Conservative versus surgical management of traumatic acute subdural hematoma: a systematic review and meta-analysis.

In 30 seconds

This systematic review and random-effects meta-analysis compared surgical with conservative management of traumatic acute subdural hematoma in adults. Eleven studies included 3,792 patients; those treated surgically had worse admission Glasgow Coma Scale scores and greater hematoma thickness and midline shift. Although crude mortality was higher after surgery (25.9% vs. 11.6%), pooled analysis found no statistically significant mortality difference (RR 1.36; 95% CI [0.74, 2.50]; p = 0.32). Because surgical patients were more severely affected at baseline and patient-level adjustment was absent, the findings cannot establish surgery’s effect on mortality.

Key findings

• Surgical patients had lower admission GCS scores (MD - 1.93; 95% CI [- 3.35, - 0.52]; p = 0.007), greater hematoma thickness (MD + 3.56 mm; p = 0.0009), and larger midline shift (MD + 4.83 mm; p < 0.00001).
• Crude mortality was 25.9% after surgery versus 11.6% with conservative management, but pooled mortality did not differ significantly (RR 1.36; 95% CI [0.74, 2.50]; p = 0.32).
• Hospital stay was longer in surgical patients (MD + 6.77 days; p = 0.003).

Why it matters

The comparison addresses uncertainty about management when traumatic acute subdural hematoma does not clearly meet established surgical thresholds. The apparent mortality contrast should not be interpreted as evidence that surgery is harmful or ineffective: patients selected for surgery had more severe clinical and radiological findings, and the available observational data could not adjust at the patient level.

What to keep in mind

The evidence was observational, heterogeneous, and lacked patient-level adjustment; no randomized data were available. Baseline severity differed substantially between treatment groups, limiting causal interpretation of mortality comparisons.