Rotterdam Computed Tomography Scores as a Predictor of Craniotomy or Decompressive craniectomy for Acute Subdural Hematomas After Traumatic Brain Injury

Introduction: The indications to perform a craniotomy vs. decompressive craniectomy (DC) for acute subdural hematomas (aSDH) after traumatic brain injury (TBI) remains controversial. We have previously demonstrated the association between the Rotterdam computed tomography (RCT) score and treatment decisions such as withdrawal of care and elevated intracranial pressure. However, no study has examined the association between RCT and a decision for craniotomy or DC in TBI patients with aSDH.

Methods: A single-center retrospective review was conducted on adult patients who presented with aSDH and received either a craniotomy or DC between 2018 and 2021. Baseline demographics and clinical presentation characteristics were collected. Chi-square, Wilcoxon sum rank test, and t-test were used to compare variance and means. Multivariate stepwise logistic regression analysis was used to develop a predictive model and the receiver operating characteristic curve was analyzed.

Results: A total of 126 patients were identified. The DC group was significantly more likely to have younger age, fewer African Americans, higher Injury Severity Scores (ISS), lower Glasgow Come Scale scores (GCS), higher RCT scores, and presence of a penetrating injury. After, stepwise logistic regression, age, ISS, and RCT scores greater than or equal to 3 were significant factors in predicting DC. RCT scores ≥3 were independently associated with DC (OR=3.233, 95% CI: (1.378, 8.032)) and had a higher odds for DC than age (OR=0.981, 95% CI: (0.961, 0.999)) and ISS (OR=1.087, 95% CI: (1.024, 1.163)). The model had a c-statistic of 0.756.

Conclusion : RCT scores greater than or equal to 3, younger age, and higher ISS are independently associated with greater odds ratio of undergoing DC compared to craniotomy for traumatic aSDHs. RCT scores ≥3 demonstrated the strongest association with DC in acute SDH. A growing body of evidence suggests the utility of RCT scores in clinical decision-making for patients with severe TBI.