BRIDGE: Burr hole vs. craniotomy - radiomic indicators determining the chronification grid in acute subdural hematoma evaluation.

Introduction: Acute subdural hematoma (aSDH) is commonly treated by craniotomy. In some patients, however, the hematoma evolves into a chronic subdural hematoma (cSDH), which can be safely evacuated by delayed burr-hole trepanation - a less invasive procedure associated with lower morbidity. Research question: This study aimed to identify clinical, laboratory, and radiomic predictors of hematoma chronification requiring delayed burr-hole trepanation in aSDH. Material and methods: After excluding patients with decompressive hemicraniectomy, those with contusions, and patients with epidural hematoma, we retrospectively analyzed 118 patients with traumatic aSDH admitted between 2015 and 2022. Patients underwent either primary craniotomy (n = 64), developed chronification requiring burr-hole trepanation (n = 16), or were managed conservatively without subsequent surgery (n = 38). Clinical, laboratory, and radiomics-derived variables were assessed. Results: The burr-hole group had lower SOFA scores (p = 0.034), lower leukocyte counts (p = 0.043), and fewer postoperative seizures (13% vs. 44%, p = 0.023). Radiomic analysis revealed significantly higher hematoma elongation (p = 0.001), which remained the sole independent predictor of chronification (OR 22.0, 95% CI 3.7-132.6; p = 0.001). Compared with conservative management, the burr-hole group was more frequently male (p = 0.049), had lower leukocyte counts (p = 0.031), and showed higher elongation (p = 0.008) and sphericity (p = 0.004). In multivariable analysis, elongation independently predicted chronification (OR 4.0, 95% CI 1.2-13.1; p = 0.021). Conclusion: Radiomic parameters support the stratification of patients who are more likely to benefit from delayed burr-hole trepanation rather than acute craniotomy.