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Admission Neurological Status, Radiological Mass Effect, and In-Hospital Mortality Among Surgically Treated Patients
1Department of Neurosurgery, Faculty of Medicine, Yozgat Bozok University, Yozgat, Türkiye.
Background:
Traumatic acute subdural hematoma (ASDH) carries high morbidity and mortality despite surgery. We evaluated associations of admission neurological status and radiological mass effect with in-hospital mortality. An exploratory analysis examined a composite unfavorable Glasgow Outcome Scale (GOS) outcome, with in-hospital mortality as its largest component.
Methods:
This retrospective study included 82 adults treated surgically for traumatic ASDH between January 2020 and December 2025. The Zumkeller index (midline shift minus hematoma thickness) was categorized as <0, 0-3, or >3 mm. Two multivariable mortality models, including a Firth-penalized model with the Zumkeller index, underwent 1,000-resample bootstrap validation.
Results:
In-hospital mortality was 44%. Higher admission Glasgow Coma Scale (GCS) score was associated with lower odds of mortality (adjusted OR, 0.72; 95% CI, 0.57-0.91), whereas greater midline shift (adjusted OR, 1.14; 95% CI, 1.04-1.25) and abnormal pupillary response (adjusted OR, 3.18; 95% CI, 1.09-9.28) were associated with higher odds. Older age was modestly associated with mortality (adjusted OR, 1.03; 95% CI, 1.00-1.07). Mortality was 33%, 62%, and 82% across Zumkeller categories; 9 of 11 patients with an index >3 mm died. An index >3 mm remained associated with mortality in the Firth model (adjusted OR, 4.72; 95% CI, 1.01-22.94). The composite outcome occurred in 47 patients: 36 in-hospital deaths and 11 additional unfavorable outcomes among survivors.
Conclusions:
These findings reflect our institutional experience. A Zumkeller index >3 mm identified a small subgroup with high in-hospital mortality. Optimism-corrected AUCs were numerically close, and external validation is required.
