{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T03:15:12Z","timestamp":1782875712109,"version":"3.54.5"},"reference-count":38,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,10,1]]},"abstract":"\n OBJECTIVE<\/jats:title>\n 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).<\/jats:p>\n <\/jats:sec>\n \n METHODS<\/jats:title>\n Patients with firearm-related pTBI and resultant SDH were retrospectively identified using the American College of Surgeons Trauma Quality Program dataset (2017\u20132019). 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.<\/jats:p>\n <\/jats:sec>\n \n RESULTS<\/jats:title>\n 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\u20130.71; 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\u20130.67; p < 0.001).<\/jats:p>\n <\/jats:sec>\n \n CONCLUSIONS<\/jats:title>\n 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.<\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/2025.3.jns242450","type":"journal-article","created":{"date-parts":[[2025,6,27]],"date-time":"2025-06-27T22:45:45Z","timestamp":1751064345000},"page":"1009-1015","source":"Crossref","is-referenced-by-count":1,"title":["Association between cranial surgery and mortality among patients with firearm-related traumatic brain injury resulting in subdural hematoma"],"prefix":"10.3171","volume":"143","author":[{"given":"Kathleen R.","family":"Ran","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiaqi","family":"Liu","sequence":"additional","affiliation":[{"name":"Georgetown University School of Medicine, Washington, DC;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vikas N.","family":"Vattipally","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Richard","family":"Cook","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sruthi","family":"Ranganathan","sequence":"additional","affiliation":[{"name":"Department of Medicine, University of Cambridge, United Kingdom;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jacob","family":"Jo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jowah","family":"Gorbachev","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John R.","family":"Williams","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jordina","family":"Rincon-Torroella","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elliott R.","family":"Haut","sequence":"additional","affiliation":[{"name":"Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose I.","family":"Suarez","sequence":"additional","affiliation":[{"name":"Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Judy","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chetan","family":"Bettegowda","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James P.","family":"Byrne","sequence":"additional","affiliation":[{"name":"Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tej D.","family":"Azad","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"5","key":"b1","series-title":"J Neurosurg","first-page":"1138","article-title":"Predictors of outcome in civilian gunshot wounds to the head","volume":"120","author":"Aarabi B","year":"2014","unstructured":"Aarabi B, Tofighi B, Kufera JA, Predictors of outcome in civilian gunshot wounds to the head. J Neurosurg. 2014;120(5):1138\u20131146."},{"issue":"21","key":"b2","series-title":"Neurology","first-page":"2244","article-title":"Predicting survival after acute civilian penetrating brain injuries: the SPIN score","volume":"87","author":"Muehlschlegel S","year":"2016","unstructured":"Muehlschlegel S, Ayturk D, Ahlawat A, Predicting survival after acute civilian penetrating brain injuries: the SPIN score. Neurology. 2016;87(21):2244\u20132253."},{"key":"b3","series-title":"J Clin Neurosci","first-page":"71","article-title":"Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: a decision-tree algorithm based on a single trauma center","volume":"75","author":"Kim LH","year":"2020","unstructured":"Kim LH, Quon JL, Cage TA, Lee MB, Pham L, Singh H. Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: a decision-tree algorithm based on a single trauma center. J Clin Neurosci. 2020;75:71\u201379."},{"issue":"2","key":"b4","series-title":"JAMA Intern Med","first-page":"237","article-title":"Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009-2017","volume":"181","author":"Kaufman EJ","year":"2021","unstructured":"Kaufman EJ, Wiebe DJ, Xiong RA, Morrison CN, Seamon MJ, Delgado MK. Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009-2017. JAMA Intern Med. 2021;181(2):237\u2013244."},{"issue":"1","key":"b5","series-title":"Trauma Surg Acute Care Open","first-page":"e000483","article-title":"Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications","volume":"5","author":"Khan AD","year":"2020","unstructured":"Khan AD, Elseth AJ, Brosius JA, Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications. 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J Neurosurg. 2022;137(3):782\u2013788."},{"issue":"3","key":"b7","series-title":"Neurosurgery","first-page":"427","article-title":"Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations","volume":"87","author":"Hawryluk GWJ","year":"2020","unstructured":"Hawryluk GWJ, Rubiano AM, Totten AM, Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations. Neurosurgery. 2020;87(3):427\u2013434."},{"issue":"1","key":"b8","series-title":"Neurotrauma Rep","first-page":"240","article-title":"Rationale and methods for updated guidelines for the management of penetrating traumatic brain injury","volume":"3","author":"Hawryluk GWJ","year":"2022","unstructured":"Hawryluk GWJ, Selph S, Lumba-Brown A, Rationale and methods for updated guidelines for the management of penetrating traumatic brain injury. Neurotrauma Rep. 2022;3(1):240\u2013247."},{"key":"b9","series-title":"World Neurosurg","first-page":"653","article-title":"Penetrating bihemispheric traumatic brain injury: a collective review of gunshot wounds to the head","volume":"104","author":"Turco L","year":"2017","unstructured":"Turco L, Cornell DL, Phillips B. Penetrating bihemispheric traumatic brain injury: a collective review of gunshot wounds to the head. World Neurosurg. 2017;104:653\u2013659."},{"issue":"2","key":"b10","series-title":"Surg Neurol","first-page":"98","article-title":"Prognostic factors and treatment of penetrating gunshot wounds to the head","volume":"60","author":"Martins RS","year":"2003","unstructured":"Martins RS, Siqueira MG, Santos MT, Zanon-Collange N, Moraes OJ. Prognostic factors and treatment of penetrating gunshot wounds to the head. 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JAMA Surg. 2018;153(9):852\u2013853."},{"issue":"3","key":"b13","series-title":"Emerg Radiol","first-page":"301","article-title":"A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment","volume":"24","author":"Vakil MT","year":"2017","unstructured":"Vakil MT, Singh AK. A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg Radiol. 2017;24(3):301\u2013309."},{"key":"b14","series-title":"J Surg Res","first-page":"101","article-title":"Management of penetrating traumatic brain injury: operative versus non-operative intervention","volume":"257","author":"D\u2019Agostino R","year":"2021","unstructured":"D\u2019Agostino R, Kursinskis A, Parikh P, Letarte P, Harmon L, Semon G. Management of penetrating traumatic brain injury: operative versus non-operative intervention. J Surg Res. 2021;257:101\u2013106."},{"issue":"22","key":"b15","series-title":"J Neurotrauma","first-page":"2605","article-title":"Civilian gunshot wounds to the head: prognostic factors affecting mortality: meta-analysis of 1774 patients","volume":"35","author":"Maragkos GA","year":"2018","unstructured":"Maragkos GA, Papavassiliou E, Stippler M, Filippidis AS. Civilian gunshot wounds to the head: prognostic factors affecting mortality: meta-analysis of 1774 patients. J Neurotrauma. 2018;35(22):2605\u20132614."},{"issue":"3","key":"b16","series-title":"JAMA Netw Open","first-page":"e231077","article-title":"Comparative effectiveness of intracranial pressure monitoring vs no monitoring in severe penetrating brain injury management","volume":"6","author":"Mansour A","year":"2023","unstructured":"Mansour A, Rowell S, Powla PP, Horowitz P, Goldenberg FD, Lazaridis C. Comparative effectiveness of intracranial pressure monitoring vs no monitoring in severe penetrating brain injury management. JAMA Netw Open. 2023;6(3):e231077."},{"issue":"3","key":"b17","series-title":"J Emerg Trauma Shock","first-page":"395","article-title":"Management of penetrating brain injury","volume":"4","author":"Kazim SF","year":"2011","unstructured":"Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock. 2011;4(3):395\u2013402."},{"issue":"1","key":"b18","series-title":"J Trauma Acute Care Surg","first-page":"114","article-title":"Variation in neurosurgical intervention for severe traumatic brain injury: the challenge of measuring quality in trauma center verification","volume":"91","author":"Truong EI","year":"2021","unstructured":"Truong EI, Stanley SP, DeMario BS, Variation in neurosurgical intervention for severe traumatic brain injury: the challenge of measuring quality in trauma center verification. J Trauma Acute Care Surg. 2021;91(1):114\u2013120."},{"key":"b19","series-title":"Clin Neurol Neurosurg","first-page":"107545","article-title":"Long-term benefits for younger patients with aggressive immediate intervention following severe traumatic brain injury: a longitudinal cohort analysis of 175 patients from a prospective registry","volume":"224","author":"Agarwal N","year":"2023","unstructured":"Agarwal N, Wilkins TE, Nwachuku EL, Long-term benefits for younger patients with aggressive immediate intervention following severe traumatic brain injury: a longitudinal cohort analysis of 175 patients from a prospective registry. Clin Neurol Neurosurg. 2023;224:107545."},{"issue":"5","key":"b1","series-title":"J Neurosurg","first-page":"1138","article-title":"Predictors of outcome in civilian gunshot wounds to the head","volume":"120","author":"Aarabi B","year":"2014","unstructured":"Aarabi B, Tofighi B, Kufera JA, Predictors of outcome in civilian gunshot wounds to the head. J Neurosurg. 2014;120(5):1138\u20131146."},{"issue":"21","key":"b2","series-title":"Neurology","first-page":"2244","article-title":"Predicting survival after acute civilian penetrating brain injuries: the SPIN score","volume":"87","author":"Muehlschlegel S","year":"2016","unstructured":"Muehlschlegel S, Ayturk D, Ahlawat A, Predicting survival after acute civilian penetrating brain injuries: the SPIN score. Neurology. 2016;87(21):2244\u20132253."},{"key":"b3","series-title":"J Clin Neurosci","first-page":"71","article-title":"Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: a decision-tree algorithm based on a single trauma center","volume":"75","author":"Kim LH","year":"2020","unstructured":"Kim LH, Quon JL, Cage TA, Lee MB, Pham L, Singh H. Mortality prediction and long-term outcomes for civilian cerebral gunshot wounds: a decision-tree algorithm based on a single trauma center. J Clin Neurosci. 2020;75:71\u201379."},{"issue":"2","key":"b4","series-title":"JAMA Intern Med","first-page":"237","article-title":"Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009-2017","volume":"181","author":"Kaufman EJ","year":"2021","unstructured":"Kaufman EJ, Wiebe DJ, Xiong RA, Morrison CN, Seamon MJ, Delgado MK. Epidemiologic trends in fatal and nonfatal firearm injuries in the US, 2009-2017. JAMA Intern Med. 2021;181(2):237\u2013244."},{"issue":"1","key":"b5","series-title":"Trauma Surg Acute Care Open","first-page":"e000483","article-title":"Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications","volume":"5","author":"Khan AD","year":"2020","unstructured":"Khan AD, Elseth AJ, Brosius JA, Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications. Trauma Surg Acute Care Open. 2020;5(1):e000483."},{"issue":"3","key":"b6","series-title":"J Neurosurg","first-page":"782","article-title":"External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study","volume":"137","author":"Tourigny JN","year":"2022","unstructured":"Tourigny JN, Boucher V, Paquet V, External validation of the updated Brain Injury Guidelines for complicated mild traumatic brain injuries: a retrospective cohort study. J Neurosurg. 2022;137(3):782\u2013788."},{"issue":"3","key":"b7","series-title":"Neurosurgery","first-page":"427","article-title":"Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations","volume":"87","author":"Hawryluk GWJ","year":"2020","unstructured":"Hawryluk GWJ, Rubiano AM, Totten AM, Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations. Neurosurgery. 2020;87(3):427\u2013434."},{"issue":"1","key":"b8","series-title":"Neurotrauma Rep","first-page":"240","article-title":"Rationale and methods for updated guidelines for the management of penetrating traumatic brain injury","volume":"3","author":"Hawryluk GWJ","year":"2022","unstructured":"Hawryluk GWJ, Selph S, Lumba-Brown A, Rationale and methods for updated guidelines for the management of penetrating traumatic brain injury. Neurotrauma Rep. 2022;3(1):240\u2013247."},{"key":"b9","series-title":"World Neurosurg","first-page":"653","article-title":"Penetrating bihemispheric traumatic brain injury: a collective review of gunshot wounds to the head","volume":"104","author":"Turco L","year":"2017","unstructured":"Turco L, Cornell DL, Phillips B. Penetrating bihemispheric traumatic brain injury: a collective review of gunshot wounds to the head. World Neurosurg. 2017;104:653\u2013659."},{"issue":"2","key":"b10","series-title":"Surg Neurol","first-page":"98","article-title":"Prognostic factors and treatment of penetrating gunshot wounds to the head","volume":"60","author":"Martins RS","year":"2003","unstructured":"Martins RS, Siqueira MG, Santos MT, Zanon-Collange N, Moraes OJ. Prognostic factors and treatment of penetrating gunshot wounds to the head. Surg Neurol. 2003;60(2):98\u2013104."},{"issue":"3","key":"b11","series-title":"Neurosurgery","first-page":"470","article-title":"Comparative effectiveness of early neurosurgical intervention in civilian penetrating brain injury management","volume":"94","author":"Mansour A","year":"2024","unstructured":"Mansour A, Powla PP, Fakhri F, Comparative effectiveness of early neurosurgical intervention in civilian penetrating brain injury management. Neurosurgery. 2024;94(3):470\u2013477."},{"issue":"9","key":"b12","series-title":"JAMA Surg","first-page":"852","article-title":"Practical guide to surgical data sets: National Trauma Data Bank (NTDB)","volume":"153","author":"Hashmi ZG","year":"2018","unstructured":"Hashmi ZG, Kaji AH, Nathens AB. Practical guide to surgical data sets: National Trauma Data Bank (NTDB). JAMA Surg. 2018;153(9):852\u2013853."},{"issue":"3","key":"b13","series-title":"Emerg Radiol","first-page":"301","article-title":"A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment","volume":"24","author":"Vakil MT","year":"2017","unstructured":"Vakil MT, Singh AK. A review of penetrating brain trauma: epidemiology, pathophysiology, imaging assessment, complications, and treatment. Emerg Radiol. 2017;24(3):301\u2013309."},{"key":"b14","series-title":"J Surg Res","first-page":"101","article-title":"Management of penetrating traumatic brain injury: operative versus non-operative intervention","volume":"257","author":"D\u2019Agostino R","year":"2021","unstructured":"D\u2019Agostino R, Kursinskis A, Parikh P, Letarte P, Harmon L, Semon G. Management of penetrating traumatic brain injury: operative versus non-operative intervention. J Surg Res. 2021;257:101\u2013106."},{"issue":"22","key":"b15","series-title":"J Neurotrauma","first-page":"2605","article-title":"Civilian gunshot wounds to the head: prognostic factors affecting mortality: meta-analysis of 1774 patients","volume":"35","author":"Maragkos GA","year":"2018","unstructured":"Maragkos GA, Papavassiliou E, Stippler M, Filippidis AS. Civilian gunshot wounds to the head: prognostic factors affecting mortality: meta-analysis of 1774 patients. J Neurotrauma. 2018;35(22):2605\u20132614."},{"issue":"3","key":"b16","series-title":"JAMA Netw Open","first-page":"e231077","article-title":"Comparative effectiveness of intracranial pressure monitoring vs no monitoring in severe penetrating brain injury management","volume":"6","author":"Mansour A","year":"2023","unstructured":"Mansour A, Rowell S, Powla PP, Horowitz P, Goldenberg FD, Lazaridis C. Comparative effectiveness of intracranial pressure monitoring vs no monitoring in severe penetrating brain injury management. JAMA Netw Open. 2023;6(3):e231077."},{"issue":"3","key":"b17","series-title":"J Emerg Trauma Shock","first-page":"395","article-title":"Management of penetrating brain injury","volume":"4","author":"Kazim SF","year":"2011","unstructured":"Kazim SF, Shamim MS, Tahir MZ, Enam SA, Waheed S. Management of penetrating brain injury. J Emerg Trauma Shock. 2011;4(3):395\u2013402."},{"issue":"1","key":"b18","series-title":"J Trauma Acute Care Surg","first-page":"114","article-title":"Variation in neurosurgical intervention for severe traumatic brain injury: the challenge of measuring quality in trauma center verification","volume":"91","author":"Truong EI","year":"2021","unstructured":"Truong EI, Stanley SP, DeMario BS, Variation in neurosurgical intervention for severe traumatic brain injury: the challenge of measuring quality in trauma center verification. J Trauma Acute Care Surg. 2021;91(1):114\u2013120."},{"key":"b19","series-title":"Clin Neurol Neurosurg","first-page":"107545","article-title":"Long-term benefits for younger patients with aggressive immediate intervention following severe traumatic brain injury: a longitudinal cohort analysis of 175 patients from a prospective registry","volume":"224","author":"Agarwal N","year":"2023","unstructured":"Agarwal N, Wilkins TE, Nwachuku EL, Long-term benefits for younger patients with aggressive immediate intervention following severe traumatic brain injury: a longitudinal cohort analysis of 175 patients from a prospective registry. 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