Is There a Role for Hyperosmolar Therapy in Acute Traumatic Subdural Hematoma? A Comparative Study of Operative Traumatic Brain Injury Patients

Introduction: While hypertonic saline (HTS) and mannitol are known to reduce intracranial pressure (ICP) in traumatic brain injury (TBI), their effectiveness and applicability in treating acute subdural hematomas remain a subject of considerable debate, with some prefering to avoid their use, as the hematoma may potentially enlarge to fill the space caused by the decrease in cerebral mass volume.

Methods: A retrospective analysis was performed on patients treated at a Level 1 trauma center in New England from 2007 to 2021. For this analysis, we selected patients with surgical subdural hematoma. Demographic data, comorbidities, clinical characteristics, and imaging findings were collected. The variables of interest included mortality, length of stay (LOS), functional outcomes evaluated through the modified Rankin scale (mRS), and discharge disposition. A univariate analysis was conducted to compare the outcomes of interest between patients receiving hyperosmolar therapy and those not receiving it.

Results: The sample included 232 patients, predominantly male (69%), with a median age of 60 years. The median hematoma thickness was 15 mm (IQR = 10-20), and the median midline shift was 9 mm (IQR = 4.4-12). Hyperosmolar therapy was administered to almost half of the sample (42.7%), most of whom were categorized as having moderate (8.1%) or severe TBI (64.6%). Among patients with severe TBI (n=108), those receiving hyperosmolar therapy had a longer ICU stay (12.5 vs. 7 days; p = 0.0039) compared to those that did not receive it. However, there were no statistically significant differences in the rates of non-routine discharge (89.1% vs. 84.1%; p = 0.45), rates of functional independence (37.5% vs. 43.2%; p = 0.55), and mortality (42.2% vs. 45.2%; p = 0.99).

Conclusion : Length of ICU stay was longer in patients with severe TBI and acute subdural hematoma receiving hyperosmolar therapy. Further multicenter studies and clinical trials are necessary to validate these results in a larger dataset of patients.