Surgery not linked to better outcomes for acute subdural hematoma, study finds

Researchers observed no improvement in functional outcomes in patients with acute subdural hematoma who underwent surgical evacuation compared with initial conservative treatment, according to a study published in The Lancet Neurology.

“In patients with rapid neurological deterioration because of a large acute subdural hematoma, the decision to operate in the acute phase is clear,” Thomas A. van Essen, MD, of the Leiden University Medical Centre in the Netherlands, and colleagues wrote. “Without acute surgery, high intracranial pressure will persist, and the patient will die. In most cases however, the benefit of acute surgery is less clear, and patients might, at least initially, be safely managed conservatively.”

Seeking to compare the effectiveness of acute surgical intervention with initial conservative treatment for patients with acute subdural hematoma, van Essen and colleagues conducted a prospective, multicenter, observational study with data from the Collaborative Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The primary endpoint was functional outcome at 6 months, assessed using the eight-point Glasgow Outcome Scale Extended (GOSE).

Of 4,559 eligible participants enrolled in the study from 2014 to 2017, 31% (n = 1,407) presented with acute subdural hematoma within 24 hours of traumatic brain injury. Surgical removal was performed in 336 patients (craniotomy in 245, decompressive craniectomy in 91), while 982 patients received conservative treatment, of whom 107 underwent delayed decompressive craniectomy or craniotomy.

Results showed that the percentage of patients who underwent acute surgery ranged from 5.6% to 51.5% (IQR = 12.3–35.9) between centers, with a nearly two-times higher probability of receiving acute surgery for an identical patient in one center compared with another center at random (adjusted median OR for acute surgery = 1.8). In addition, practice variation was low for patients with a Glasgow Coma Scale score of 15 (good prognosis), with between 91% and 100% receiving conservative treatment initially.

Further, center preference for acute surgery over initial conservative treatment was not associated with improvements in functional outcome per GOSE at 6 months (adjusted common OR per 23.6% [IQR increase] more acute surgery in a center = 0.92; 95% CI, 0.77-1.09).

“In a patient with an acute subdural hematoma for whom a neurosurgeon sees no clear superiority for surgery vs. conservative treatment, initial conservative treatment might be considered,” van Essen and colleagues wrote.