Neurosurgical Treatment Variation of Traumatic Brain Injury: Evaluation of Acute Subdural Hematoma Management in Belgium and The Netherlands

Abstract

Several recent global traumatic brain injury (TBI) initiatives rely on practice variation in diagnostic and treatment methods to answer effectiveness questions. One of these scientific dilemmas, the surgical management of the traumatic acute subdural hematoma (ASDH) might be variable among countries, among centers within countries, and even among neurosurgeons within a center, and hence be amenable for a comparative effectiveness study. The aim of our questionnaire, therefore, was to explore variations in treatment for ASDH among neurosurgeons in similar centers in a densely populated geographical area. An online questionnaire, involving treatment decisions on six case vignettes of ASDH, was sent to 93 neurosurgeons in The Netherlands and Belgium. Clinical and radiological variables differed per case. Sixty neurosurgeons filled out the questionnaire (response rate 65%). For case vignettes with severe TBI and an ASDH, there was a modest variation in the decision to evacuate the hematoma and a large variation in the decision to combine the evacuation with a decompressive craniectomy. The main reasons for operating were "neurological condition" and "mass effect." For ASDH and mild/moderate TBI, there was large variation in the decision of whether to operate or not, whereas "hematoma size" was the predominant motivation for surgery. Significant inter-center variation for the decision to evacuate the hematoma was observed (p = 0.01). Most pronounced was that 1 out of 7 (14%) neurosurgeons in one region chose a surgical strategy compared with 9 out of 10 (90%) in another region for the same scenario. In conclusion, variation exists in the neurosurgical management of TBI within an otherwise homogeneous setting. This variation supports the methodology of the international Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) initiative, and shaped the Dutch Neurotraumatology Quality Registry (Net-QuRe) initiative.

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

“…Substantial variation exists in surgical practice, owing to an inadequate evidence base for international guidelines on surgical indications. [312][313][314] Additionally, at the level of individual patients, there is debate among clinicians regarding which patients might benefit from some procedures (such as surgical treatment for traumatic intracranial lesions and for raised ICP) and uncertainty regarding the optimum timing of surgery. Surgery might be life-saving and preserve neurological function in some patients, 315 but others might survive with an unfavourable functional outcome, ranging from severe neurological and cognitive deficits to a vegetative state (section 7).…”

“…CER approaches could provide a more cost-effective means of evaluating these interventions (and, potentially, novel therapies) in real-world settings. Early evidence in support of non-experimental designs as a promising approach for research on severe TBI comes from studies that relate outcomes to structural parameters 250,251,260 (section 4) or that compare surgical or medical interventions (ie, process parameters) 312 (section 5) using CER.…”

Isolated subdural hematomas in mild traumatic brain injury. Part 2: a preliminary clinical decision support tool for neurosurgical intervention

“…Variation in surgical practice has been shown, and model creation on small sample sizes can have the potential for overfitting; nevertheless, our models showed excellent discrimination and calibration. 4,8,34 Also, with 64% of our patients ≥ 65 years of age, our patient population may not be representative of all other trauma centers and therefore may not be fully generalizable across all trauma centers. Additionally, our model has not been externally validated in multiple, independent patient populations.…”

Comparative Effectiveness of Surgery for Traumatic Acute Subdural Hematoma in an Aging Population

“…5,[7][8][9] Moreover, CER could be worthwhile because, partly as a result of current treatment guidelines featuring low class evidence, considerable between-center differences in the clinical management of TBI are seen. [10][11][12][13][14][15][16] ''To operate or not?'' is a burning clinical question every surgeon frequently has to answer.…”

“…As a result, management strategies vary considerably among neurosurgical departments, even among those within dedicated level 1 trauma centers with protocolled emergency medicine schemes. [10][11][12] Clearly, there is a need for comparative studies to elucidate the optimal treatment of traumatic ASDH. As randomized surgical trials are not practically feasible because of the moral boundaries of treating physicians, the comparison of cohorts among homogenous regions managing ASDH in different ways may be the best available alternative to assess the effectiveness of surgical therapy.…”