Protected-Airway Local/Regional Analgesia-Dominant Strategy Versus General Anesthesia and ICU Length of Stay in Elderly Patients with Traumatic Intracranial Hemorrhage: A Propensity Score-Matched Cohort Study

Background/Objectives: Older adults undergoing surgery for intracranial hemorrhagic lesions after head trauma are clinically heterogeneous, and burr-hole drainage for trauma-related chronic or localized subdural hematoma differs substantially from craniotomy for acute lesions. We evaluated whether a protected-airway local/regional analgesia-dominant strategy (LA), in which airway protection was maintained but continuous maintenance-dose general anesthesia was not planned, was associated with shorter intensive care unit (ICU) stay than conventional general anesthesia (GA). Materials and Methods: In this single-center propensity score-matched retrospective cohort study, 330 patients aged ≥65 years with admission Glasgow Coma Scale (GCS) ≤ 8 who underwent surgery between 2015 and 2024 were analyzed. The LA approach was a pragmatic, jointly selected anesthesiologist–neurosurgeon strategy for carefully selected short burr-hole or localized subdural hematoma procedures; it was not an awake technique and not a protocol of leaving an intubated patient without drugs for airway-device tolerance. A protected airway could include a tracheal tube, supraglottic airway, or preexisting endotracheal tube according to clinical context, and titrated analgesic, sedative, or rescue anesthetic medications were permitted when clinically required. Propensity scores were estimated using age, sex, admission GCS, American Society of Anesthesiologists class, and Charlson Comorbidity Index; lesion category, procedure type, antithrombotic therapy, and intraoperative hypotension were examined as major sources of residual confounding. Results: After matching, the LA group had shorter ICU stay (4 [IQR 2–6] vs. 6 [4–10] days; p < 0.001). Negative binomial regression showed a 28% lower expected ICU stay with LA (incidence rate ratio 0.72, 95% CI 0.58–0.89; p = 0.003), and competing-risk analysis showed faster alive ICU discharge (subdistribution hazard ratio 1.41, 95% CI 1.08–1.84; p = 0.012). Conclusions: In this heterogeneous retrospective cohort, the LA strategy was associated with shorter ICU stay, particularly within selected burr-hole-dominant cases. These findings are hypothesis-generating and should not be interpreted as proof of superiority across acute traumatic brain injury, all lesion types, or all neurosurgical procedures.