Guideline Adherence and Outcome in Neurosurgical Treatment of Traumatic Acute Subdural Hematoma

An acute subdural hematoma (ASDH) is the most common focal injury in traumatic brain injury (TBI) and a major cause of death and morbidity worldwide. The decision to perform neurosurgical evacuation of the ASDH is complex. The Brain Trauma Foundation (BTF) issued guidelines in 2006, recommending evacuation for ASDHs >1 cm or with >5 mm midline shift regardless of patients' Glasgow Coma Scale (GCS) score, and in cases of neurological deterioration, abnormal pupillary reaction, or high intracranial pressure (ICP). Despite their global recognition, the evidence supporting these guidelines is weak. This study assesses adherence to BTF guidelines in a European cohort and determines the effect on mortality and functional outcomes. Data from the prospective observational Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study were analyzed. Patients presenting after a TBI with an ASDH on the initial computed tomography scan across 65 trauma centers in Europe and Israel between 2014 and 2018 were included. Patients with concomitant epidural hematoma were excluded. Adherence to BTF guidelines for ASDH surgery and ICP monitoring was assessed, including subgroup analyses based on age and TBI severity. Multivariable logistic regression models examined the association between guideline adherence and outcomes, adjusting for prespecified confounders. Among 985 patients with traumatic ASDH, overall guideline adherence was 74% (n = 724), with higher adherence to conservative treatment (95% [n = 533]) compared with surgical recommendations (45% [n = 191]). Adherence varied by age and TBI severity, being lower in elderly and severely injured patients. ICP monitoring adherence in comatose patients was 63% (n = 240). Adherence to surgical ASDH guidelines was not significantly associated with in-hospital mortality (odds ratio [OR]: 0.72 [0.43-1.2]) or 6-month functional outcome (OR: 0.73 [0.47-1.1]). Overall adherence to BTF guidelines for surgical ASDH management was low. The current surgical thresholds do not align with clinical practice. Elderly patients and those with severe TBI were less likely to be treated per guidelines. Incorporating patient age, GCS and hematoma volume into the guidelines may enhance their relevance and adherence in clinical practice.