Neurosurgeon University of Cambridge Cambridgeshire, Ireland
Introduction: Traumatic acute subdural hematomas frequently require surgical evacuation via a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but it is unclear if it is associated with better outcomes. We conducted a trial to compare the two techniques.
Methods: Patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned in a 1:1 ratio to craniotomy or decompressive craniectomy of ≥11 cm anteroposterior diameter in both groups. Patients with intra-operative brain swelling that would be anticipated to prevent replacement of the bone flap without compressing the brain were not enrolled. The primary outcome was the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death [1] to “upper good recovery”, reflecting no problems, [8]) at 12 months, obtained by questionnaires. Secondary outcomes included GOSE at 6 months and quality of life on the EQ-5D-5L scale.
Results: A total of 450 patients were enrolled; 228 assigned to craniotomy and 222 to craniectomy. The median size of the bone flap was 13 cm (IQR 12 to 14) in both groups. The common odds ratio for the differences across GOSE scores at 12 months was 0.85 (95% confidence interval, 0.6 to 1.18; p=0.324). Results were similar at 6 months. At 12 months death had occurred in 30.2% in the craniotomy group versus 32.2% in the craniectomy group; vegetative state occurred in 2.3% versus 2.8%, and good recovery occurred in 25.6% versus 19.9%, respectively. EQ-5D-5L scores were similar in the two trial groups at 12 months. Additional cranial surgery within 2 weeks after randomization was required in 14.5% of patients in the craniotomy group and 6.9% of patients in the craniectomy group. Wound complications, including surgical site infections, occurred in 3.9% patients in the craniotomy group and 12.1% patients in the craniectomy group.
Conclusion : Among patients undergoing evacuation of acute traumatic subdural hematoma with decompressive craniectomy or craniotomy of the sizes used in this trial, disability and quality of life outcomes were similar in both groups. Additional surgery was required in a higher proportion of the craniotomy group but more wound complications occurred in the craniectomy group.
