Predictors of Decompressive Craniectomy in Patients with Acute Subdural Hematoma: A Retrospective Study

Appropriate indications for decompressive craniectomy (DC) in patients with acute subdural hematoma (ASDH) remain controversial. This study aimed to identify clinical factors associated with postoperative brain swelling after hematoma evacuation and to explore predictors that may support surgical decision-making regarding the need for DC.

This retrospective study included 74 patients with ASDH who underwent hematoma evacuation via craniotomy between 2017 and 2021. Patients were classified into swelling and non-swelling groups according to postoperative clinical and radiological findings. Clinical, radiological, and treatment-related variables were compared using univariate and multivariate analysis. Model performance was evaluated using the coefficient of determination (R²), corrected Akaike information criterion (AICc), and C-index.

Twenty-one patients (28.4%) were classified into the swelling group and 53 patients (71.6%) into the non-swelling group. Univariate analysis demonstrated significant associations between postoperative brain swelling and younger age, severe consciousness disturbance (Glasgow Coma Scale [GCS] 3-8), concomitant cerebral contusion, and shorter time from injury to surgery. Multivariate logistic regression identified cerebral contusion as the only independent factor associated with brain swelling (OR, 20.95; 95% confidence interval [CI], 3.81-206.51; P < 0.001). The predictive model showed an R² of 0.47 and a C-index of 0.90, suggesting good discriminative ability.

Postoperative brain swelling following surgery for ASDH was strongly associated with severe traumatic brain injury, particularly in patients with concomitant cerebral contusion. These findings may contribute to improved preoperative risk stratification and support surgical decision-making when considering decompressive craniectomy in high-risk patients.