Surgical Treatment of Penetrating Wounds After Resuscitation study: a new classification system for penetrating injuries to the posterior fossa.

Objective: The goal of this retrospective study was to evaluate the new Surgical Treatment of Penetrating Wounds After Resuscitation (STOPWAR) posterior fossa penetrating traumatic brain injury (pTBI) classification scheme, which is based only on features of the projectile trajectory.

Methods: This retrospective investigation evaluated a consecutive series of 71 patients with penetrating posterior fossa injuries who arrived at Mechnikov Dnipropetrovsk Regional Clinical Hospital in Dnipro, Ukraine, between February 24, 2022, and May 2, 2024. Univariable and multivariable analyses were performed to examine the relationships between STOPWAR classification and 1-month mortality as well as 1-month outcome on the dichotomized Glasgow Outcome Scale (GOS). Other classification and prognostic schemes for patients with traumatic brain injury (TBI) were also evaluated.

Results: The 1-month mortality rate in this series was 21%. The STOPWAR classification scheme had an area under the receiver operating characteristic curve (AUC) of 0.9298 and OR of 4.054 (95% CI 2.287-9.126) for 1-month mortality and an AUC of 0.8373 and OR of 3.154 (95% CI 1.954-5.830) for 1-month dichotomized GOS outcome. This performance was comparable to that of the other TBI classification schemes that were evaluated.

Conclusions: In the largest reported series of patients with posterior fossa pTBI, 1-month mortality was lower than that in other published series, suggesting that patients with military pTBI, which is caused primarily by shrapnel, may have a better outcome than those with civilian pTBI, most of whom have gunshot wounds. The STOPWAR classification system performed well. A major advantage of the STOPWAR scale is that it is based only on imaging findings and may be used when clinical examination is impossible or potentially inaccurate. The slightly worse performance of the STOPWAR scheme for GOS outcome than for mortality may reflect the inadequacy of using the GOS as an outcome metric at the early postinjury time point of 1 month. Unfortunately, more detailed outcome assessments at longer postinjury time intervals are currently not possible in Ukraine. These and other improvements in study design can be explored in future investigations, which may also evaluate the role of the STOPWAR scale in civilian pTBI patients and in casualties from other armed conflicts.