [MD] for Q5: 2.83 days, 95% CI 1.40–4.26 days, p < 0.001, reference = Q1). For level III and IV trauma centers, both hospital LOS and ICU LOS were longer for the highest volume quintile (adjusted MD for Q5: LOS 4.6 days, 95% CI 2.3–7.0 days, p < 0.001; ICU LOS 3.2 days, 95% CI 1.6–4.8 days, p < 0.001).CONCLUSIONSHigher volumes of severe TBI cases at a lower level of trauma center may be associated with a longer LOS. These results may assist policymakers with target interventions for resource allocation and point to the need for careful prehospital decision-making in patients with severe TBI.

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Comparison of Outcomes in Level I vs Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury

Neurosurgery ◽

10.1093/neuros/nyy634 ◽

2019 ◽

Vol 86 (1) ◽

pp. 107-111 ◽

Cited By ~ 5

Author(s):

Nohra Chalouhi ◽

Nikolaos Mouchtouris ◽

Fadi Al Saiegh ◽

Robert M Starke ◽

Thana Theofanis ◽

...

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Confidence Interval ◽

Hospital Mortality ◽

Odds Ratio ◽

Functional Independence ◽

Trauma Centers ◽

Level Ii ◽

Severe Tbi ◽

Level I

ABSTRACTBACKGROUNDTraumatic brain injury (TBI) carries a devastatingly high rate of morbidity and mortality.OBJECTIVETo assess whether patients undergoing craniotomy/craniectomy for severe TBI fare better at level I than level II trauma centers in a mature trauma system.METHODSThe data were extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients > 18 yr with severe TBI (Glasgow Coma Scale [GCS] score less than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania from January 1, 2002 through September 30, 2017.RESULTSOf 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline characteristics were similar between the 2 groups except for significantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I centers vs 40.4% in level II centers (P = .08). Mean Functional Independence Measure (FIM) scores at discharge were significantly higher in level I (10.9 ± 5.5) than level II centers (9.8 ± 5.3; P < .005). In multivariate analysis, treatment at level II trauma centers was significantly associated with in-hospital mortality (odds ratio, 1.2; 95% confidence interval, 1.03-1.37; P = .01) and worse FIM scores (odds ratio, 1.4; 95% confidence interval, 1.1-1.7; P = .001). Mean hospital and ICU length of stay were significantly longer in level I centers (P < .005).CONCLUSIONThis study showed superior functional outcomes and lower mortality rates in patients undergoing a neurosurgical procedure for severe TBI in level I trauma centers.

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