{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T03:15:10Z","timestamp":1782875710225,"version":"3.54.5"},"reference-count":52,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,11,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Traumatic subdural hematoma (SDH) is a common form of traumatic brain injury (TBI) that often represents a neurosurgical emergency. Surgical evacuation is recommended for SDH with midline shift (MLS) &gt; 5 mm, regardless of the presenting Glasgow Coma Scale (GCS) score; however, real-world practice is unknown. The objective of this study was to test the hypothesis that significant variation exists in the tendency for operative neurosurgical intervention for traumatic SDH among trauma centers (TCs) and that this variation is associated with patient outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>The authors performed a retrospective cohort study of adult patients (age \u2265 18 years) treated for blunt severe TBI (GCS score \u2264 8) and SDH with MLS &gt; 5 mm at level I and II TCs participating in the American College of Surgeons Trauma Quality Improvement Program (2017\u20132019). Patients with nonsurvivable injuries (Abbreviated Injury Scale score 6), advance directives, or emergency department death were excluded. Hierarchical logistic regression was used to estimate each TC\u2019s unique odds of performing operative neurosurgery for traumatic SDH. Risk adjustment accounted for patient baseline and injury characteristics. TCs were grouped into quartiles of increasing tendency for neurosurgery. The risk-adjusted association between TC tendency for operative neurosurgery and outcomes was then measured. The primary outcome was inpatient mortality. The secondary outcome was favorable discharge, defined as discharge to home or rehabilitation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>The authors identified 13,087 patients with traumatic SDH treated at 454 level I and II TCs. Significant variation in TC tendency for operative neurosurgery was observed. Specifically, TCs with the greatest tendency for neurosurgical intervention (quartile 4) performed surgery on 60% of patients, whereas TCs with the lowest tendency (quartile 1) performed surgery on only 26%, even though there were no differences in GCS scores or pupillary examination findings. After risk adjustment, a greater hospital tendency for neurosurgical intervention was associated with lower inpatient mortality and higher odds of favorable discharge. Patients with traumatic SDH treated at TCs with the highest versus the lowest tendency for neurosurgery were 30% less likely to die (adjusted odds ratio [aOR] 0.7, 95% CI 0.6\u20130.8) and more likely to have a favorable discharge (aOR 1.3, 95% CI 1.1\u20131.6). These effects were most pronounced among patients with abnormal pupillary examination findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>Significant variation exists between trauma centers in performing operative neurosurgery for traumatic SDH. The TCs more likely to perform surgery were associated with lower odds of inpatient mortality and higher odds of a favorable discharge. Consensus-based guidelines are needed to improve standardization in the care of patients with traumatic SDH.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2025.3.jns242811","type":"journal-article","created":{"date-parts":[[2025,7,26]],"date-time":"2025-07-26T01:29:11Z","timestamp":1753493351000},"page":"1234-1244","source":"Crossref","is-referenced-by-count":4,"title":["Operative neurosurgery for traumatic subdural hematoma: association between trauma center variation and patient outcomes"],"prefix":"10.3171","volume":"143","author":[{"given":"Vikas N.","family":"Vattipally","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kathleen R.","family":"Ran","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Debraj","family":"Mukherjee","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose I.","family":"Suarez","sequence":"additional","affiliation":[{"name":"Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Judy","family":"Huang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chetan","family":"Bettegowda","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elliott R.","family":"Haut","sequence":"additional","affiliation":[{"name":"Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph V.","family":"Sakran","sequence":"additional","affiliation":[{"name":"Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Witiw","sequence":"additional","affiliation":[{"name":"Division of Neurosurgery, St. Michael\u2019s Hospital\/Unity Health Toronto, Ontario;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Gomez","sequence":"additional","affiliation":[{"name":"Division of General Surgery, St. Michael\u2019s Hospital\/Unity Health Toronto, Ontario; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tej D.","family":"Azad","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James P.","family":"Byrne","sequence":"additional","affiliation":[{"name":"Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"World Neurosurg","first-page":"e431","article-title":"Impact of antithrombotic medications and reversal strategies on the surgical management and outcomes of traumatic acute subdural hematoma","volume":"182","author":"Vattipally VN","year":"2024","unstructured":"Vattipally VN, Ran KR, Giwa GA,  Impact of antithrombotic medications and reversal strategies on the surgical management and outcomes of traumatic acute subdural hematoma. World Neurosurg. 2024;182:e431\u2013e441."},{"issue":"2","key":"b2","series-title":"J Neurosurg","first-page":"212","article-title":"Acute subdural hematoma: morbidity, mortality, and operative timing","volume":"74","author":"Wilberger JE","year":"1991","unstructured":"Wilberger JE, Harris M, Diamond DL. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg. 1991;74(2):212\u2013218."},{"key":"b3","series-title":"J Clin Neurosci","first-page":"52","article-title":"Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes","volume":"119","author":"Ran KR","year":"2024","unstructured":"Ran KR, Vattipally VN, Giwa GA,  Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes. J Clin Neurosci. 2024;119:52\u201358."},{"key":"b4","article-title":"Guidelines for the surgical management of TBI","unstructured":"Brain Trauma Foundation. Guidelines for the surgical management of TBI. Accessed May 1, 2025. https:\/\/braintrauma.org\/coma\/guidelines\/surgical"},{"issue":"2","key":"b5","series-title":"J Trauma","first-page":"274","article-title":"Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?","volume":"60","author":"Tien HC","year":"2006","unstructured":"Tien HC, Cunha JRF, Wu SN,  Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?. J Trauma. 2006;60(2):274\u2013278."},{"issue":"3","key":"b6","series-title":"Asian J Neurosurg","first-page":"565","article-title":"Acute subdural hematoma evacuation: predictive factors of outcome","volume":"13","author":"Lavrador J","year":"2018","unstructured":"Lavrador J, Teixeira J, Oliveira E, Sim\u00e3o D, Santos M, Simas N. Acute subdural hematoma evacuation: predictive factors of outcome. 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BMJ. 2005;330(7497):960\u2013962."},{"issue":"4","key":"b18","series-title":"J Epidemiol Community Health","first-page":"290","article-title":"A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena","volume":"60","author":"Merlo J","year":"2006","unstructured":"Merlo J, Chaix B, Ohlsson H,  A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health. 2006;60(4):290\u2013297."},{"issue":"6","key":"b19","series-title":"J Stat Soft","article-title":"Multiple imputation using SAS software","volume":"45","author":"Yuan Y","year":"2011","unstructured":"Yuan Y. Multiple imputation using SAS software. 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Neurosurgery. 2020;86(1):107\u2013111."},{"issue":"12","key":"b22","series-title":"Arch Surg","first-page":"1213","article-title":"Effect of trauma center designation on outcome in patients with severe traumatic brain injury","volume":"143","author":"DuBose JJ","year":"2008","unstructured":"DuBose JJ, Browder T, Inaba K, Teixeira PGR, Chan LS, Demetriades D. Effect of trauma center designation on outcome in patients with severe traumatic brain injury. 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Clin Neurol Neurosurg. 2023;224:107545."},{"issue":"2","key":"b24","series-title":"J Neurosurg","first-page":"544","article-title":"Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery","volume":"140","author":"Griepp DW","year":"2024","unstructured":"Griepp DW, Miller A, Sorek S,  Emergency decompressive surgery in patients with transtentorial brain herniation and pupillary abnormalities: the importance of improved pupillary response after osmotherapy and surgery. J Neurosurg. 2024;140(2):544\u2013551."},{"issue":"1","key":"b25","series-title":"Injury","first-page":"28","article-title":"Survival of trauma patients with coma and bilateral fixed dilated pupils","volume":"40","author":"Chaudhuri K","year":"2009","unstructured":"Chaudhuri K, Malham GM, Rosenfeld JV. Survival of trauma patients with coma and bilateral fixed dilated pupils. 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Guidelines for the surgical management of TBI. Accessed May 1, 2025. https:\/\/braintrauma.org\/coma\/guidelines\/surgical"},{"issue":"2","key":"b5","series-title":"J Trauma","first-page":"274","article-title":"Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?","volume":"60","author":"Tien HC","year":"2006","unstructured":"Tien HC, Cunha JRF, Wu SN,  Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?. J Trauma. 2006;60(2):274\u2013278."},{"issue":"3","key":"b6","series-title":"Asian J Neurosurg","first-page":"565","article-title":"Acute subdural hematoma evacuation: predictive factors of outcome","volume":"13","author":"Lavrador J","year":"2018","unstructured":"Lavrador J, Teixeira J, Oliveira E, Sim\u00e3o D, Santos M, Simas N. Acute subdural hematoma evacuation: predictive factors of outcome. 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J Neurotrauma. 2017;34(4):881\u2013889."},{"issue":"1","key":"b12","series-title":"J Trauma Acute Care Surg","first-page":"114","article-title":"Variation in neurosurgical intervention for severe traumatic brain injury: the challenge of measuring quality in trauma center verification","volume":"91","author":"Truong EI","year":"2021","unstructured":"Truong EI, Stanley SP, DeMario BS,  Variation in neurosurgical intervention for severe traumatic brain injury: the challenge of measuring quality in trauma center verification. J Trauma Acute Care Surg. 2021;91(1):114\u2013120."},{"issue":"3","key":"b13","series-title":"Acta Neurochir (Wien)","first-page":"435","article-title":"Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study","volume":"161","author":"van Essen TA","year":"2019","unstructured":"van Essen TA, den Boogert HF, Cnossen MC,  Variation in neurosurgical management of traumatic brain injury: a survey in 68 centers participating in the CENTER-TBI study. Acta Neurochir (Wien). 2019;161(3):435\u2013449."},{"issue":"2","key":"b14","series-title":"J Trauma","first-page":"253","article-title":"The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility","volume":"68","author":"Hemmila MR","year":"2010","unstructured":"Hemmila MR, Nathens AB, Shafi S,  The Trauma Quality Improvement Program: pilot study and initial demonstration of feasibility. 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Neurosurgery. 2020;86(1):107\u2013111."},{"issue":"12","key":"b22","series-title":"Arch Surg","first-page":"1213","article-title":"Effect of trauma center designation on outcome in patients with severe traumatic brain injury","volume":"143","author":"DuBose JJ","year":"2008","unstructured":"DuBose JJ, Browder T, Inaba K, Teixeira PGR, Chan LS, Demetriades D. Effect of trauma center designation on outcome in patients with severe traumatic brain injury. Arch Surg. 2008;143(12):1213\u20131217."},{"key":"b23","series-title":"Clin Neurol Neurosurg","first-page":"107545","article-title":"Long-term benefits for younger patients with aggressive immediate intervention following severe traumatic brain injury: a longitudinal cohort analysis of 175 patients from a prospective registry","volume":"224","author":"Agarwal N","year":"2023","unstructured":"Agarwal N, Wilkins TE, Nwachuku EL,  Long-term benefits for younger patients with aggressive immediate intervention following severe traumatic brain injury: a longitudinal cohort analysis of 175 patients from a prospective registry. 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