Outcomes of Surgical Versus Conservative Management in Severe Traumatic Brain Injury (GCS 3-4) With Evacuable Mass...

Management of patients with severe traumatic brain injury (TBI) presenting with Glasgow Coma Scale (GCS) scores of 3-4 and surgically evacuable intracranial hematomas remains controversial because of perceived futility and poor outcomes. This study compared outcomes of surgical versus conservative management in this patient population.

This retrospective observational study included patients with TBI (GCS 3-4) and surgically evacuable intracranial mass lesions admitted to a tertiary care centre between December 2015 and December 2023. Among 3,657 TBI admissions, 752 patients met inclusion criteria: 568 underwent surgical management and 184 were treated conservatively. Clinical and radiological variables were analysed. Outcomes were assessed at 6 months using the Glasgow Outcome Scale (GOS). Favorable outcome was defined as GOS 3-5, given the high mortality in this cohort. Subgroup analysis and multivariable logistic regression analysis were performed.

Six-month mortality was significantly lower in the surgical group (79.2% vs. 94.5%). Surgery was associated with shorter intensive care unit stay (p=0.001) and fewer systemic complications (p=0.003). Favourable outcomes were significantly more frequent following surgery in patients aged <40 years, with extradural hematoma, unilateral or bilateral pupillary dilation, and intervention within 6 hours of injury (all p<0.05). On adjusted analysis, surgical management was significantly associated with favorable outcome (odds ratio, 3.7; 95% confidence interval, 2.0-6.8; p<0.001).

Despite an overall poor prognosis, surgical evacuation of mass lesions in TBI patients with GCS 3-4 was associated with improved survival and functional outcomes in selected patients, although causality cannot be inferred.