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Surgery versus conservative treatment for traumatic acute subdural haematoma: a prospective, multicentre, observational, comparative effectiveness study

2022; Elsevier BV; Volume: 21; Issue: 7 Linguagem: Inglês

10.1016/s1474-4422(22)00166-1

1474-4465

Thomas A. van Essen, Hester F. Lingsma, Dana Pisică, Ranjit D. Singh, Victor Volovici, Hugo F. den Boogert, Alexander Younsi, Lianne D. Peppel, Majanka H. Heijenbrok–Kal, Gerard M. Ribbers, R. Walchenbach, David Menon, Peter J. Hutchinson, Bart Depreitere, Ewout W. Steyerberg, Andrew I.R. Maas, Godard C. W. de Ruiter, Wilco C. Peul, Cecilia Åkerlund, Krisztina Amrein, Nada Anđelić, Lasse Andreassen, Audny Anke, Anna Antoni, Gérard Audibert, Philippe Azouvi, Maria Luisa Azzolini, Ronald Bartels, Pál Barzó, Romuald Beauvais, Ronny Beer, Bo‐Michael Bellander, Antonio Belli, Habib Benali, Maurizio Berardino, Luigi Beretta, Morten Blaabjerg, Peter Bragge, Alexandra Bražinová, Vibeke Brinck, Joanne Brooker, Camilla Brorsson, András Büki, Monika Bullinger, Manuel Cabeleira, Alessio Caccioppola, Emiliana Calappi, Maria Rosa Calvi, Peter Cameron, Guillermo Carbayo Lozano, Marco Carbonara, Ana M. Castaño‐León, Simona Cavallo, Giorgio Chevallard, Arturo Chieregato, Giuseppe Citerio, Hans Clusmann, Mark Steven Coburn, Jonathan Coles, D. James Cooper, Marta Correia, Amra Čović, Nicola Curry, Endre Czeiter, Marek Czosnyka, Claire Dahyot‐Fizelier, Paul Dark, Helen Dawes, Véronique De Keyser, Vincent Degos, Françesco Della Corte, Đula Đilvesi, Abhishek Dixit, Emma Donoghue, Jens P. Dreier, Guy‐Loup Dulière, Ari Ercole, Patrick Esser, Erzsébet Ezer, Martin Fabricius, Valery L. Feigin, Kelly Foks, Shirin Frisvold, Alex Furmanov, Pablo Gagliardo, Damien Galanaud, Dashiell Gantner, Guoyi Gao, Pradeep George, Alexandre Ghuysen, Lelde Giga, Ben Glocker, Jagoš Golubović, Pedro A. Gómez, Johannes Gratz, Benjamin Gravesteijn, Francesca Grossi, Russell L. Gruen, Deepak Gupta, Juanita A. Haagsma, Iain Haitsma, Raimund Helbok, Eirik Helseth, Lindsay Horton, Jilske Huijben, Bram Jacobs, Stefan Jankowski, Mike Jarrett, Jiyao Jiang, Faye Johnson, Kelly Jones, Mladen Karan, Angelos G. Kolias, Erwin J. O. Kompanje, Daniel Kondziella, Evgenios Kornaropoulos, Lars‐Owe Koskinen, Noémi Kovács, Alfonso Lagares, Linda Lanyon, Steven Laureys, Fiona Lecky, Didier Ledoux, Rolf Lefering, Valérie Legrand, Aurélie Lejeune, Leon Levi, Roger Lightfoot, Marc Maegele, Marek Majdán, Alex Manara, Geoffrey T. Manley, Hugues Maréchal, Costanza Martino, Julia Mattern, Catherine McMahon, Béla Melegh, Tomas Menovsky, Ana Mikolić, Benoît Misset, Visakh Muraleedharan, Lynnette Murray, Nandesh Nair, Ancuța Negru, David Nelson, Virginia Newcombe, Daan Nieboer, József Nyirádi, Matej Orešič, Fabrizio Ortolano, Olubukola Otesile, Aarno Palotie, Paul M. Parizel, Jean‐François Payen, Natascha Perera, Vincent Perlbarg, Paolo Persona, Anna Piippo-Karjalainen, Matti Pirinen, Horia Pleș, Suzanne Polinder, Iñigo Pomposo, Jussi P. Posti, Louis Puybasset, Andreea Rădoi, Arminas Ragauskas, Rahul Raj, Malinka Rambadagalla, Veronika Rehorčíková, Isabel Retel Helmrich, Jonathan R. Rhodes, Sylvia Richardson, Sophie Richter, Samuli Ripatti, Saulius Ročka, Cecilie Røe, Olav Røise, Jonathan Rosand, Jeffrey V. Rosenfeld, Christina Rosenlund, Guy Rosenthal, Rolf Rossaint, Sandra Rossi, Daniel Rueckert, Martin Rusňák, Juan Sahuquillo, Oliver Sakowitz, Renán Sánchez-Porras, János Sándor, Nadine Schäfer, Silke Schmidt, Herbert Schöechl, Guus Schoonman, Rico Frederik Schou, Elisabeth Schwendenwein, Charlie Sewalt, Toril Skandsen, Peter Smielewski, Abayomi Sorinola, Emmanuel A. Stamatakis, Simon Stanworth, Ana Kowark, Robert D. Stevens, William Stewart, Nino Stocchetti, Nina Sundström, Riikka Takala, Viktória Tamás, Tomas Tamošuitis, Mark Taylor, Braden Te Ao, Olli Tenovuo, Alice Theadom, Matt Thomas, Dick Tibboel, Marjolijn Timmers, Christos Tolias, Tony Trapani, Cristina Maria Tudora, Andreas Unterberg, Peter Vajkoczy, Egils Valeinis, Shirley Vallance, Zoltán Vámos, Mathieu van der Jagt, Joukje van der Naalt, Gregory Van der Steen, Jeroen T.J.M. van Dijck, Wim Van Hecke, Caroline van Heugten, Dominique Van Praag, Ernest van Veen, Roel van Wijk, Thijs Vande Vyvere, Alessia Vargiolu, Emmanuel Vega, Kimberley Velt, Jan Verheyden, Paul Vespa, Anne Vik, Rimantas Vilcinis, Nicole von Steinbüchel, Daphne Voormolen, Petar Vuleković, Kevin Wang, Eveline Wiegers, Guy Williams, Lindsay Wilson, Stefan Winzeck, Stefan Wolf, Zhihui Yang, Peter Ylén, Frederick A. Zeiler, Agate Ziverte, Tommaso Zoerle,

Spinal Fractures and Fixation Techniques

Background Despite being well established, acute surgery in traumatic acute subdural haematoma is based on low-grade evidence.We aimed to compare the effectiveness of a strategy preferring acute surgical evacuation with one preferring initial conservative treatment in acute subdural haematoma. MethodsWe did a prospective, observational, comparative effectiveness study using data from participants enrolled in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) cohort.We included patients with no pre-existing severe neurological disorders who presented with acute subdural haematoma within 24 h of traumatic brain injury.Using an instrumental variable analysis, we compared outcomes between centres according to treatment preference for acute subdural haematoma (acute surgical evacuation or initial conservative treatment), measured by the case-mix-adjusted percentage of acute surgery per centre.The primary endpoint was functional outcome at 6 months as rated with the Glasgow Outcome Scale Extended, which was estimated with ordinal regression as a common odds ratio (OR) and adjusted for prespecified confounders.Variation in centre preference was quantified with the median OR (MOR).CENTER-TBI is registered with ClinicalTrials.gov,number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). FindingsBetween Dec 19, 2014 and Dec 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI, of whom 1407 (31%) presented with acute subdural haematoma and were included in our study.Acute surgical evacuation was done in 336 (24%) patients, by craniotomy in 245 (73%) of those patients and by decompressive craniectomy in 91 (27%).Delayed decompressive craniectomy or craniotomy after initial conservative treatment (n=982) occurred in 107 (11%) patients.The percentage of patients who underwent acute surgery ranged from 5•6% to 51•5% (IQR 12•3-35•9) between centres, with a two-times higher probability of receiving acute surgery for an identical patient in one centre versus another centre at random (adjusted MOR for acute surgery 1•8; p<0•0001]).Centre preference for acute surgery over initial conservative treatment was not associated with improvements in functional outcome (common OR per 23•6% [IQR increase] more acute surgery in a centre 0•92, 95% CI 0•77-1•09).Interpretation Our findings show that treatment for patients with acute subdural haematoma with similar characteristics differed depending on the treating centre, because of variation in the preferred approach.A treatment strategy preferring an aggressive approach of acute surgical evacuation over initial conservative treatment was not associated with better functional outcome.Therefore, in a patient with acute subdural haematoma for whom a neurosurgeon sees no clear superiority for acute surgery over conservative treatment, initial conservative treatment might be considered.