Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma

Peter J Hutchinson ¹, Hadie Adams ¹, Midhun Mohan ¹

¹From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.).

⁰From the Division of Neurosurgery, Addenbrooke's Hospital (P.J.H., H.A., M.M., E.V., A.E.H., I.S.T., C.T., A.G.K.), the Department of Clinical Neurosciences (P.J.H., H.A., M.M., H.M., M.G.S., E.V., A.E.H., I.S.T., C.T., A.G.K.), and the Division of Anaesthesia (D.K.M.), University of Cambridge, and the Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust (C.T.), Cambridge, the Neurosurgery Department, Royal London Hospital (C.U., S.H.), and the Department of Neurosurgery, Imperial Neurotrauma Centre, Imperial College Academic Health Sciences Centre, St. Mary's Hospital (M.H.W.), London, Wessex Neurological Centre, University Hospitals Southampton NHS Foundation Trust, Southampton (D.B., A.Z.), the Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool (C.J.M., M.G.S.), the Department of Neurosurgery and the Academic Directorate of Neurosciences, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield (Y.Z.A.-T.), the Department of Neurosurgery, Leeds General Infirmary, Leeds (S.T.), the Department of Neurosurgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham (A.B.), the Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Manchester (A.T.K.), Norwich Medical School, University of East Anglia, Norwich (S.P., G.B.), and the Neurosurgical Trials Group, Wolfson Research Centre, Newcastle University, Newcastle upon Tyne (B.G.) - all in the United Kingdom; the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (B.I.D., D.P.S.), and the Department of Neurosurgery, Aster RV Hospital (D.I.B.), Bangalore, the Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi (D.K.G.), and the Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh (M.K.T., M.T.) - all in India; the Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium (A.R.M.); Humanitas Research Hospital-IRCCS and Humanitas University, Rozzano, Milan (F.S.); and the University of California, San Francisco, San Francisco (G.T.M.).

The New England Journal of Medicine +

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April 24, 2023

View abstract on PubMed

Summary

Surgical evacuation of traumatic acute subdural hematomas via craniotomy or decompressive craniectomy yielded similar patient outcomes. While craniotomy required more follow-up surgeries, decompressive craniectomy was associated with increased wound complications, indicating comparable overall effectiveness.

Area Of Science

Neurosurgery
Trauma Surgery
Critical Care Medicine

Background

Traumatic acute subdural hematomas often necessitate surgical intervention.
Surgical options include craniotomy (bone flap replaced) and decompressive craniectomy (bone flap not replaced).
The comparative effectiveness of these procedures on patient outcomes remains unclear.

Purpose Of The Study

To compare the outcomes of craniotomy versus decompressive craniectomy in patients with traumatic acute subdural hematomas.
To evaluate functional status and quality of life at 6 and 12 months post-surgery.

Main Methods

A randomized trial involving 450 patients with traumatic acute subdural hematoma.
Patients were assigned to either craniotomy or decompressive craniectomy.
Primary outcome: Extended Glasgow Outcome Scale (GOSE) at 12 months. Secondary outcomes: GOSE at 6 months, EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L).

Main Results

No significant difference in GOSE ratings at 12 months between craniotomy and decompressive craniectomy (common odds ratio: 0.85; P=0.32).
Similar outcomes at 6 months and comparable quality-of-life scores (EQ-5D-5L) at 12 months.
Craniotomy group had higher rates of additional surgery (14.6%) while the decompressive craniectomy group experienced more wound complications (12.2%).

Conclusions

Craniotomy and decompressive craniectomy demonstrate similar functional and quality-of-life outcomes for traumatic acute subdural hematomas.
The choice between procedures involves a trade-off between the need for subsequent surgeries and the risk of wound complications.
Both surgical techniques are viable options for managing traumatic acute subdural hematomas.