Study Finds No Clear Benefit of Early Surgery Over Conservative Care in Traumatic Acute Subdural Hematoma
Netherlands: A new study published in JAMA Network Open has found that outcomes for patients with traumatic acute subdural hematoma (ASDH) do not significantly differ between those treated in centers favoring early surgical intervention and those preferring conservative management.
Thomas A. Van Essen from the University Neurosurgical Center, Holland, Leiden University Medical Center, Haaglanden Medical Center & Haga, Leiden–The Hague, Netherlands, and colleagues aimed to determine whether an aggressive surgical approach offers better functional recovery compared to conservative management in patients with ASDH following traumatic brain injury (TBI).
The comparative effectiveness analysis included 711 patients from 18 Level 1 trauma centers across the United States who were enrolled between February 2014 and July 2018 as part of the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study.
The study led to the following findings:
- Researchers observed significant variation across centers in their treatment preferences for acute subdural hematoma (ASDH).
- The proportion of patients undergoing acute surgery ranged from 0% to 86%, with a median of 17%.
- Despite the wide variation in treatment strategies, six-month functional outcomes were similar across centers that preferred early surgery and those that opted for conservative management.
- Out of 711 patients analyzed, 148 (21%) underwent acute cranial surgery, while 563 (79%) received initial conservative management.
- Patients who underwent surgery generally had more severe injuries, reflected by lower Glasgow Coma Scale (GCS) scores and higher rates of pupil abnormalities.
- Among those who had surgery, 87% underwent decompressive craniectomy, and 11% underwent craniotomy.
- In the conservative treatment group, 12% of patients later required delayed surgical intervention.
- Statistical evaluation showed that center-based treatment preference strongly influenced the likelihood of receiving acute surgery.
- However, this variation in treatment approach did not lead to differences in long-term functional outcomes.
- The adjusted common odds ratio for improved outcomes with higher surgical intervention rates was 1.05, indicating no significant benefit of acute surgery over conservative management.
The findings indicate that even with substantial differences in treatment strategies between trauma centers, six-month outcomes for patients with ASDH remained consistent. This suggests that when clinical judgment allows for equipoise—meaning when it is unclear whether surgery or conservative management is superior—conservative treatment may be a reasonable option.
According to the authors, the study highlights the need for further investigation into which subsets of patients might truly benefit from acute surgery, considering variables such as age, neurological status, and comorbid conditions. They recommend future high-quality comparative studies and meta-analyses using patient-level data to strengthen the evidence base for optimal management strategies in traumatic ASDH.
"The large multicenter study underscores that treatment outcomes for traumatic acute subdural hematoma are similar regardless of whether centers favor early surgical intervention or conservative management. For patients in whom neurosurgeons face uncertainty about the need for immediate surgery, initial conservative management may be a safe and appropriate approach," the authors concluded.
Reference:
Van Essen TA, Yue JK, Barber J, et al. Acute Surgery vs Conservative Treatment for Traumatic Acute Subdural Hematoma. JAMA Netw Open. 2025;8(10):e2535200. doi:10.1001/jamanetworkopen.2025.35200
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