Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma.

N Engl J Med

From 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.).

Published: June 2023

Background: Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear.

Methods: We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L).

Results: A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group.

Conclusions: Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.).

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http://dx.doi.org/10.1056/NEJMoa2214172	DOI Listing

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