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Emergency surgery for TBI Timely and appropriate surgical intervention for TBI – critical It has long been known that quick and effective surgical intervention for TBI is associated with a much more favourable outcome. Because of this, burr holes for intracranial haematomas and the elevation of depressed skull fractures are both recognised by multiple international organisations as procedures that are essential to be accessible to all worldwide. Despite this, the Lancet Commission on Global Surgery recently estimated that 5 million people worldwide lack access to safe, affordable, accessible surgical care and this deficiency is particularly apparent in the provision of neurosurgery. And to highlight the disparities in care, if you look at the top left image you’ll see an image of our extremely well equipped neurocritical care unit in Cambridge from a BBC documentary on acute brain injury from 2010. In contrast, the bottom image is from a BBC TV report from Aleppo, Syria last year that some of you may have seen. The individual on the left is Dr Omar Ibrahim Abdallah, an Egyptian neurosurgeon volunteering in Syria who has worked with us on some projects. Here, Dr Abdallah can be seen performing emergency burr holes to decompress a patient with an ASDH in the hospital corridor floor as there were no theatres or beds in ITU. The patient later went on to have a craniotomy and recovered to GCS 15 on discharge.

Proposal The GNOS study aims, for the first time, to provide a comprehensive picture of the management and outcomes of patients undergoing emergency cranial surgery after a TBI worldwide. “Snapshot clinician-driven study” methodology successfully used by the GlobalSurg 1 project which collected data on 10,745 patients undergoing emergency abdominal surgery from 357 centres in 58 countries. There is growing recognition that the challenges inherent in delivering surgical care in LMICs can be more effectively met with contextual research. To begin to investigate this problem, we propose conducting an international, multi-centre, clinician-led snapshot study of outcomes following emergency surgery for TBI, with a similar methodology to previous studies by international groups such as GlobalSurg and PaedSurg Africa in general surgery and paediatric surgery respectively and the BNTRC locally.

Methodology Multi-centre, prospective observational study Any hospital in the world performing emergency cranial surgery for TBI can participate Each hospital will have a lead investigator A team of up to 4 collaborators (including lead investigator) will identify patients and collect data Lead investigators will also be responsible for gaining local approvals and creating clear methods for collecting all required data on all eligible patients The participation of residents / registrars / trainees is encouraged

Inclusion criteria Every patient (adult and paediatric) receiving emergency surgery for TBI in any consecutive 30-day period between October 2018 and April 2019 This wide period has been chosen in order to maximise flexibility Each local team of investigators should select the most convenient consecutive 30- day period

Exclusion criteria Patients who ONLY have an external ventricular drain or intraparenchymal wire (or other monitoring device) inserted for the diagnosis and/or management of intracranial hypertension. Patients who undergo procedures for chronic subdural haematoma(s), including burr holes or mini-craniotomies. Elective (planned admission) or semi-elective (where patient initially admitted as an emergency, then discharged from hospital, and re-admitted at later time for surgery) procedures. Patients who have previously had emergency cranial surgery for traumatic brain injury rendering them eligible for inclusion in this study (regardless of whether they were included).

Outcome measures 14-day mortality Return to operating theatre for cranial surgery during follow-up period Length of stay in hospital / length of stay in ICU GCS at discharge Surgical site infection We recognise the importance of long-term outcomes following TBI but believe that short-term outcomes will provide adequate information for the purposes of this study, whilst at the same time minimising the “loss to follow-up” rate

Data collection tool Internet-based Highly secure

Publications

GNOS