It is well accepted that prompt surgical decompression of traumatic intracranial haematomas leads to improved outcomes for head injured patients. [1–3] In keeping with this, recent prognostic models have identified non-evacuated intracranial haematomas as strong predictors of poor outcome in severe head injured patients. As such, it is usual for patients with traumatic intracranial mass lesions to be transferred to a neurosciences centre for surgery and neurointensive care.
Conversely, due to lack of infrastructure, patients deemed to have non-surgical head injuries have often been managed outside of neuroscience centres. This approach to allocating limited resources is based on a long-held belief that individuals with focal surgical lesions will do better than those with diffuse injuries. Indeed, contemporary data predicts that individuals with extradural haematomas (EDH) will do better than patients with other types of severe closed head injury. This is intuitive because an EDH compromises neural function by compression, but often has minimal associated underlying parenchymal injury; prompt surgical evacuation will thus lead to a good recovery.
However, biased resource allocation in favour of the surgical group is now controversial because it has been shown that the non-surgical group of severely head injured patients also fare better by treatment in a specialist centre. Moreover, the prognostic advantage for EDH should not necessarily be extrapolated to other traumatic mass lesions such as acute subdural haematomas or contusions, where associated parenchymal injury is a usual feature.
Despite this, there remains a paucity of evidence in the literature on the expected outcome of severely head injured patients without a mass lesion as compared to those with a surgical lesion when both groups are treated in a specialist centre. Therefore, we have compared our outcomes for severely head injured patients with and without mass lesions.