Meta-Analysis Comparing Outcomes of Hinge Craniotomy to Decompressive Craniectomy in Patients Suffering from Elevated...

Traumatic brain injury (TBI) and stroke constitute 60% of the global neurosurgical case volume. Although decompressive craniectomy (DC) has been historically used for treating elevated intracranial pressures (ICP), it remains a controversial technique and is also associated with cranioplasty-related complications and additional costs. Hinge craniotomy (HC) may offer a potentially safer and, importantly, cheaper alternative to DC in low- and middle-income countries (LMICs), which bear the greatest burden of TBI cases. In this article, we aimed to provide a comprehensive meta-analysis comparing patients undergoing HC vs those undergoing DC for elevated ICP.

The MEDLINE and Cochrane databases were systematically searched from inception to May 2024. We included all studies comparing outcomes in patients with elevated ICP undergoing HC vs those undergoing DC. Random effects models were used to pool dichotomous outcomes as risk ratios and continuous outcomes as mean differences.

Seven observational studies and one randomized controlled trial comprising 1335 patients were included in our meta-analysis. Both surgical techniques achieved comparable intracranial volume expansion (mean differences: -9.94 mm 3 ) and had similar rates of postoperative hydrocephalus (risk ratio [RR]: 0.46), wound infections (RR: 0.61), and subdural hematoma (RR: 1.37). However, patients undergoing HC showed significant improvement in functional outcomes at discharge (RR: 3.32), although long-term outcomes in this respect were similar between the 2 arms (RR: 1.12).

Our meta-analysis, the first of its kind, depicts that HC offers an equally efficacious alternative to DC with the added benefit of achieving quicker functional recovery postoperatively. This is of particular clinical utility in LMICs which bear the greatest burden of TBI cases. However, in future, a cost-effectiveness analysis as well as adequately powered randomized controlled trials are needed to definitively delineate the optimal surgical approach needed to improve outcomes in our patient population.