Acute Surgery vs Conservative Treatment for Traumatic Acute Subdural Hematoma

1. Across 18 U.S. centers, preference for surgical or conservative management for acute subdural hematoma (ASDH) varied widely but did not affect six-month functional outcomes.

Evidence Rating Level: 2 (Good) 

ASDH is common in patients with TBI, but there remains limited evidence to support the decision between surgery or conservative management in treating patients with ASDH. This multicenter comparative effectiveness evaluated whether acute surgical evacuation offers better outcomes than initial conservative management for traumatic ASDH. Using data from the TRACK-TBI cohort (2014–2018) across 18 U.S. Level 1 trauma centers, 711 patients with nonpenetrating TBI and CT-confirmed ASDH were included (21% underwent acute surgery, 79% initial conservative care). Researchers compared outcomes between centers favoring surgery versus those favoring conservative management, applying an instrumental-variable approach adjusted for patient mix and prognostic factors. Despite large practice variation (acute surgery rates 0–86%), six-month functional outcomes on the Glasgow Outcome Scale-Extended were similar between the two strategies (adjusted OR 1.05, 95% CI 0.88–1.26). Mortality, quality of life, and other secondary outcomes also did not differ significantly. The findings suggest that when neurosurgeons face clinical equipoise, namely in circumstances where emergent surgery is not clinically indicated, initial conservative treatment is a reasonable option without compromising long-term outcomes.

Click here to read this study in JAMA Network Open

Image: PD

©2025 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.