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Published Online: 30 December 2022

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?

Publication: Journal of Neurotrauma
Volume 40, Issue Number 1-2


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.

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Transparency, Rigor, and Reproducibility Summary

The data, which include individual study data, a database with a data dictionary defining each field and the Stata syntax, are available on reasonable request. The pre-defined study protocol has been published (PROSPERO [registration number CRD42015025491])


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cover image Journal of Neurotrauma
Journal of Neurotrauma
Volume 40Issue Number 1-2January 2023
Pages: 22 - 32
PubMed: 35699084


Published in print: January 2023
Published online: 30 December 2022
Published ahead of print: 30 August 2022
Published ahead of production: 14 June 2022


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    Thomas Arjan van Essen* [email protected]
    University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.
    Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
    Lodewijk Res
    University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.
    Jan Schoones
    Directorate of Research Policy (Walaeus Library), and Leiden University Medical Center, Leiden, The Netherlands.
    Godard C.W. de Ruiter**
    University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.
    Olaf Dekkers
    Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
    Andrew Maas
    Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
    Wilco Peul
    University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.
    Niels Anthony van der Gaag
    University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.
    Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.


    Address correspondence to: Thomas Arjan van Essen, MD, MSc, Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, J-11-R-83, 2333 ZA, Leiden, The Netherlands [email protected]
    Correction added on May 20, 2023 after first online publication of December 30, 2022: Author Godard C.W. de Ruiter's middle initials were inadvertently omitted. Godard C.W. de Ruiter's name has been updated.

    Authors' Contributions

    Authors TvE and NG conceived and designed the review. The literature search was devised by TvE and JS. TvE and LR performed study screening for inclusion, data extraction, assessment of risk of bias, and selection of studies for inclusion in meta-analyses. Full texts were reviewed by three authors (TvE, LR, NvdG), and any disagreements were settled by these same authors. Analysis of the data was performed by TvE and LR. All authors contributed to the review protocol, methodological decisions, and manuscript.

    Author Disclosure Statement

    No competing financial interests exist.

    Funding Information

    The authors' work on this study is funded by the Hersenstichting Nederland (the Dutch Brain Foundation, grant number ps2014.06) for the Dutch Neurotraumatology Quality Registry (Net-QuRe) and the European Union seventh Framework Program (grant 602150) for CENTER-TBI.

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