Initial aggressive surgical approach in acute subdural hematoma not tied to better functional outcomes: Lancet

Netherlands: In a new study it was shown that in acute subdural hematoma a treatment strategy preferring an aggressive approach of acute surgical evacuation over initial conservative treatment was not associated with better functional outcomes. Also because of differences in the preferred strategy, therapy for patients with acute subdural hematoma with identical features varies depending on the treating center. The findings of this study were published in The Lancet Neurology.

Despite the fact that it is widely established, acute surgery for traumatic acute subdural hematoma is based on low-grade data. As a result, Thomas A van Essen and the team undertook this study to assess the efficacy of an acute surgical evacuation approach vs one that prefers early conservative therapy in acute subdural hematoma.

The study was a prospective, observational, comparative effectiveness study that used data from the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) cohort. Patients without pre-existing severe neurological problems who reported acute subdural hematoma within 24 hours of traumatic brain injury and had brain CT results were included in the study. Using an instrumental variable analysis, outcomes for acute subdural hematoma (acute surgical evacuation or first conservative therapy) were compared among centers, as indicated by the case-mix-adjusted percentage of acute surgery per center. The primary outcome was the functional outcome at 6 months as measured by the Glasgow Outcome Scale Extended, which was computed as a common odds ratio (OR) using ordinal regression and adjusted for prespecified covariates.

The key findings of this study were as follows:

1. Between December 19, 2014, and December 17, 2017, 4559 traumatic brain injury patients were recruited in CENTER-TBI, with 1407 (31%) presenting with acute subdural hematoma and being included in our research.

2. Acute surgical evacuation was performed on 336 (24%) patients, craniotomy on 245 (73%) patients, and decompressive craniectomy on 91 patients (27%).

3. Delayed decompressive craniectomy or craniotomy occurred in 107 (11%) patients after initial conservative therapy (n=982).

4. The percentage of patients who got acute surgery ranged from 5.6% to 51.5% amongst centers, with an identical patient having a two-fold greater chance of obtaining acute surgery in one center vs another at random.

5. The choice for acute surgery over first conservative care at the hospital was not related to improved functional results.

In conclusion, a therapeutic plan that prioritized an active strategy of acute surgical evacuation over initial conservative therapy did not result in a superior functional outcome. As a result, if a neurosurgeon believes that there is no apparent advantage for acute surgery over conservative treatment in a patient with acute subdural hematoma, conservative treatment may be attempted first.

Reference:

van Essen, T. A., Lingsma, H. F., Pisică, D., Singh, R. D., Volovici, V., den Boogert, H. F., Younsi, A., Peppel, L. D., Heijenbrok-Kal, M. H., Ribbers, G. M... Zoerle, T. (2022). Surgery versus conservative treatment for traumatic acute subdural haematoma: a prospective, multicentre, observational, comparative effectiveness study. In The Lancet Neurology. Elsevier BV. https://doi.org/10.1016/s1474-4422(22)00166-1