Early surgery versus conservative treatment in patients with traumatic intracerebral hematoma: a CENTER-TBI study

Abstract

Purpose: Evidence regarding the effect of surgery in traumatic intracerebral hematoma (t-ICH) is limited and relies on the STITCH(Trauma) trial. This study is aimed at comparing the effectiveness of early surgery to conservative treatment in patients with a t-ICH.

Methods: In a prospective cohort, we included patients with a large t-ICH (< 48 h of injury). Primary outcome was the Glasgow Outcome Scale Extended (GOSE) at 6 months, analyzed with multivariable proportional odds logistic regression. Subgroups included injury severity and isolated vs. non-isolated t-ICH.

Results: A total of 367 patients with a large t-ICH were included, of whom 160 received early surgery and 207 received conservative treatment. Patients receiving early surgery were younger (median age 54 vs. 58 years) and more severely injured (median Glasgow Coma Scale 7 vs. 10) compared to those treated conservatively. In the overall cohort, early surgery was not associated with better functional outcome (adjusted odds ratio (AOR) 1.1, (95% CI, 0.6-1.7)) compared to conservative treatment. Early surgery was associated with better outcome for patients with moderate TBI and isolated t-ICH (AOR 1.5 (95% CI, 1.1-2.0); P value for interaction 0.71, and AOR 1.8 (95% CI, 1.3-2.5); P value for interaction 0.004). Conversely, in mild TBI and those with a smaller t-ICH (< 33 cc), conservative treatment was associated with better outcome (AOR 0.6 (95% CI, 0.4-0.9); P value for interaction 0.71, and AOR 0.8 (95% CI, 0.5-1.0); P value for interaction 0.32).

Conclusions: Early surgery in t-ICH might benefit those with moderate TBI and isolated t-ICH, comparable with results of the STITCH(Trauma) trial.

Keywords: Conservative treatment; Contusion; Neurosurgery; Surgical treatment; Traumatic intracerebral hematoma.

Fig. 1

Flow diagram of study population and data analyses. *Primary outcome. ^§Secondary outcomes. Qolibri exclusion criteria is patients with GOSE 1 (death) or GOSE 2/3 (vegetative state/lower severe disability). Abbreviations: t-ICH, traumatic intracerebral hematoma; GOSE: Glasgow Outcome Scale Extended, Qolibri: Quality of Life after Brain Injury Questionnaire

Fig. 2

Subgroup analyses of the primary outcome comparing early surgery versus initial conservative treatment. *TBI severity: mild TBI (GCS 15–13), moderate TBI (GCS 9–12), and severe TBI (GCS < 9). **Isolated t-ICH: without concomitant ASDH or EDH. ***Volume of t-ICH: median split of 33 cc used. ****Acute: large t-ICH on admission, decision made after first CT scan. Delayed: blossoming large t-ICH within 48 h of admission (not present on admission), decision made after that specific CT scan. ****Only subgroup analyses performed on location of the largest t-ICH “frontal” and “temporal” as sample size did not allow for analyses on other locations. Abbreviations: CI: confidence interval; TBI: traumatic brain injury; t-ICH: traumatic intracerebral