Adherence in Evidence-Based Neurotrauma Guidelines: A Worldwide Survey

Traumatic brain injury (TBI) management guidelines vary across regions and there is limited research on real-world adherence to these guidelines. We conducted a global survey to assess the adherence of neurosurgeons to TBI guidelines and evidence-based medicine (EBM). A 24-item survey was created using Google Forms, covering demographic information, neurotrauma training, basic knowledge of EBM, surgical and in-hospital management. Responses were collected from 233 neurosurgeons across 53 different countries. Approximately 45% of respondents reported not staying up to date with Brain Trauma Foundation (BTF) guidelines, and 48% indicated a preference for relying on their own experience over EBM guidelines. Neurosurgeons from Asia and Africa were more likely to rely on personal experience, while those from Europe, North/Central and South America leaned towards EBM (p=0.021). Additionally, 56% of respondents reported that their neurotrauma management at least sometimes diverged from recommended guidelines. Specifically, 58% never or rarely managed epidural hematoma of 30cm³ conservatively, and 45% sometimes, often, or always treated subdural hematomas conservatively, even when EBM recommended surgery. Moreover, 24% at least sometimes managed patients conservatively despite a Glasgow Coma Scale (GCS) score of less than 9 or a decrease of two or more points. In cerebellar hematomas, 46% sometimes opted for external ventricular drainage alone. Neurosurgeons from Europe, North/Central and South America tend to follow EBM guidelines more closely, while those from Asia and Africa often favor individual decision-making approaches.