Neurosurgical and prehospital timing in severe traumatic brain injury: Insights from the prospective Resuscitation Outcomes Consortium hypertonic saline trial

BACKGROUNDAND OBJECTIVES: – Prompt management is critical in severe traumatic brain injury (TBI) to prevent secondary injury, but an unanswered question is whether, by the time patients reach the operating room, the injury has largely become irreversible. We aimed to evaluate the impact of prehospital time, emergency department (ED) length of stay, and time to neurosurgical intervention on mortality and functional outcomes for these patients. METHODS: – A retrospective cohort study was conducted using data from the prospective Resuscitation Outcomes Consortium TBI trial. Our cohort included adult patients with severe [ie, Glasgow Coma Scale (GCS) ≤8] TBI. Multivariable logistic and ordinal regression models were specified to test associations between prehospital time, ED length of stay, and time to neurosurgical intervention with inpatient mortality and functional outcomes at discharge. RESULTS: – Among 859 patients included (median age, 34 y), most patients presented with a GCS of 3 (median, 3; interquartile range, 3–4). Multivariable logistic regression among the full cohort revealed no association between prehospital time or time to intracranial pressure (ICP) monitor placement and inpatient mortality. However, in a high acuity subgroup of 104 patients who underwent craniotomy within 12 hours and ICP monitoring, increasing time to ICP monitor placement was significantly associated with increased inpatient mortality [odds ratio (OR), 1.07 per hour; 95% confidence interval (CI), 1.00–1.16; p=0.04], reduced Glasgow Outcome Scale Extended (GOSE) at discharge (OR, 0.93 per hour; 95% CI, 0.87–1.00; p=0.03), and reduced GOSE at 6 months follow-up (OR, 0.93 per hour; 95% CI, 0.84–0.99; p=0.04). CONCLUSION: – While prehospital and ED time intervals were not meaningfully associated with outcomes, delays in ICP monitor placement among patients needing urgent cranial surgery were significantly linked to higher mortality and poorer neurologic recovery, highlighting the importance of timely neurosurgical intervention in severe TBI. (J Trauma Acute Care Surg. 2026;101: 682–688.) LEVEL OF EVIDENCE: – Therapeutic/Care Management; Level III