Prognostic Performance of the Richmond Acute Subdural Hematoma (RASH) Score, Surgical Timing, and Decompressive Modality for Predicting In-Hospital Mortality Following Traumatic Acute Subdural Hematoma Evacuation at an Indonesian Tertiary Referral Center

Abstract

Background: Traumatic acute subdural hematoma (ASDH) carries high postoperative mortality, particularly where prehospital delays add to secondary intracranial hypertension. The Richmond Acute Subdural Hematoma (RASH) score combines age, Glasgow Coma Scale (GCS) score, pupillary reactivity, midline shift (MLS) >5 mm, and loss of consciousness into an 8-point scale.

Objective: To evaluate the discrimination, calibration, and multivariable independence of the preoperative RASH score, with surgical modality and injury-to-incision latency, for in-hospital mortality in an Indonesian referral cohort.

Methods: This retrospective cohort study included consecutive adults who underwent craniotomy or decompressive craniectomy (DC) for traumatic ASDH at Dr. Mohammad Hoesin General Hospital, Palembang, from January 2022 to December 2024 (67 of 95 screened admissions). We used receiver operating characteristic (ROC) curves, Youden's J index, likelihood ratios, and Firth penalized logistic regression.

Results: In-hospital mortality was 20.9% (14/67). Non-survivors had higher median RASH scores (5.5 vs. 3.0; p < 0.001) and longer injury-to-incision latency (9.5 vs. 5.8 hours; p = 0.008). Mortality rose from 0.0% (0/18) at scores 0–2 to 66.7% (2/3) at scores 7–8. The area under the curve was 0.824 (95% CI: 0.715–0.933). At RASH ≥5, sensitivity was 78.6%, specificity 77.4%, and negative predictive value 93.2%. In Firth regression, the RASH score (aOR = 2.95 per point; 95% CI: 1.52–5.74), DC (aOR = 3.42; 1.14–10.26), and delay (aOR = 1.24 per hour; 1.04–1.48) were each associated with death.

Conclusion: The RASH score showed good discrimination in this single-center cohort. RASH ≥5 may support operative triage and family counseling, pending prospective validation.