Surgical Treatment of Penetrating Wounds after Resuscitation (STOPWAR) Study: A Classification System for Penetrating Injuries to the Posterior Fossa

Introduction: This study aimed to evaluate the proposed Surgical Treatment of Penetrating Wounds After Resuscitation (STOPWAR) posterior fossa penetrating traumatic brain injury (pTBI) classification system, which is based only on features of projectile trajectory.

Methods: We retrospectively evaluated a consecutive series of 71 patients with penetrating posterior fossa injuries treated at Mechnikov Hospital in Dnipro, Ukraine. The STOPWAR classification includes missile trajectory and location, crossing of midline, and presence of brainstem injury. Univariable and multivariable analyses examined relationships between STOPWAR classification, one-month mortality, and one-month outcome on the dichotomized Glasgow Outcome Scale (GOS). Other traumatic brain injury (TBI) classification schemes were also evaluated.

Results: One-month mortality rate was 21%. Favorable outcomes (GOS of good recovery/moderate disability) were seen in 55% of patients. STOPWAR classification was significantly associated with one-month mortality (AUC 0.9298; OR 4.054 [95% CI 2.287-9.126]) and one-month dichotomized GOS outcome (AUC 0.8373; OR 3.154 [95% CI 1.954-5.830]). The STOPWAR classification performed favorably compared to other TBI classification schemes.

Conclusion : In this largest reported series of posterior fossa pTBI patients, one-month mortality was lower than previously described, suggesting that patients with military pTBI (primarily from shrapnel) may have better outcomes than those with civilian pTBI (primarily gunshot wounds). A major advantage of the STOPWAR classification is reliance on only radiographic findings, which enables its use when clinical examination is impossible or potentially inaccurate. Slightly worse performance of STOPWAR for GOS outcome than mortality may reflect the inadequacy of using the GOS to measure outcomes at only one month after injury. Unfortunately, more detailed outcome assessments at longer postinjury time intervals are not currently possible in Ukraine. Longer outcome tracking and other improvements in study design can be explored in future investigations, including evaluation of the STOPWAR classification in civilian pTBI patients and in casualties from other armed conflicts.