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Observational Study
. 2025 Oct 1;8(10):e2535200.
doi: 10.1001/jamanetworkopen.2025.35200.

Acute Surgery vs Conservative Treatment for Traumatic Acute Subdural Hematoma

Thomas A Van Essen  1   2   3   4 , John K Yue  3   4 , Jason Barber  5 , Hester F Lingsma  6 , Dana Pisica  6 , Hugo F den Boogert  1 , Jeroen T van Dijck  1   2 , Wouter A Moojen  1   2 , Peter Hutchinson  7   8 , Amy J Markowitz  3   4 , Ewout W Steyerberg  9   10 , David O Okonkwo  11 , Yelena G Bodien  12   13   14 , Alex B Valadka  15 , Ramon Diaz-Arrastia  16 , Claudia S Robertson  17 , Brandon Foreman  18   19 , Vincent Y Wang  20 , Michael A McCrea  21 , Joseph T Giacino  22 , Esther L Yuh  23 , Godard C W de Ruiter  1 , Nancy R Temkin  5   24 , Andrew I R Maas  25   26 , Wilco C Peul  1   2 , Geoffrey T Manley  3   4 ; Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Study Investigators
Collaborators, Affiliations
Observational Study

Acute Surgery vs Conservative Treatment for Traumatic Acute Subdural Hematoma

Thomas A Van Essen et al. JAMA Netw Open. .

Abstract

Importance: It is unclear whether performing surgery for most patients with an acute subdural hematoma (ASDH) and traumatic brain injury (TBI) is superior to conservative treatment.

Objective: To compare the effectiveness of a strategy preferring acute surgical ASDH evacuation with one preferring initial conservative treatment.

Design, setting, and participants: This comparative effectiveness study used data from February 1, 2014, to July 31, 2018, from the prospective observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study, conducted at 18 Level 1 trauma centers in the US. The study included patients with nonpenetrating TBI presenting to the emergency department and admitted within 24 hours after injury with ASDH detected on acute head computed tomography scan. Statistical analysis was performed from December 1, 2022, to December 20, 2024.

Exposures: Acute surgical hematoma evacuation vs initial conservative treatment, comparing outcomes between centers according to treatment preferences, measured by the case mix-adjusted probability of undergoing acute surgery (vs conservative treatment) per center.

Main outcomes and measures: Functional disability at 6 months was assessed with the Glasgow Outcome Scale-Extended at 6 months, analyzed with ordinal logistic regression adjusted for prespecified confounders, quantified with a common odds ratio (OR). Variation in center preference was quantified with a median OR (MOR).

Results: Of 2697 included patients, 711 (mean [SD] age, 46.5 [19.4] years; 539 men [76%]) had an ASDH, of whom 148 (21%) underwent acute cranial surgery and 563 (79%) underwent initial conservative treatment. The acute surgery cohort had lower mean (SD) Glasgow Coma Scale scores (6.8 [4.4] vs 11.4 [4.6]), more pupil abnormalities (both pupils unreacting: 43 of 133 [32%] vs 41 of 477 [9%]), and fewer isolated ASDHs (eg, more with concurrent intracranial lesions; 92 of 133 [69%] vs 297 of 563 [53%%]) compared with the conservative treatment cohort. In the surgical cohort, 129 of 148 patients (87%) underwent decompressive craniectomy (DC), and 17 of 148 (11%) underwent craniotomy. In the conservative treatment cohort, 67 of 563 patients (12%) underwent delayed cranial surgery (DC or craniotomy). The proportion of patients undergoing acute surgery ranged from 0% to 86% (median, 17% [IQR, 5%-27%]) between centers, with up to a 3-fold higher probability of prognostically similar patients receiving acute surgery in one center compared with another random center (MOR, 2.95 [95% CI, 1.79-7.47]; P = .06). Center preference for acute surgery over initial conservative treatment was not associated with a better outcome (OR, 1.05 [95% CI, 0.88-1.26] per 22% [IQR, 5%-27%] increase in acute surgery at a given trauma center).

Conclusions and relevance: In this comparative effectiveness study, similar patients with traumatic ASDH were treated differently due to center-specific treatment preferences. Outcomes were similar in centers preferring surgical evacuation and those preferring initial conservative treatment. This study suggests that, for a patient with ASDH for whom a neurosurgeon experiences clinical equipoise between acute surgery vs (initial) conservative treatment, conservative treatment may be considered.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Yue reported receiving grants from the Weill Neurohub Clinician-Scientist Award Awarded to the University of California, San Francisco (UCSF; Project ID 7032139) during the conduct of the study. Dr Hutchinson reported receiving grants from the National Institute for Health and Care Research during the conduct of the study. Dr Markowitz reported receiving grants from the US Department of Defense TRACK-TBI NETWORK during the conduct of the study. Dr Bodien reported receiving grants from Spaulding Rehabilitation Hospital and Massachusetts General Hospital during the conduct of the study. Dr Diaz-Arrastia reported being a member of the scientific advisory board for BrainBox Solutions and also holding stock options in BrainBox Solutions. Dr Robertson reported grants from the National Institutes of Health (NIH) and grants from the US Department of Defense during the conduct of the study. Dr Foreman reported receiving personal fees from UCB Pharma, Ceribell Inc, Marinus Pharmaceuticals, and Natus Medical Inc and grants from the US Department of Defense outside the submitted work. Dr McCrea reported receiving grants from UCSF Subaward to the Medical College of Wisconsin (MCW) during the conduct of the study and grants from the NIH to MCW, the US Department of Defense to MCW, the National Collegiate Athletic Association to MCW, and the National Football League to MCW outside the submitted work. Dr Giacino reported receiving grants from the Department of Defense with the money paid to the institution, grants from National Institute of Neurological Disorders and Stroke with money paid to the institution during the conduct of the study, grants from the National Institute on Disability Independent Living and Rehabilitation Research, the SameYou Foundation, and the Barbara Epstein Foundation outside the submitted work. Dr Yuh reported receiving grants from the NIH during the conduct of the study. Dr Temkin reported receiving grants from US federal government during the conduct of the study. Dr Maas reported receiving grants for CENTER-TBI from the European Union Fp7 program. Dr Manley reported receiving grants from the US Department of Defense/MTEC TRACK-TBI NETWORK during the conduct of the study, a specimen collection from Abbott Laboratories for the evaluation of traumatic brain injury in adults and pediatrics, and grants from the National Football League outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow Diagram of Study Population and Data Analyses
ASDH indicates acute subdural hematoma; CT, computed tomography; DC decompressive craniectomy; ED, emergency department; GOSE, Glasgow Outcome Scale Extended; Qolibri-OS, Quality of Life after Brain Injury Overall Scale; and TRACK-TBI, Transforming Research and Clinical Knowledge in Traumatic Brain Injury.
Figure 2.
Figure 2.. Between-Center Differences in Acute Surgery for Traumatic Acute Subdural Hematoma
The x-axis presents the log odds of the adjusted acute surgery rates per center. A logistic random-effects model, adjusted for the predefined confounders of age, Glasgow Coma Scale score, pupil reactivity, concomitant contusion, and midline shift, was used to estimate acute surgery preference per center with corresponding 95% CIs. MOR indicates median odds ratio.
See this image and copyright information in PMC

References

    1. Maas AIR, Menon DK, Adelson PD, et al. ; InTBIR Participants and Investigators . Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017;16(12):987-1048. doi: 10.1016/S1474-4422(17)30371-X - DOI - PubMed
    1. Munro D. The diagnosis and treatment of subdural hematoma. N Engl J Med. 1934;210:1-16. doi: 10.1056/NEJM193405312102201 - DOI
    1. Servadei F, Compagnone C, Sahuquillo J. The role of surgery in traumatic brain injury. Curr Opin Crit Care. 2007;13(2):163-168. doi: 10.1097/MCC.0b013e32807f2a94 - DOI - PubMed
    1. Bullock MR, Chesnut R, Ghajar J, et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006;58(3 suppl):S16-S24; discussion Si-Siv. - PubMed
    1. van Essen TA, de Ruiter GCW, Kho KH, Peul WC. Neurosurgical treatment variation of traumatic brain injury: evaluation of acute subdural hematoma management in Belgium and The Netherlands. J Neurotrauma. 2017;34(4):881-889. doi: 10.1089/neu.2016.4495 - DOI - PubMed