Research Summary

No Outcome Advantage for Immediate Surgery Over Conservative Care in Acute Subdural Hematoma, TRACK-TBI Study Finds

Kate Young

Key Highlights:

  • 21% of participants received acute surgery; 79% underwent initial conservative treatment.
  • Center preference for early surgery varied widely (0%–86%) and was not linked to improved functional outcomes.
  • Findings indicate conservative management may be appropriate when neurosurgeons face clinical uncertainty.

A new comparative effectiveness study published in JAMA Network Open evaluated whether immediate surgical evacuation of traumatic acute subdural hematoma (ASDH) provides superior outcomes to initial conservative treatment. The analysis, part of the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) project, challenges longstanding assumptions regarding the benefits of early surgery for this critical condition.

The prospective observational study analyzed data collected between February 2014 and July 2018 from 18 U.S. Level 1 trauma centers participating in TRACK-TBI. The cohort included 711 patients with nonpenetrating traumatic brain injury (TBI) and ASDH identified by computed tomography within 24 hours of injury. Outcomes were compared across centers with differing treatment preferences, quantified as the adjusted probability of acute surgery per site. The primary outcome was functional disability at 6 months, assessed using the Glasgow Outcome Scale–Extended (GOSE). Statistical analyses employed ordinal logistic regression and accounted for multiple confounders, including age, Glasgow Coma Scale (GCS) score, and pupil reactivity.

Study Findings

Of the 711 participants (mean age 46.5 years; 76% men), 148 (21%) underwent acute surgical evacuation, while 563 (79%) received initial conservative management. Patients in the surgical cohort had more severe presentations, including lower GCS scores (6.8 vs 11.4) and higher rates of pupil abnormalities.

Practice variation was pronounced: acute surgery rates across centers ranged from 0% to 86% (median 17%). Despite this variation, outcomes were similar. The adjusted common odds ratio for a better 6-month outcome in centers favoring surgery compared with conservative care was 1.05 (95% CI, 0.88–1.26). Even when analyses were restricted to patients with reactive pupils and moderate impairment, results remained consistent. Secondary outcomes—including mortality, quality of life, and length of stay—showed no significant differences between treatment approaches.

Clinical Implications

The findings suggest that for patients with ASDH in whom neurosurgeons experience clinical equipoise, immediate surgical evacuation may not yield superior outcomes compared with conservative management. These results mirror prior findings from the European CENTER-TBI study, reinforcing that nonoperative management can be considered for select patients without signs of herniation or rapid neurologic decline.

Expert Commentary

“In this comparative effectiveness study, similar patients with traumatic ASDH received different acute surgical and conservative treatments across different centers due to center-specific factors. Outcomes were similar in centers preferring surgical evacuation and those preferring initial conservative treatment,” the researchers concluded. “For a patient with ASDH for whom a neurosurgeon finds clinical equipoise between acute surgery and initial conservative, nonsurgical management, initial conservative treatment may be considered.”

Reference:
Van Essen TA, Yue JK, Barber J, et al; TRACK-TBI Study Investigators. Acute surgery vs conservative treatment for traumatic acute subdural hematoma. JAMA Netw Open. 2025;8(10):e2535200. doi:10.1001/jamanetworkopen.2025.35200