Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute?

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

(In)appropriate neurosurgical consultation.

OBJECTIVES: Whether or not a patient could benefit from a computed tomography (CT) scan and/or the evaluation by a neurosurgeon requires judgment by a clinician of the risk of clinical deterioration. To assess this clinical process we aimed to determine how many of the consultations to the Neurosurgical department (NSG) of UC Davis are appropriately indicated for neurosurgical input or management. Secondly, we investigated how CT is used in the University of California Davis Medical Center (UCDMC) in NSG consults of head injured patients compared to a validated and highly sensitive decision making tool, the Canadian CT Head Rule (CCHR). PATIENTS AND METHODS: Patients were enrolled in this prospective study if they presented to a department of UCDMC other than neurosurgery and when, consequently, the NSG was consulted. The emergency consultations were categorized into three groups: head injury, spine injury and others. Subsequently, the appropriateness of the consultations was evaluated based on the need for evaluation determined by the likelihood of clinically important intracranial lesions for head injury and by the likelihood of clinically important spinal cord injury or spinal cord instability for spine injury. Of the head injured patients with a CT scan the appropriateness of the scan was determined by way of the CCHR. RESULTS: Between 21 July and 15 August 2008 99 consultations were included: 32 patients with head injuries, 29 with spine injuries, 34 with other diseases and 4 not sufficiently documented patients. 23 classified inappropriate, 69 appropriate and 7 remained unclassified. Of the head injured patients, 10 (31.2%) had gotten a CT scan that was classified inappropriate. CONCLUSION: NSG receives 3-4 requests for consultations per day from the other services of UCDMC, of which one is of questionable validity and one of the three CT scans for head injury is not necessary. These results suggest the use of the CCHR in UCDMC would improve patient care and could result in large health-care savings, while there would also be less radiation exposure.