CNS ORAL PRESENTATIONS 178 Comparison of Outcomes in Level I versus Level II Trauma Centers in Patients Undergoing Craniotomy or Craniectomy for Severe Traumatic Brain Injury Nohra Chalouhi, MD; Fadi Al Saiegh, MD; Robert M. Starke, MD, MSc; Jack Jallo, MD, PhD, FACS INTRODUCTION: Traumatic brain injury (TBI) still carries a devastatingly high rate of morbidity and mortality. This study is the first to assess whether patients undergoing a craniotomy or craniectomy for severe TBI fare better at level I than level II trauma centers. METHODS: The data were extracted from the Pennsylvania Trauma Outcome Study database (the Pennsylvania Trauma Systems Foundation statewide trauma registry), which contains data collected by each of the 31 accredited level I and II trauma centers in the state. Inclusion criteria were patients older than the age of 18 yr with severe TBI (Glasgow Coma Scale [GCS] score of lower than 9) undergoing craniotomy or craniectomy in the state of Pennsylvania between January 2002 and September 2017. RESULTS: Of 3980 patients, 2568 (64.5%) were treated at level I trauma centers and 1412 (35.5%) at level II centers. Baseline charac- teristics were grossly similar between the 2 groups except for signifi- cantly worse GCS scores at admission in level I centers (P = .002). The rate of in-hospital mortality was 37.6% in level I trauma centers versus 40.4% in level II trauma centers (P = .08). Likewise, mean 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 a level II trauma center significantly predicted in-hospital mortality (odds ratio [OR] 1.2; 95% confidence interval [CI] 1.03-1.37; P = .01) and worse FIM scores (OR 1.4; 95% CI 1.1-1.7; P = .001). Mean hospital and intensive care unit length of stay were significantly longer in level I centers (P < .005). CONCLUSION: Even in a mature trauma system, patients under- going craniotomy or craniectomy for severe TBI have superior functional outcomes and lower mortality rates in level I compared with level II trauma centers. The findings support the rapid transfer of such patients to level I trauma centers. 179 To Scan or Not to Scan: The Role of Follow-up CT Scanning for Management of Chronic Subdural Hematoma After Neurosurgical Evacuation (TOSCAN) a Randomized, Controlled Trial Philippe Schucht, MD; Urs Fischer; Christian Fung, MD; Corrado Bernasconi; Jens Fichtner; Sonja Vulcu, MD; Daniel Schöni; Andreas Nowacki; Stefan Wanderer; Christian Eisenring; Anna-Katharina Jetzer; Nicole Soell; Luca Tochtermann; Werner Z‘Graggen; Andreas Raabe, MD; Juergen Beck, MD INTRODUCTION: Chronic subdural hematoma has a high recur- rence rate after surgery and postoperative scans often show substantial residuals, eventually leading to a higher rate of reoperation. However, the benefit of postsurgical imaging for patient outcome remains unknown. METHODS: We randomly assigned 368 patients with newly diagnosed chronic subdural hematoma within 48 h after surgery to either a combined radiological and clinical follow-up (CT arm) or a clinical follow-up with scans only in case of neurological deterioration (no-CT arm). The primary outcome was the modified Rankin scale (mRS) score at 90 d; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death). RESULTS: A follow-up protocol with CT imaging did not improve the primary outcome; there was no significant between-arm difference for mRS as a categorical variable (P = .79) or as numerical variable (P = .37). The proportion of patients who survived without severe disability (mRS 0-3) was 89% in the CT arm and 93% in the no-CT arm (odds ratio 1.4, 95% confidence interval 3.72-0.82, P = .15). Death occurred in 12 patients in the CT arm and in 8 patients in the no-CT arm (P = .5). Re- operation for recurrent hematomas was performed in 59 patients in the CT arm and in 39 patients in the no-CT arm (P = .055). Complications were seen in 26 patients in the CT arm and in 19 patients in the no-CT arm (P = .34). CONCLUSION: Routinely scheduled CT scans after neurosurgical evacuation of chronic subdural hematoma have no benefit on outcome. 180 Recovery Trajectories and Long-Term Outcomes in Traumatic Brain Injury: A Secondary Analysis of the Phase 3 COBRIT Clinical Trial Ross Puffer, MD; John K. Yue, BA; Julia Billigen, RN; Jane Sharpless, MS; Anita L. Fetzick; Ava Puccio; Ramon Diaz-Arrastia; David O. Okonkwo, MD, PhD INTRODUCTION: Prospects for recovery after traumatic brain injury (TBI) are often underestimated, and this can lead to withdrawal of care in the severe TBI patient in a coma who may ultimately have a favorable outcome with continued aggressive care. METHODS: A secondary analysis of the phase 3 COBRIT was performed analyzing recovery trajectories and long-term outcomes at 30, 90, and 180 d after injury. Subjects were analyzed according to their Glasgow Coma Scale at presentation, and outcomes were based on GOS- E. A GOS-E of 4 or greater was considered favorable. RESULTS: There were high rates of favorable outcome (63% of severe TBI, 87% of moderate TBI, and 96% of complicated mild TBI) at 6-mo follow-up. These favorable outcomes often converted from initially low rates of favorable outcome at 1-m follow-up (21% in severe TBI, 54% in moderate TBI, and 87% in complicated mild TBI). Recovery trajectory projections suggest that further improvement is likely seen beyond 6 mo after injury, and the long-term outcomes in moderate and severe TBI more closely mimic recovery in complicated mild TBI when projected to follow-up at 2 yr after injury. CONCLUSION: The majority of patients had favorable outcomes by GOS-E at 6 mo after injury in all TBI groups (complicated mild 96%, moderate 87%, severe 63%). There was substantial improvement in all groups from 1-mo to 6 mo after injury, and predictive models suggest that this improvement continues beyond 6 mo. The small group of subjects with an unfavorable outcome (GOS-E 2-3) at 1 mo should continue close observation as approximately 20% will improve to a favorable outcome by 6 mo after injury. Further clinical trials should evaluate outcomes beyond 6 mo to better capture recovery trajec- tories and assist providers with more accurate predictions for individual patients. Future clinical trials should also consider recovery curves with repeated measures to assess outcomes, as arbitrary single-moment outcome determination likely underestimates treatment effect in TBI care. 108 | VOLUME 65 | NUMBER 1 | SEPTEMBER 2018 www.neurosurgery-online.com Downloaded from https://academic.oup.com/neurosurgery/article-abstract/65/CN_suppl_1/108/5074940 by guest on 30 May 2020