The Association Between Surgical Waiting Time and Glasgow Outcome Scale–Extended (GOSE) in Traumatic Brain Injury Patients Undergoing Craniotomy at Dr. Sardjito General Hospital

Baseline characteristics and outcomes of the subjects

This study included 272 patients with TBI admitted during the observation period. Of these, 201 patients did not undergo craniotomy, while 71 patients met the inclusion criteria. One patient was lost to follow-up. Therefore, 70 patients were included in the final analysis. Most patients were 19 years old and 71.4% were male. Based on GCS scores at admission, 51.4% of patients had a score of 13–15, indicating relatively preserved consciousness, 20% had a score of 9–12, and 28.6% had a score ≤8, reflecting more severe injury. Regarding clinical status at admission, most patients (92.9%) did not exhibit airway or breathing difficulties, whereas 32.9% were intubated. Head CT scans revealed that 35.7% of patients had cerebral edema, 62.9% demonstrated intracranial hemorrhage, and 70% presented with skull fractures. Based on the GOSE assessment, 27.1% of patients achieved good recovery, 27.1% had upper moderate disability, 10% had lower moderate disability, 21.4% had upper severe disability, 5.7% had lower severe disability, and 8.6% died. These findings are summarized in Table 1.

Nonparametric ROC analysis and comparison of ROC areas with the dependent variable GOSE

The analysis involved determining cutoff points for admission-to-incision time (surgical waiting time) and injury-to-incision time for craniotomy using the Liu/Youden method. Although no statistically significant differences were observed between the calculated cutoff points, the highest area under the curve (AUC) was identified at 7 hours, which was selected as the definitive cutoff for admission-to-incision time ( Table 2). For injury-to-incision time a cutoff of 17 hours was determined ( Table 2).

Multivariable logistic regression of sociodemographic and clinical factors on poor GOSE outcomes

Multivariable logistic regression analysis demonstrated that age (OR = 1.04; p = 0.028) and an injury-to-incision time exceeding 17 hours (OR = 7.94; p = 0.022) were significantly associated with poor GOSE outcomes, including upper severe disability, lower severe disability, and death. In contrast, an admission-to-incision time (surgical waiting time) greater than 7 hours was not significantly associated with poor GOSE outcomes (p > 0.05) ( Table 3).

Challenges in comparing time intervals across studies

Comparing the interval from admission to craniotomy incision across studies presents several challenges. These include differences in healthcare systems, infrastructure, and triage protocols implemented in different countries. For instance, the availability of emergency facilities and referral systems can significantly influence patient management times. Variations in the methods used to measure time intervals also pose challenges, as the time of injury may be determined from patient reports, accident witnesses, medical records, or ambulance documentation. Additionally, external factors such as geographic conditions, traffic congestion, and local health policies contribute to the observed differences in time intervals.

In the present study, the median of injury-to-admission time was 8.5 hours. The median of admission-to-incision time (surgical waiting time) was 7 hours and median of injury-to-incision time was 16 hours. These durations are longer than those reported in a similar study in New Zealand, where the injury-to-admission time was 7 hours and the injury-to-incision time was 7.5 hours.³ Surgical waiting times in this study were also longer compared to a study in the United Kingdom, which reported a median duration of 6.7 hours.⁴ These differences highlight the need to improve pre-hospital triage systems and referral efficiency. In a study conducted in Malaysia,⁵ the median door-to-skin time was 605 minutes (10 hours), with an interquartile range of 494–766 minutes. At hospital discharge, 68.2% of patients had poor outcomes; this proportion decreased to 37.7% at six months. Factors such as polytrauma, episodes of hypotension, mechanical ventilation, severe TBI, and door-to-skin time were associated with adverse outcomes.

Effect of surgical waiting time on GOSE

The interval from injury to neurosurgical intervention has a significant impact on patients’ neurological outcomes. According to the Brain Trauma Foundation in the United States, a four-hour window is considered the optimal threshold for surgical intervention.⁶ In Europe, guidelines emphasize the importance of rapid referral and transfer to neurosurgical centers to improve patient outcomes.⁷ Multiple studies have demonstrated that earlier intervention is associated with better prognosis, particularly in terms of neurological recovery.^8,9 Although the findings of the present study did not reach strong statistical significance in multivariable regression analysis, longer intervals from injury to incision were associated with poorer GOSE outcomes, consistent with prior research.¹⁰

Factors affecting patients’ GOSE outcomes

This study also demonstrated that increasing age was associated with poorer GOSE outcomes, consistent with previous findings.^11,12 In elderly patients, physiological factors such as brain atrophy and impaired neuroplasticity increase vulnerability to brain injury and worsen functional recovery.^13,14 Systemic comorbidities, including hypertension and diabetes, further influence the prognosis in older adults.¹⁵ Additionally, this study found that patients who were intubated in the emergency department had a higher risk of poor GOSE outcomes, likely reflecting more severe clinical conditions upon arrival at the referral hospital.^16,17

This study is limited by its single-center design, which may reduce generalizability to other healthcare settings. The relatively small sample size may have limited statistical power to detect associations between surgical waiting time and GOSE outcomes. Time intervals such as injury-to-admission were partly based on patient or witness reports and medical records, which could introduce measurement bias. Unmeasured confounding factors, including injury severity, pre-hospital care, and intraoperative management, may also have influenced outcomes. Follow-up was limited to hospital discharge, preventing assessment of long-term recovery.

Future studies should involve multicenter cohorts with larger sample sizes and standardized time recording to reduce bias. Long-term follow-up is needed to evaluate functional outcomes beyond hospital discharge. Investigating interactions between surgical timing, injury severity, comorbidities, and pre-hospital interventions could inform predictive models to optimize emergency neurosurgical care and patient outcomes.