Large decompressive craniotomy in the treatment of acute subdural hematoma

A series of 42 patients who had large decompressive craniotomies for acute subdural hematoma has been reviewed with regard to long term results. Postoperative mortality (within 30 days of surgery) was 36%. Delayed but related deaths accounted for an additional 19% mortality, for a total mortality of 55%. Fourteen patients (33%) were able to return home, but there was a significant morbidity in terms of intellectual impairment, hemiparesis, and dysphasia. Recommended management includes establishment of an adequate airway, intravenous administration of mannitol, and performance of an emergency computerized tomographic (CT) scan before operation. A large decompressive craniotomy is performed, with removal of the blood clot, establishment of hemostasis, patch-grafting of the dura, and removal of the bone flap to allow the edematous, swollen brain to expand away from the brain stem. The mortality and morbidity will probably always remain high because in the majority of the cases significant structural damage to the cortical and brain stem structures occurs at the time of the injury.