medwireNews: Craniotomy and decompressive craniectomy have comparable outcomes for global disability and recovery in patients with traumatic acute subdural hematoma, researchers say.
For the study, published in The New England Journal of Medicine, the team randomly assigned 228 patients requiring surgical evacuation of an acute subdural hematoma to undergo a craniotomy, where the bone flap is replaced, and 222 to receive decompressive craniectomy, where the bone flap is not replaced. The size of the bone flap was a median 13 cm in both groups.
The participants were aged an average 48 years and the majority (65%) had an Extended Glasgow Outcome Scale (GOSE) of 3 to 8, with approximately 15% in each group taking an anticoagulant or antiplatelet medication at baseline.
At 12 months, data were available for 215 patients in the craniotomy group and 211 in the decompressive craniectomy group, and these showed that craniotomy patients were around 15% less likely to have a poor GOSE rating after surgery than those receiving decompressive craniectomy, but the difference was not statistically significant.
Specifically, 30.2% of the patients in the craniotomy group and 32.2% of those in the decompressive craniectomy group had died, while 2.3% and 2.8%, respectively, had entered a vegetative state. Additionally, 25.6% of patients receiving a craniotomy saw a lower or upper good recovery, as did 19.9% of patients in the craniectomy group.
The researchers note that wound complications, such as surgical site infections, were significantly more common with decompressive craniectomies, affecting 12.2% of 222 patients, compared with just 3.9% of 228 patients in the craniotomy group. By contrast, patients receiving craniotomies were more likely to need additional cranial surgery within 2 weeks, as seen in 14.6% of 192 patients versus 6.9% of 188 patients who received decompressive craniectomies. Most of the extra surgical interventions were decompressive craniectomies for brain swelling.
Peter Hutchinson, from the University of Cambridge in the UK, and co-authors remark that there could be practical implications from this trial.
“If the bone flap can be replaced without compression of the brain, surgeons may consider doing so, as opposed to performing a preemptive decompressive craniectomy,” they write. “These findings may not be relevant for resource-limited or military settings, where preemptive craniectomy is often used owing to the absence of advanced ICU facilities for postoperative care.”
Welcoming the findings in a related editorial, Shankar Gopinath (Baylor College of Medicine, Houston, Texas, USA) commented: “With these results, I expect that surgeons will be reassured that it is relatively safe to perform the quicker procedure of removal of the bone, knowing that if the bone is left in place, compression of the brain under the hematoma and the need for reoperation can largely be prevented.”
She continued: “Because the incidence of local infections was low in both trial groups but was admittedly higher with craniectomy, the trial also showed that the price paid for choosing the quicker procedure is medical complications, most of which are treatable, such as infection related to repairing replacing the skull defect — a trade-off for fewer intracranial risks that might be considered satisfactory.”
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