Acta Neurochir (2014) 156:177185
DOI 10.1007/s00701-013-1932-5
CLINICAL ARTICLE - BRAIN INJURY
Acute neurosurgery for traumatic brain injury by general
surgeons in Swedish county hospitals: A regional study
Ann Fischerstrm & Lena Nyholm & Anders Lewn &
Per Enblad
Received: 10 July 2013 / Accepted: 21 October 2013 / Published online: 24 November 2013
# Springer-Verlag Wien 2013
Abstract
Background Traditionally acute life-saving evacuations of
extracerebral haematomas are performed by general surgeons
on vital indication in county hospitals in the Uppsala-rebro
health care region in Sweden, a region characterized by long
distances and a sparsely distributed population. Recently, it
was stated in the guidelines for prehospital care of traumatic
brain injury from the Scandinavian Neurosurgical Society that
acute neurosurgery should not be performed in smaller hospi-
tals without neurosurgical expertise.
The aim of this study was to investigate: how often does
acute decompressive neurosurgery occur in county hospitals
in the Uppsala-rebro region today, what is the indication for
surgery, and what is the clinical outcome? Finally, the goal
was to evaluate whether the current practice in the Uppsala-
rebro region should be revised.
Method Patients referred to the neurointensive care unit at the
Department of Neurosurgery in Uppsala after acute evacua-
tion of intracranial haematomas in the county hospitals 2005
2010 were included in the study. Data was collected retro-
spectively from the medical records following a predefined
protocol. The presence of vital indication, radiological and
clinical results, and long-term outcome were evaluated.
Findings A total of 49 patients (17 epidural haematomas and
32 acute subdural haematomas) were included in the study. The
operation was judged to have been performed on vital indica-
tion in all cases. The postoperative CT scan was improved in
92 % of the patients. The reaction level and pupillary reactions
were significantly improved after surgery. Long-term outcomes
showed 51 % favourable outcome, 33 % unfavourable out-
come, and in 16 % the outcome was unknown.
A. Fischerstrm : L. Nyholm : A. Lewn : P. Enblad (*)
Department of Neuroscience, Section of Neurosurgery,
Uppsala University, SE-751 85 Uppsala, Sweden
e-mail: Per.Enblad@neuro.uu.se
Conclusions Looking at the indication for acute neurosurgery,
the postoperative clinical and radiological results, and the long-
term outcome, it appears that our regional policy regarding life-
saving decompressive neurosurgery in county hospitals by gen-
eral surgeons should not be changed. We suggest a curriculum
aimed at educating general surgeons in acute neurosurgery.
Keywords Traumatic brain injury . Acute subdural
haematoma . Epidural haematoma . Acute neurosurgery .
General surgeons . Local hospitals . Glasgow outcome score .
Scandinavian guidelines
Introduction
The intracranial space has a limited ability to compensate for
extra volume caused by an intracranial haematoma [10].
When the compensatory mechanisms for extra intracranial
volume are exhausted, the intracranial pressure (ICP) rises
very quickly. The MonroKellie doctrine explains the pres-
surevolume relationship (Fig. 1). The time factor is impor-
tant, and even after a mild traumatic brain injury (TBI), a
haematoma can quickly increase the ICP and cause life-
threatening brain herniation. It can be crucial and life-saving
that an intracranial haematoma is evacuated without unneces-
sary delay [7]. This is a challenging fact for the organization of
national healthcare, especially in large and sparsely populated
regions. The Department of Neurosurgery at Uppsala
University Hospital (UUH), Sweden, has a catchment area
of approximately 2 million people. Most patients with TBI in
the Uppsala-rebro region are initially transmitted to a county
hospital that lacks neurosurgeons on site for early care accord-
ing to the ATLS concept [2]. This is done for practical reasons
and to secure the vital functions as soon as possible. The most
distant hospital is located 382 km from UUH. Traditionally, a
number of general surgeons in every county hospital in the
178
Fig. 1 Schematic diagram. The pressurevolume relationship is non-
linear. The MonroKellie hypothesis states that the sum of the intracranial
volumes of brain, cerebrospinal fluid, circulating blood and for example a
haematoma is constant and that the skull is an inelastic compartment. The
cerebrospinal fluid and venous blood volumes are reduced when a
haematoma enlarges. When the compensatory mechanisms for extra
volume are exhausted, the intracranial pressure increases very quickly
to high levels, a situation which demands urgent surgical evacuation
Uppsala-rebro region receive some education and training in
neurosurgery. This is to ensure that they can perform acute life-
saving evacuations of extracerebral haematomas on vital indica-
tion after consultation with the Department of Neurosurgery in
UUH. Except for evacuations of chronic subdural haematomas,
no planned neurosurgery should be performed in the county
hospitals of the Uppsala-rebro region.
The aim of this study was to investigate clinical outcome for
acute TBI patients operated on vital indication in hospitals
lacking neurosurgical expertise on site. The questions of inves-
tigation were: how often did acute decompressive neurosurgery
occur in county hospitals in the Uppsala-rebro region, what
was the indication for surgery, and what was the clinical
outcome? Finally, the goal was to evaluate whether the current
practice in the Uppsala-rebro region should be revised.
Patients and methods
Management policy and patient inclusion
The management policy for TBI patients in the Uppsala-
rebro region is that all TBI patients with pathological CT
scan and/or impaired consciousness or focal neurological
signs should be discussed with the neurosurgical consultant
on call at UUH after electronic transmission of the CT scans.
Decisions are made regarding whether the patient should be
transferred acutely or not, and whether a life-saving evacua-
tion of an expansive intracranial haematoma should be per-
formed before transportation. The general principle is that all
patients undergoing life-saving haematoma evacuation in the
county hospitals should be transferred to UUH after surgery.
The following criteria should be met by all patients to be
included in this study: (1) Patients with acute TBI (chronic and
subacute haematomas were excluded); (2) Trauma and
Acta Neurochir (2014) 156:177185
admission to county hospital occurred 20052010; (3) Acute
neurosurgery performed at a county hospital in the UUH
catchment area; (4) Referral to the Neurosurgical Intensive
Care Unit (NICU) at UUH after surgery.
Eligible patients were identified by investigating the
NICUs database and patient lists, and UUHs computerized
medical record system.
Data and questionnaires
Data was collected retrospectively from the patients medical
records following a predefined protocol. The following param-
eters were analyzed: demographics, patients former and ongo-
ing diseases, time for admission to the county hospital, type of
trauma, intoxication, neurological status on admission to the
county hospital, extracranial injuries, preoperative neurological
status, presence of free lucid interval, pre- and postoperative
computerized tomography (CT) scans, and also date of surgery
and whether there was a vital indication. Neurological status
was assessed on admission to and at discharge from the NICU.
Additional actions at the NICU were recorded, i.e., reoperation
at the NICU within or after 24 hours, respectively, from prima-
ry surgery and insertion of ventricular catheter or intracerebral
ICP transducer for ICP monitoring. Clinical outcome was
evaluated at discharge from the NICU, and functional global
outcome was evaluated six months or later after the trauma.
Neurological assessments were made using the Reaction Level
Scale-85 (RLS) [9], which is widely used in Sweden. It is
simple to use and agrees well with the Glasgow Coma Scale
[5, 11]. The correspondence between the Glasgow Coma Scale
Motor score and the RLS grade is summarized in Table 1.
Considering status on admission to and preoperatively at the
local hospital, pupils with no response to light bilaterally were
valued equal to bilateral dilatation. Recordings of RLS 3 solely
were valued equal to RLS 3b (Table 1). Determination of a free
lucid interval required that the patient was awake at some
Table 1 Summary of the Reaction Level Scale grades (RLS 85) in
relation to the Glasgow Coma Scale Motor scores (GCS M). In order to
differentiate between very delayed responses and warding-off pain, RLS
3 has been subdivided into 3A and 3B
RLS 85 GCS M
1 - alert response 6 obeys
2 - delayed response 6 obeys
3A - very delayed response 6 - obeys
3B - wards off pain 5 - localizing
4 - localizes pain 5 - localizing
5 - withdrawing movements 4 - normal flexion/withdrawal
6 - stereotype flexion 3 - abnormal flexion
7 - stereotype extension 2 - extending
8 - no response 1 - no response
Acta Neurochir (2014) 156:177185
period after the trauma, but later became unconscious (RLS>
3B). Preoperative RLS level was either the level at admission to
the county hospital or a later assessment if available.
Major extracranial injuries due to the trauma were recorded
if the injuries themselves would have required hospital care.
Assessment of whether surgery was performed on acute
life-saving (vital) indication was made subjectively on clinical
grounds by evaluating preoperative CT findings, level of
consciousness on admission to the county hospital and chang-
es in level of consciousness preoperatively. Characteristics
considered to support a vital indication for surgery were
preoperative RLS level 48, pupillary dilatation (one or both
eyes), free lucid interval, haematoma width >10 mm, and shift
of the midline >5 mm.
The radiological outcome of surgery was evaluated by
comparing the preoperative and postoperative CT scans and
assessed as improved, unchanged or worsened. The judgment
was predominantly based on whether the shift of the midline
was reduced.
Functional global outcome was measured by means of the
Glasgow Outcome Scale Extended (GOSE) [14], an extension
of the Glasgow Outcome Scale (GOS) [4]. GOS is an ordinal
scale with five levels; good recovery (GR), moderate disabil-
ity (MD), severe disability (SD), vegetative state (VS) and
dead due to TBI (D). It inquires into basic communication,
need of assistance at and away from home, traveling, work
status, hobbies, social life, and return to normal life. The
category of lowest level of function generates the GOS score.
GOSE is an extended scale in which the three highest levels
(GR, MD, SD) are subdivided into higher and lower characterized in Table 2. Intoxication was confirmed by lab-
levels of function. Both scales have been validated for use
after TBI [12, 15].
GOSE scores after approximately 6 months for patients
injured during years 20082010 were retrieved from the
Uppsala TBI quality-register at Uppsala Clinical Research
Center (UCR) (http://www.ucr.uu.se/tbi). Patients injured
between 20052007 were interviewed by telephone at the
time of this study, i.e., during year 2011. If not reachable,
they were sent a questionnaire by mail. In case of inability to
fill in the questionnaire, close relatives were interviewed
instead. The patients were instructed to value their present
function and also take into account the preceding couple of
weeks. The resulting GOSE-levels were afterwards dichoto-
mized into two groups: favourable (GR, MD) and unfavourable
outcome (SD, VS, D).
TBI was considered the cause of death in all patients
who died within 6 months after the trauma and in those
who died later when death was related to the TBI. For
patients who died of unrelated causes and were not yet
GOSE-evaluated when death occurred, the functional
global outcome was based on their latest physical and
neurological status from their county hospital medical
record before the fatal condition.
179
Contemporary injuries affecting level of function were
requested, such as former brain injury or extracranial
injury (e.g., severe fracture). Only the dominating prob-
lem was noted.
Statistical analysis
The results are presented in a descriptive way. When the
number of patients is presented, the percentage of the total
number of patients is provided in brackets. Mean value is
followed by standard deviation within brackets. For compar-
isons between groups, Fishers exact test was used for signif-
icance assessment of the difference between proportions in
contingency tables. P-values<0.05 were considered statisti-
cally significant.
Ethics
Informed consent was acquired from all living patients prior to
inclusion in the study.
Results
Clinical characteristics and preoperative conditions
During the 6-year period, a total of 49 patients were enrolled
to this study: 34 (69 %) men and 15 (31 %) women, with a
mean age of 47 (20) years (range 578). The patients are
oratory tests in 13 (27 %) of all patients and 9 (69 %) of them
were between 3160 years of age.
A total of 23 major extracranial injuries were recorded
from 14 (29 %) of the patients. Thoracic injuries were the
most common and occurred in 9 (18 %) cases, followed by
severe bleeding in 4 (8 %), injuries to extremities in 4 (8 %),
injuries to the vertebral column in 3 (6 %), abdominal injuries
in 2 (4 %) cases and in 1 (2 %) case facial fractures. No spinal
cord or pelvic injuries occurred. For traffic accidents
extracerebral injuries were present in 7 out of 10 cases (70 %).
A total of 28 (57 %) of all patients had a known free lucid
interval after the trauma. The presence of a free interval was
uncertain in 13 (26 %) cases, e.g., in patients found uncon-
scious at home.
See Figs. 2, 3 and 4 for preoperative status at the county
hospital.
All 49 patients had abnormal preoperative CT findings.
The dominating findings on the preoperative CT scan were
an acute subdural haematoma (ASDH) in 32 (65 %) cases and
an epidural haematoma (EDH) in 17 (35 %) cases (Table 3).
All patients showed significant shifts of the midline, i.e., more
than 5 mm (Table 3), except for one who had an occipital
epidural haematoma.
180 Acta Neurochir (2014) 156:177185

Table 2 Demographics and

characteristics of 49 patients en- Age range 578, mean 47 (20)
rolled in the study 01/01/2005
31/12/2010. For the specific con- Age groups < 18 5 (10 %)
ditions listed under medical his- 18-30 7 (47 %)
tory, a single patient can be 31-60 23 (47 %)
counted for several times
>60 14 (29 %)
Sex 34 (69 %) male and 15 (31 %) female
Medical history Patients without current or former disease 30 (61 %)
Patients with current or former disease 19 (39 %)
Former brain trauma or brain disease, 7 (14 %)
TBI 1
Stroke 3
Miscellaneousa 3
Diabetes mellitus of all types 6 (12 %)
Hypertension or cardiac disease 10 (20 %)
Otherb 8 (16 %)
Use of warfarin Confirmed 9 (18 %)
Negated 26 (53 %)
Unknown 14 (29 %)
Type of trauma Fall accidentc 17 (35 %)
Traffic accident 10 (20 %)
Unknown 7 (14 %)
a
Epilepsy, developmental dis- Sports injury 6 (12 %)
abilities or tumour. Assault 5 (10 %)
b
Four cases of known alcoholism, Other 3 (6 %)
one case each of radiotherapy
treated medulloblastoma with Work 1 (2 %)
multiple endocrine insufficiency, Intoxication Confirmed 13 (27 %)
Morbus Menire, COPD, and met- Negated 2 (4 %)
astatic prostate cancer with bone
Unknown 34 (69 %)
marrow depression, respectively.
c Free interval Confirmed 28 (57 %)
Fall due to epileptic seizure.
Syncope was registered as other Negated 8 (16 %)
trauma. Unknown 13 (27 %)
d
Cardiac or respiratory arrest di- Major extracranial injury 14 (29 %)
rectly after the trauma or on ad- Severe cerebral ischaemiad 0 (0 %)
mission to the county hospital.

Fig. 2 Number of patients and 18 17

their neurological status
16
(unknown, RLS grade1-8 or 14
dead) preoperatively at the county 14
Number of patients

hospital, on admission to the

NICU and at discharge from the 12
10
NICU. For three patients recorded 10 9 9
as RLS 3 without a or b on 8
admission to the county hospital, 8 7 7
b was chosen (n=49). Fishers 6 6 6 6
6 5 5 5
exact test (unknown excluded), 4 4
conscious (RLS 1-3b) vs. 4 3 3 3
unconscious (RLS 48): Preop vs. 2 2 2
2 1 1 1 1
Admission NICU, p =0.05 and 0 0 0 0 0 0
Preop vs. Discharge NICU, 0
p <0.0001 Preop status at the county Admission to NICU Discharge from NICU
hospital
Unknown 1 2 3a 3b 4 5 6 7 8 Dead
Acta Neurochir (2014) 156:177185 181

Fig. 3 Number of patients with 30

27
extremity paresis confirmed, 26
negated or unknown in 25 23
preoperative status at the county

Number of patients
hospital, status on admission to
the NICU and discharge from the 20 18
NICU. Patients with RLS >5 were
excluded (n=32, 40 resp. 42). 15
Fishers exact test (unknown 12
excluded), paresis vs. no paresis: 10
Admission NICU vs. Discharge
NICU, p =0.26. Pre-op status was 5
excluded from calculations due to 5
many unknowns 1 1 1
0
Preop status at the county Admission to NICU Discharge from NICU
hospital
Yes No Unknown

Primary surgery
All primary surgeries were judged to have been performed on
vital indications according to the presence of the five severe
preoperative characteristics evaluated (Table 4). Eight (16 %)
patients had all five severe characteristics and 17 (35 %)
patients had four severe characteristics. Even though some
preoperative data was missing, no patient was documented
with less than two severe characteristics.
Postoperative conditions and neurointensive care
After surgery at the county hospital, the RLS grade and pupil-
lary reactions were improved on admission to the NICU (Figs. 2
and 4). Concerning presence of paresis, the preoperative status
was unknown in too many cases to permit analysis (Fig. 3).
When the pre- and postoperative CT-findings were com-
pared and the results were classified as improved, unchanged,
or worsened, the condition was improved in 45 (92 %) of the
cases and unchanged in four (8 %). No case showed a wors-
ened state postoperatively. One patient with ASDH showed a
decreased shift but addition of an EDH, three patients had a
decreased shift but addition of contusions, and one patient was
initially improved but was later reoperated on at the county
hospital because of expanding EDH. All of them were
assessed as improved. One patient with a small EDH remnant
and additional contusions on the postoperative scan was
assessed as unchanged because of unchanged shift.
Of the patients, 15 (31 %) had neither ICP monitoring nor
additional surgery during their stay in the NICU. Regarding
ICP monitoring, 22 (45 %) of the patients received only
intraparenchymatous pressure transducers, two (4 %) patients
had only ventriculostomies for ICP monitoring, and six (12 %)
patients had both, while 19 (39 %) of the patients had neither.
Reoperation within 24 hours from TBI was done in 15 (31 %)
of the patients. Additional surgery more than 24 hours after
TBI was done on 11 (22 %) of the patients (after 121 days).
One of the later reoperations was conducted because of
suspected intracranial abscess and another because of a new
subdural haematoma (8 days after the primary surgery and
7 days after additional surgery). One patient underwent reop-
eration at the county hospital four days after the primary
surgery, and was thereafter transmitted to the NICU at UUH
where no more operations were done. This operation was not

Fig. 4 Number of patients with 45

unilateral pupillary dilatation, 40
40 38
bilateral dilatation or normal
pupillary function in response to 35
Number of patients

light preoperatively at the county

30
hospital, on admission to the
NICU and at discharge from the 25 23
NICU. (n=49, 49 resp. 48). One
20 17
patient was deceased before
discharge from the NICU. 15
Fishers exact test (unknown 8 8
10
excluded): pupillary dilatation 6
(uni- or bilateral) vs. normal 5 2 2
1 1 1
pupillary response, Preop vs.
0
Admission NICU, p <0.0001 Preop status at the county hospital Admission to NICU Discharge from NICU

Unilateral dilatation Bilateral dilatation Normal function Unknown

182
Table 3 Dominating finding on preoperative CT scan of the brain, width
of haematoma and shift of the midline (range and mean in mm) n=49.
*One patient with occipital epidural haematoma and no shift excluded
Width Shift *
Dominating findings n (%) Range Mean Range Mean
Epidural haematoma 17 (35 %) 12-38 26.2 (7.8) 3-18 9.1 (4.7)
Acute subdural 32 (65 %) 6 -30 15.9 (5.9) 6-28 14.8 (4.4)
haematoma
recorded as reoperation in the protocol. All other reoperations
were performed at UUH.
Mean time from admission to discharge from the NICU
was 11 (8) days, ranging from 2 days to 43 days. One patient
died before discharge. Patients were in general transferred
back to their county hospital.
Clinical outcome and functional global outcome
The RLS grade and pupillary reactions were improved further
from admission to the NICU to discharge (Figs. 2 and 4).
Presence of paresis appeared to be virtually unchanged (Fig. 3).
Follow-up on functional global outcome with GOSE was
conducted 685 months after the injury (mean 38 [29] and
median 40 months). Results are summarized in Figs. 5 and 6.
Good recovery was achieved in 20 (41 %) of the 49 patients
(15 higher and 5 lower), moderate disability in 7(14 %) (5
higher and 2 lower) and severe disability in 8 (16 %) (2 higher
and 6 lower). Nine (18 %) patients were dead due to TBI. Five
(10 %) of the patients were lost to follow up and had unknown
clinical course. Two (4 %) patients were classified according to
their last known condition before death, which was considered
to be unrelated to the TBI (1 SD-H RLS 2 at discharge from
the NICU, GOSE-evaluation from medical records 11 months
after the TBI, death due to ruptured thoracic aneurysm
11 months after the TBI and 1 MD-L RLS 2 at discharge
from the NICU, GOSE-evaluated 8 months after the TBI,
unknown cause of death 4.5 years after the TBI). Among the
nine patients who were classified as dead due to TBI, seven
were deceased within 6 months after TBI, and two after
26 months and 13 months respectively of persistent vegetative
state. Six were >60 years old (four fall accidents and two traffic
accidents), one of them was treated with anticoagulants, one
Table 4 Number of patients with each of the severe characteristics supporting that there was a vital indication. No single patient had less than two of the
characteristics. Unconscious refers to preoperative RLS level 48 at the county hospital. (n=49)
Unconscious Pupillary dilatation
Yes 30 (61 %) 25 (51 %)
No 12 (25 %) 1 (2 %)
Unknown 7 (14 %) 23 (47 %)
Acta Neurochir (2014) 156:177185
had metastatic cancer and one was a known alcoholic who died
after 13 months of persistent vegetative state. The three other
patients classified as dead due to TBI were in age group 31
60 years old; one was a known alcoholic and the other was the
patient who died in vegetative state 26 months after TBI. Of all
49 patients, 27 (55 %) had a favourable (GR, MD), 17 (35 %)
an unfavourable (SD, VS and D) and 5 (10 %) an unknown
outcome (lost to follow up). Coexisting injuries potentially
affecting GOSE-results were found in 5 (14 %) of the 35
patients available for follow-up.
In Table 5, preoperative characteristics, e.g., sex, age, initial
RLS, type of haematoma, and use of anticoagulants are listed
in contingency tables with outcome data. Traffic accidents (10
cases) resulted in 4 (40 %) favourable cases, 5 (50 %)
unfavourable cases and 1 (10 %) case with unknown outcome.
Fall accidents (17 cases) resulted in 9 (53 %) favourable, 6
(35 %) unfavourable and 2 (12 %) cases with unknown
outcome. For the 14 cases with presence of extracranial injury
outcome was in 7 (50 %) cases favourable, 6 (43 %) cases
unfavourable and 1 (7 %) case unknown.
Discussion
In our retrospective study, 49 patients underwent acute evac-
uation of extracerebral haematomas at county hospitals in the
Uppsala-rebro region during a period of 6 years. Outcome
was favourable in 27 (55 %) cases, unfavourable in 17 (35 %),
and unknown in 5 (15 %) cases. The question is whether this
result is acceptable to such an extent that the current practice
with life-saving primary neurosurgery in county hospitals
should be preserved in our region. We believe that the answer
is yes, according to the following reasoning.
This study is the first of its kind to be performed in the
Uppsala-rebro region. The outcome-results can be compared
to a similar Norwegian study [13] where a larger percentage of
the patients had an unfavourable outcome (48 %) and where the
mortality rate was higher (29.8 %). The different results may be
explained by differences in patient characteristics concerning
the degree of vital indication for acute decompressive surgery
as well as differences in surgical experience and general man-
agement. In contrast to our study, the patients in the Norwegian
study [13] were rarely sent to a neurointensive care unit after
Free lucid interval Haematoma width Midline shift
(>3b) >10 mm >5 mm
26 (53 %) 44 (90 %) 44 (90 %)
10 (20 %) 5 (10 %) 5 (10 %)
13 (27 %) 0 (0 %) 0 (0 %)
Acta Neurochir (2014) 156:177185 183

Fig. 5 Number of patients in 16 15

each GOSE-category. GR, good
14
recovery; MD, moderate
disability; SD, severe disability; 12

Number of patients
VS, vegetative state; D, dead due
to TBI; H and L, higher and lower 10 9
level of function (n=49)
8
6
6 5 5 5

4
2 2
2
0
0
GR-H GR-L MD-H MD-L SD-H SD-L VS D Unknown
GOSE

surgery, but stayed in the county hospitals for further treatment
and recovery. Also, the staff and surgeons in that study were not
educated in neurosurgery or neurointensive care. This fact
might in part explain the difference in outcome. Despite that
the local demographic structure and organization of health care
may differ within and between countries, and that it is very
difficult to generalize experiences, the Norwegian study men-
tioned above was the foundation to the statement in the new
guidelines for prehospital care of severe traumatic brain injury
from the Scandinavian neurosurgical society that no patient
with acute brain injury should be operated on in the county
hospitals without neurosurgical expertise [1, 8]. We are not
convinced that the new guidelines should be adopted in our
region according to our findings, which will be discussed
further in the following section.
The most important question to discuss to justify acute
decompressive neurosurgery in a county hospital is wheth-
er the operations were performed on a clear vital indication
30
27
25
Number of patients
and if a delay of surgery due to transportation would have
resulted in an unfavourable outcome. In retrospect, it can
be difficult to strictly evaluate if the situation required
immediate life-saving decompressive neurosurgery. To
make the evaluation more objective, we defined five clin-
ical and radiological criteria supporting a vital indication
for surgery (preoperative RLS level 48, pupillary dilata-
tion, free lucid interval, haematoma width >10 mm and
shift of the midline >5 mm). The majority of the cases had
four or five severe characteristics (51 %), and no patient
had less than two severe characteristics, despite some
missing data. Our interpretation is, therefore, that the op-
erations appeared to have been performed with a vital
indication and one can anticipate that a delay of decom-
pressive surgery would have had severe negative influence
on the prognosis. Another important question to analyze to
justify acute decompressive neurosurgery by general sur-
geons is the quality of surgery. In our series, postoperative
CT scans were improved in 45 (92 %) cases, and in no case
worsened, which tells us that very few inadequate or un-
successful operations (from a retrospective point of view)
occurred. These results differ from the Norwegian study

[13], where 30 % of the operations retrospectively were

assessed as inadequate, e.g., when the postoperative CT
20
17 scan not were improved, when the perioperative bleeding
was out of control, or when the haematoma could not be
15
found during surgery. The result in that study was that, in
fact, only 45 % of the operations for acute severe traumatic
10
brain injury performed in county hospitals were truly
5 acute. In conclusion, looking at the indication for acute
5
neurosurgery and the postoperative clinical and radiologi-
cal result in our series, it appears that our regional policy
0
Favourable Unfavourable Unknown regarding life-saving decompressive neurosurgery in coun-
ty hospitals by general surgeons should not be changed,
Outcome
and that the experience from Norway cannot can be gen-
Fig. 6 Number of patients with favourable, unfavourable and unknown
outcome according to GOSE. Favourable refers to good recovery or
eralized to our region. This opinion is further strengthened
moderate disability. Unfavourable refers to severe disability, vegetative by the results of the follow-up considering that most pa-
state or dead due to TBI (n=49) tients were in a very severe condition preoperatively.
184 Acta Neurochir (2014) 156:177185

Table 5 Preoperative characteristics and the distribution of patients in severe disability, vegetative state or dead due to TBI. (n=49). Fishers
favourable and unfavourable outcome according to GOSE. Favourable exact test, unknown excluded
refers to good recovery or moderate disability. Unfavourable refers to

Circumstance Favourable outcome Unfavourable outcome Unknown outcome p

Men (n=34) 19 (56 %) 11 (32 %) 4 (12 %) p=0.75

Women (n=15) 8 (53 %) 6 (40 %) 1 (7 %)
< 65 years old at time of trauma (n=39) 22 (56 %) 13 (33 %) 4 (10 %) p=0.72
65 years or older at time of trauma (n=10) 5 (50 %) 4 (40 %) 1 (10 %)
RLS 1-3b preop at the county hospital (n=12) 6 (50 %) 4 (33 %) 2 (17 %) p=1.00
RLS 48 preop at the county hospital (n=30) 16 (53 %) 11 (37 %) 3 (10 %)
RLS unknown preop at the county hospital (n=7) 5 (71 %) 2 (29 %) 0 (0 %)
Use of anticoagulants confirmed (n=9) 1 (11 %) 6 (67 %) 2 (22 %) p<0.01
Use of anticoagulants negated (n=26) 18 (69 %) 6 (23 %) 2 (8 %)
Use of anticoagulants unknown (n=14) 8 (57 %) 5 (36 %) 1 (7 %)
Epidural haematoma (n=17) 13 (76 %) 3 (18 %) 1 (6 %) p=0.05
Subdural haematoma (n=32) 14 (44 %) 14 (44 %) 4 (13 %)

A few more interesting observations were also done in our
study. Not surprisingly, we found that a high preoperative RLS
score (more severe state) at the county hospital resulted in a
more unfavourable outcome (Table 5). This finding is, of
course, to some extent a reflection of the severity of the primary
brain injury, but probably also an illustration of the need for
immediate decompressive neurosurgery when a secondary
extracerebral haematoma develops. Epidural haematomas
showed better outcome than acute subdural haematomas,
which is in accordance with the finding in the Norwegian study
[13]. Another finding was that patients injured in traffic acci-
dents in general had a more unfavourable outcome than pa-
tients injured in fall accidents (50 % vs. 35 %). This is consis-
tent with a previous Swedish study [3], where traffic accidents
were found to cause more severe injuries than, for example, fall
accidents. This might be partly due to a more high-energy
trauma and presence of severe extracranial injuries (70 % vs.
12 %). In our study, anticoagulants (warfarin) were associated
with a more unfavourable outcome (67 % vs. 23 %). A former
British observational study [6] found that the mortality rate was
close to five times higher for TBI patients treated with antico-
agulants compared to non-treated patients.
A strength with this study was that relatively few TBI
patients were lost to follow-up, but a weakness was that
the time from trauma to follow-up varied up to 85 months
(685) between patients. The reason for the great varia-
tion was that not all patients had been followed up
prospectively at six months, but rather retrospectively at
the time of the study. However, there is no reason to
believe that this circumstance would influence the report-
ed clinical outcome substantially, and it does not at all
influence the assessment of indication for surgery and the
postoperative radiological and clinical results at discharge
from the NICU. Another methodological issue is that it
was not possible, for practical reasons, to verify that all
acutely evacuated patients in the local hospitals were
admitted to the neurosurgical department in Uppsala,
according to the policy in the region. However, the clear
impression is that definitely less than five patients per
year are not admitted after evacuation, and those patients
are usually judged to be not possible to treat already
before surgery (poor neurological grade, wide pupils,
signs of severe primary injury on CT scan, high age,
etc.). Thus, it is not reasonable to believe that the exis-
tence of such patients would influence the overall results
in a substantial way.
To summarize, the tradition in our region, characterized by
long distances and highly developed primary county hospitals,
has been that a few of the general surgeons in every county
hospital have received some education and training in neuro-
surgery at our department. The regional policy has been that no
planned neurosurgery should be performed in the county hos-
pitals (except for evacuations of chronic subdural haematomas),
but acute life-saving evacuations of extracerebral haematomas
must be done when there is a clear vital indication and a delay is
judged to be fatal. The neurosurgeon on call should always be
consulted before acute decompressive neurosurgery is per-
formed. Considering the results from our study, we believe that
there is no reason to change our regional policy. We should
continue to strive for that a number of general surgeons from
each county hospital undergo education and training in acute
neurosurgery. In order to formalize the policy for our region and
other corresponding regions as well, we would like to introduce
a curriculum aimed at educating general surgeons in acute
neurosurgery including both general management and surgical
technique. The estimated duration of the education should be
36 months. The mission statement with areas to master and
have knowledge about should be as follows:
Acta Neurochir (2014) 156:177185
& Ability to trepanate and evacuate chronic subdural
haematomas.
& Ability to evacuate acute extracerebral haematomas via
bone flap.
& Master acute pre- and postoperative evaluation and man-
agement of TBI.
& Knowledge of coma scales.
& Knowledge of the interpretation of CT scans.
& Knowledge of the NICU principles.
& Knowledge of neurosurgical instruments, e.g., trephines.
& Knowledge of neurosurgical haemostasis principles.
& Knowledge about principles for antibiotic and thrombo-
embolic prophylaxis.
& Knowledge of acute epilepsy therapy.
& Knowledge of management of skull fractures.
& Knowledge of cerebral shunt-dysfunction.
Acknowledgements The hospitals in the Uppsala-rebro health care
region are acknowledged for their good collaboration.
Conflicts of interest None.
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