Admission Neurological Status, Radiological Mass Effect, and In-Hospital Mortality Among Surgically Treated Patients With Traumatic Acute Subdural Hematoma: A Single-Center Experience From Türkiye.

Abstract

Traumatic acute subdural hematoma (ASDH) carries high morbidity and mortality despite surgery. We evaluated associations of admission neurological status and radiological mass effect with in-hospital mortality. An exploratory analysis examined a composite unfavorable Glasgow Outcome Scale (GOS) outcome, with in-hospital mortality as its largest component. This retrospective study included 82 adults treated surgically for traumatic ASDH between January 2020 and December 2025. The Zumkeller index (midline shift minus hematoma thickness) was categorized as <0, 0-3, or >3 mm. Two multivariable mortality models, including a Firth-penalized model with the Zumkeller index, underwent 1,000-resample bootstrap validation. In-hospital mortality was 44%. Higher admission Glasgow Coma Scale (GCS) score was associated with lower odds of mortality (adjusted OR, 0.72; 95% CI, 0.57-0.91), whereas greater midline shift (adjusted OR, 1.14; 95% CI, 1.04-1.25) and abnormal pupillary response (adjusted OR, 3.18; 95% CI, 1.09-9.28) were associated with higher odds. Older age was modestly associated with mortality (adjusted OR, 1.03; 95% CI, 1.00-1.07). Mortality was 33%, 62%, and 82% across Zumkeller categories; 9 of 11 patients with an index >3 mm died. An index >3 mm remained associated with mortality in the Firth model (adjusted OR, 4.72; 95% CI, 1.01-22.94). The composite outcome occurred in 47 patients: 36 in-hospital deaths and 11 additional unfavorable outcomes among survivors. These findings reflect our institutional experience. A Zumkeller index >3 mm identified a small subgroup with high in-hospital mortality. Optimism-corrected AUCs were numerically close, and external validation is required.