Outcomes of Surgical Versus Conservative Management in Severe Traumatic Brain Injury (GCS 3–4) With Evacuable Mass Lesions: A Retrospective Cohort Study

Objective: Management of patients with severe traumatic brain injury (TBI) presenting with Glasgow Coma Scale (GCS) scores of 3-4 and surgically evacuable intracranial hematomas remains controversial because of perceived futility and poor outcomes.This study compared outcomes of surgical versus conservative management in this patient population.Methods: This retrospective observational study included patients with TBI (GCS 3-4) and surgically evacuable intracranial mass lesions admitted to a tertiary care centre between December 2015 and December 2023.Among 3,657 TBI admissions, 752 patients met inclusion criteria: 568 underwent surgical management and 184 were treated conservatively.Clinical and radiological variables were analysed.Outcomes were assessed at 6 months using the Glasgow Outcome Scale (GOS).Favorable outcome was defined as GOS 3-5, given the high mortality in this cohort.Subgroup analysis and multivariable logistic regression analysis were performed.Results: Six-month mortality was significantly lower in the surgical group (79.2% vs. 94.5%).Surgery was associated with shorter intensive care unit stay (p=0.001) and fewer systemic complications (p=0.003).Favourable outcomes were significantly more frequent following surgery in patients aged <40 years, with extradural hematoma, unilateral or bilateral pupillary dilation, and intervention within 6 hours of injury (all p<0.05).On adjusted analysis, surgical management was significantly associated with favorable outcome (odds ratio, 3.7; 95% confidence interval, 2.0-6.8;p<0.001).Conclusion: Despite an overall poor prognosis, surgical evacuation of mass lesions in TBI patients with GCS 3-4 was associated with improved survival and functional outcomes in selected patients, although causality cannot be inferred.