Since the enactment of the Life-Sustaining Treatment Decision Act in Korea on February 4, 2018, 327097 people have died from refusing life-sustaining treatment between 2019 and 2023. Additionally, by June 2024, 2441805 people had completed advance directives, indicating that they did not wish to receive life-sustaining treatment [8]. Currently, one in five seniors over the age of 65 has written an advance directive. As the culture of preparing for a dignified death in advance spreads, the tendency to refuse life-prolonging treatment in cases where there is no possibility of recovery is growing stronger [8].

In the case of patients admitted to the hospital in a Glasgow coma scale (GCS) score of 3 due to traumatic brain injury, the mortality rate is extremely high [3]. This tendency is particularly evident in acute subdural hematoma (A-SDH) [9]. Although there have been exceptional cases of dramatic recovery, they are rare. One of the difficult decisions faced by neurosurgeons in the emergency room is whether to proceed with aggressive surgical treatment for patients with A-SDH or to begin conservative or end-of-life care. It is closely related to the absolute value of life [10]. Here, we analyzed data from five regional trauma hospital centers in Korea to assess the number of surgical treatments and overall treatment outcomes for patients with A-SDH admitted in a comatose state and discussed the value of such aggressive surgical interventions based on these findings.

This study received Institutional Review Board approval, and the requirement to obtain informed consent from patients was waived. Patient registration was approved by the ethics committees of five regional trauma center hospitals. Additionally, this study was approved by the ethics committee of Wonkwang University Hospital (approval No. WKUH 202410011). We retrospectively analyzed data from five regional trauma center hospitals registered with the Korean Neurotrauma Data Bank System operated by the Korean Neurotraumatology Society between January 2018 and June 2021. Adults aged 19 years or older who visited the emergency room in a comatose state due to A-SDH after traumatic brain injury (TBI) were included, and patients with a history of craniotomy or craniectomy were excluded. Among the 177 patients with a GCS score of 3 points, 58 patients who were in a comatose state due to causes other than A-SDH (14 with acute epidural hematoma, 18 with diffuse axonal injury, 20 with traumatic intracerebral hemorrhage, and six with other causes) and 10 patients with incomplete medical records were excluded, resulting in 109 patients included in this study (Fig. 1). Patients in a comatose state due to A-SDH were divided into death and survivor groups. The two groups were compared in terms of their epidemiological, physiological, and radiological characteristics, Injury severity score (ISS), mortality, computed tomography (CT) findings, and time intervals. Additionally, the patients were divided into two groups : the combined group of death and vegetative state survivors and the remaining survivors. Differences between the two groups were compared to investigate the impact of death and vegetative state. Prognosis was assessed using the extended Glasgow outcome scale (EGOS) 6 months later.

Among a total of 109 patients, the mean age was 59.28±17.15 years and the total number of deaths was 88 (80.7%). The EGOS of the 21 survivors (19.3%) was in the vegetative state in 12 patients, lower severe disability in one patient, lower moderate disability in three patients, upper moderate disability in one patient, and lower good disability in four patients. Table 1 shows the demographic and clinical characteristics of the patients with outcome measures based on age, sex, treatment, and pupil reactivity. When the patients were divided into two groups based on the age of 65 years, the group aged 65 years or younger (n=70) had 56 deaths (80.0%) and six patients (8.6%) in the vegetative state. In the group aged 66 years or older (n=39), there were 32 deaths (82.1%) and six patients (15.4%) in the vegetative state. The study included 80 males (73.4%) and 29 females (26.6%). In the male group, the number of deaths was 61 (76.3%), and the vegetative state was 10 (12.5%). In the female group, the number of deaths was 27 (93.1%) and the vegetative state was two (6.9%). Surgical treatment was performed in 42 patients (38.5%); all surgeries were craniectomies. In the surgically treated group, the number of deaths was 27 (64.3%), and nine patients (21.4%) were in a vegetative state. In the conservatively treated group (n=67, 61.5%), the number of deaths was 61 (91.0%), and three patients (4.5%) were in a vegetative state. Pupil reactivity was reactive in nine patients (8.3%), unilaterally unreactive in seven (6.4%), bilaterally unreactive in 92 (84.4%), and uncheckable in one (0.9%). The mortality rates were 44.4% in reactive pupils, 57.1% in unilateral unreactive pupils, and 85.9% in bilateral unreactive pupils.

Table 2 shows the comparison between the survivor and death groups. In multivariate exploratory data analysis (EDA), age showed that the distribution of the death group was higher, and older patients tended to be more likely to die. The ISS and Rotterdam CT scan scores showed a strong correlation with mortality, with higher scores indicating a higher probability of death. Hematoma thickness and midline shift on CT also showed a positive correlation with mortality. Systolic blood pressure tended to be lower in the death group. The survival rate was significantly higher in the surgical treatment group (p=0.001), the mortality rate was significantly higher in bilateral unreactive pupil (p=0.008), and the mortality rate was significantly higher as the Rotterdam CT score increased (p=0.007).

Table 3 shows a comparison between the combined group of deaths and vegetative survivors (n=100) and the remaining group of survivors (n=9). In the multivariate EDA, variables such as the Rotterdam CT score, midline shift on CT, hematoma thickness, and ISS tended to be higher in the combined group of deaths and vegetation. In terms of treatment, the mortality rate tended to be higher in patients who received conservative treatment. The statistically significant variables were pupil reactivity (p=0.004) and time interval from injury to hospital admission (p=0.010). Table 4 shows a comparison of the mean hospital stay by patient outcome and treatment type. The total length of hospital stay was a mean of 13.09±22.67 days. The hospital stay was 4.62±5.30 days in the death group, 48.57±31.48 days in the survival group, 47.33±35.41 days in the plant group, 23.69±29.15 days in the surgery group, and 6.45±13.75 days in the conservative treatment group. There was a statistically significant difference in hospital stay between the death group and survival group, and between the surgery group and conservative group (p<0.000 and p<0.000, respectively). All 42 surgical patients underwent craniectomy, and the mean operative time was 133±78.72 minutes and the mean blood transfusion volume was 1387.5±2475.57 mL.

Table 5 and Fig. 2 show the duration from hospital admission to death among the 88 deaths, comparing patients who received conservative treatment with those who received surgical treatment. In the surgical group, the time until death was distributed over a wider range, with a higher mortality rate during the later hospitalization period. In the conservative treatment group, the time until death tended to be shorter, with more deaths occurring during the early hospitalization period. The difference between the two groups was statistically significant (p=0.006).

In 2023, the number of patients who discontinued life-sustaining treatment reached 70720, which was 2.2 times higher than in 2018 (31765 patients). The proportion of these patients among the total deaths increased from 10.6% to 20.1% [8]. Additionally, the number of people who completed advance directives increased 5.7 times, from 100529 in 2018 to 573937 in 2023 [8]. In 2023, approximately half of the patients who discontinued life-sustaining treatment did so through advance directives or life-sustaining treatment plans that reflected their wishes. According to the current Life-Sustaining Treatment Decision Act, if two doctors determine that there is no possibility of recovery and death is imminent, they will confirm whether to discontinue life-sustaining treatment, and the decision will be made based on the patient’s or family’s wishes [8].

Recently, as the value of the quality of life has increased, the treatment goal for patients with severe TBI has changed to a ‘good quality of life.’ In the past, there was a strong belief in miracles and the perception that life should be preserved under all circumstances. However, considering various factors, it is necessary to evaluate whether a prolonged comatose state aligns with what the patient wants. In particular, in cases of ultra-severe TBI, the family’s financial and mental capacity and social, legal, ethical, and religious expectations are important considerations [4,6,10]. Although it is difficult to predict treatment outcomes accurately in the early stages, if there is no recovery over time, the possibility of remaining in a seriously disabled or vegetative state increases [6]. Therefore, in cases with a poor prognosis, such as coma caused by A-SDH, decisions about surgical decompression should involve comprehensive judgment rather than being limited to a simple life-or-death discussion [6,10].

A GCS score of 3 due to severe TBI is associated with a high mortality rate, and some reports have suggested that the chances of survival are very low. Kotwica and Jakubowski [5] reported that despite surgical treatment within 3 hours of injury in 74% of cases, 89% of patients died within 2-30 days after injury, and 7% survived in a vegetative state. Only 4% of the patients showed satisfactory outcomes, but half of these patients had stable neurological deficits. Lieberman et al. [7] reported an inhospital mortality rate of 100% in patients with a GCS score of 3 and bilateral fixed dilated pupils and 66.6% in those with reactive pupils. Tien et al. [11] reported similar results, with an inhospital mortality rate of 100% in patients with bilateral fixed dilated pupils and 42% in those with reactive pupils. Their analysis suggested that patients with bilaterally fixed and dilated pupils were more likely to be unstable, exhibit extra-axial bleeding, and present with evidence of midline shift and/or herniation. However, some studies have argued that aggressive treatment should not be denied to these patients, reporting relatively good recovery and low mortality rates. Chamoun et al. [1] reported lower mortality rates (mortality rate 23.5% for bilateral reactive pupils and 79.7% for bilateral fixed dilated pupils) than other studies. However, the mean age of survivors was 33.3 years, and the mean age of those who died was 40.3 years, and it was due to their aggressive surgical management. They argued for aggressive treatment, suggesting that younger age, lower intracranial pressure at presentation, and the presence of reactive pupils were the major prognostic factors.

In this study, the average age of the patients admitted in a comatose state due to A-SDH was 59.3 years, and the mortality rate was 80.7%. Of the 21 survivors, 12 patients (57.1%) survived in a vegetative state. Aggressive surgical treatment was performed in 38.5% of patients. Although the mortality rate was significantly lower in the aggressive surgical treatment group (64.3%) than in the conservative treatment group (91.0%), the vegetative state was higher in the surgical treatment group (21.4%) than in the conservative treatment group (4.5%). Among the eight survivors who received conservative treatment, three (37.5%) were in a vegetative state, whereas among the 15 survivors who received surgical treatment, nine (60.0%) were in a vegetative state. This indicates that while surgical treatment reduced the mortality rate of patients with GCS 3 due to A-SDH, a significant number of those who survived through surgery remained in a vegetative state. Surgical treatment showed a significant difference between survivors and deaths; however, this was supported by the fact that there was no statistical difference when the vegetative group was included in the death group. However, it may be difficult to achieve statistical significance because the number of remaining survivors (n=9) is too small compared to the combined number of deaths and vegetative survivors (n=100). There was no statistically significant difference between the survivor and death groups, although the survival rate tended to be higher in the younger age groups. However, when patients who died and those in a vegetative state were combined, they were significantly older than the remaining survivors. This shows that surgical treatment is performed more often in younger age groups and that the prognosis is better. Pupil reactivity is one of the strongest prognostic factors in most studies of patients with severe TBI. In this study, bilateral pupil reactivity was significantly associated with death and survival to the vegetative state. In this study, the mortality rates were 44.4% for reactive pupils, 57.1% for unilateral unreactive pupils, and 85.9% for bilateral unreactive pupils. Surgical treatment significantly extended the length of hospital stay for patients (surgical treatment vs. conservative treatment : 23.69 vs. 6.45 days). Most deaths occurred in the early stages of hospitalization (hospital stay of death : 4.62 days). Prolonged hospital stay leads to increased medical costs and financial burdens on caregivers. Moreover, patients in coma with a GCS score of 3 were severe cases requiring the use of an intensive care unit, which imposes a significantly higher economic burden than mild cases.

The results of this study may be clinically useful, but they should be interpreted with caution as pupillary reactivity was not taken into consideration. Low GCS scores and pupillary reactivity are two independent and significant factors for predicting poor outcomes in patients with TBI [2,11]. Several studies have argued that trauma patients with a GCS score of 3 persisting from the scene and bilaterally fixed, dilated pupils have virtually no chance of survival. In such cases, further interventions, including surgery, may not be warranted [2]. However, patients with a GCS score of 3 and normal pupillary reactivity have a significantly higher chance of survival [11]. To date, there is still limited data on the outcome of patients with ultra-severe TBI. Despite advances in neurocritical care and neurosurgery, the prognosis for patients with ultra-severe TBI is often poor, but aggressive neurosurgical intervention may be considered in selected cases. This study focuses specifically on GCS 3 patients with A-SDH as a subset of TBI. Since all patients had clear intracranial lesions (hematoma) and midline shift, only nine out of a total of 109 patients (8.3%) exhibited reactive pupils, representing a very small proportion.

In 2025, Korea will become a super-aged society, in which the elderly aged 65 years or older will exceed 20% of the total population. Therefore, it is time to go one step further from death with the dignity law and have a comprehensive consideration and social consensus on ‘how to end life.’ A model that can more accurately predict situations in which decompressive surgery should be considered for patients in a comatose state owing to A-SDH is required. Neurosurgeons must have a comprehensive understanding of the patient’s progress, the anticipated prognosis, and the various financial and psychological burdens on the family and must be able to communicate this information thoroughly. This is crucial for making more rational decisions in the treatment of comatose patients with A-SDH.