By Matthew E. Fink, MD
Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York Presbyterian/Weill Cornell Medical College
SOURCE: Hutchinson P, Adams H, Mohan M, et al. Decompressive craniectomy versus craniotomy for acute subdural hematoma. N Engl J Med 2023;388:2219-2229.
Decompressive craniectomy is a neurosurgical procedure that involves removing a large portion of the skull to prevent raised intracranial pressure in brain injuries that may cause brain swelling. The procedure first was developed in the treatment of traumatic brain injury; however, it is associated with a number of complications, including infections and difficulties associated with reconstruction of the skull.
There has been longstanding discussion about whether craniectomy results in better outcomes than craniotomy with preservation of the skull for treatment of patients with acute subdural hematomas. This multicenter, international clinical trial was designed to compare the long-term results, benefits, and complications of decompressive craniectomy vs. craniotomy in patients with acute subdural hematomas.
Eligible patients had to be older than 16 years of age and have an acute subdural hematoma on computed tomography (CT) scan that warranted evacuation. A large bone flap, at least 11 cm in diameter, by either craniotomy or craniectomy was performed. Patients with bilateral hematomas were excluded.
The primary outcome was the rating on the Glasgow Outcome Scale-Extended (GOSE), an eight-point scale ranging from death to good recovery at 12 months. Secondary outcomes included the GOSE at six months and a quality-of-life assessment as measured by the EuroQoL group 5 questionnaire. A total of 228 patients were assigned to the craniotomy group and 222 patients were assigned to the decompressive craniectomy group. At 12 months, the odds ratio for differences across the GOSE ratings was 0.85, P = 0.32. The ratings were similar at six months. After 12 months of follow-up, mortality in the craniotomy group was 30.2% and 32.2% in the craniectomy group. A vegetative state occurred in 2.3% and 2.8%, respectively, and good recovery occurred in 25.6% and 19.9%, respectively. Quality-of-life scores were similar in the two groups at 12 months.
In the craniotomy group, additional cranial surgery within two weeks after randomization had to be performed in 14.6%, and in 6.9% in the craniectomy group. Wound complications occurred in 12.2% of the craniectomy group, which was significantly higher than in the craniotomy group.
Disability, mortality, and quality-of-life outcomes were similar in both treatment approaches. Additional surgery was performed at a higher rate in patients who initially underwent craniotomy, but more wound complications occurred in the patients who underwent craniectomy. Otherwise, the two surgical approaches resulted in similar clinical outcomes.
