Craniotomy Versus Decompressive Craniectomy For Acute Subdural Hematoma

Acute subdural hematoma is a common secondary injury in traumatic brain injury,the incidence rate is about 10%-30%,often accompanied by brain contusion,the patient’s condition is often heavier,with higher disability rate and mortality rate.There are two main surgical methods,1.craniotomy involves elevation of a bone flap,removal and clearance of subdural hematoma,followed by replacement of the bone flap.2.The alternative surgical procedure is decompressive craniectomy,which also involves elevating a bone flap,hematoma evacuation,and then storage of the bone flap.Although these two surgical methods have been widely used in clinical practice,there is still controversy about how to choose the appropriate surgical method.At present,There are great differences in the choice of surgical methods around the world.According to a US data,patients with acute subdural hematoma in the United States,who underwent craniotomy were approximately 10 times more likely to undergo decompressive craniectomy.A survey in Europe found that in continental European countries,44% of neurosurgeons performed decompressive craniectomy in half of their patients,and only 21% of neurosurgeons in the UK and Ireland.At present,the indications,risks and benefits of these two surgical methods in the treatment of acute subdural hematoma are still controversial.We found in the clinic that patients with acute subdural hematoma often have severe conditions,often accompanied by brain contusion,and cerebral edema.Postoperative control of high intracranial pressure is the key to treatment.Therefore,in order to more effectively control the increase of intracranial pressure,in most cases,patients with acute subdural hematoma underwent decompressive craniectomy.However,after decompressive craniectomy,it is often accompanied by many complications such as hydrocephalus and intractable subdural effusion.In order to compare the effectiveness and safety of these two surgical methods in the treatment of acute subdural hematoma,in the first part of this study,patients with acute subdural hematoma undergoing decompressive craniectomy were analyzed for risk factors of mortality,and the effectiveness of decompressive craniectomy for acute subdural hematoma was evaluated.In the second part of this study,the Chinese and English literatures on the effectiveness of decompressive craniectomy and craniotomy for acute subdural hematoma have been systematically collected and we use it for a meta-analysis.PART ONE Analysis of Risk Factors for Mortality of Acute Subdural Hematoma after Decompressive Craniectomy ObjectiveTo investigate the effectiveness of decompressive craniectomy for acute subdural hematoma and to analyze the risk factors of mortality.MethodsWe reviewed 165 patients with acute subdural hematoma who underwent decompressive craniectomy from January 2013 to June 2018.according to whether the patients died after operation.They were divided into death group and non-death group.Among them,18 patients died and 147 patients survived.Age,gender,injury mechanism,preoperative GCS score,pupillary response,hematoma thickness,midline shift distance,ratio of hematoma thickness to midline shift distance(H/MS)<1,subarachnoid hemorrhage,brain contusion,epidural hematoma,time from injury to operation,and preoperative hypotension etc.13 factors were used for statistical analysis.Then multivariate logistic regression analysis was performed on statistically significant factors.ResultsUnivariate analysis of age(χ2=9.910,P=0.002),preoperative GCS score(χ2=13.846,P < 0.001),midline shift distance(T=-2.417,P=0.023),H/MS<1(χ2=16.472,P<0.001),brain contusion(χ2=11.604,P=0.001)and time from injury to operation(χ2=12.908,P<0.001)were statistically significant between the two groups,Multivariate logistic Regression analysis showed that age(OR=5.152,P=0.046),preoperative GCS score(OR=14.919,P=0.003),H/MS<1(OR=7.733,P=0.016),brain contusion(OR=15.557,P=0.001)and time from injury to surgery(OR=6.102,P=0.045)were risk factors for mortality of acute subdural hematoma after decompressive craniectomy.ConclusionDecompressive craniectomy can effectively control the increase of intracranial pressure and reduce the mortality.However,patients who with age ≥ 65 years,preoperative GCS score ≤ 8 points,H/MS < 1,brain contusion and injury to surgery > 4 hours has a higher mortality.We should attach great importance to it.PART TWO Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma:A Meta-Analysis ObjectiveTo systematically evaluate the efficacy and safety of craniotomy and decompressive craniectomy in the treatment of acute subdural hematoma.MethodsDatabases including Pub Med,EMbase,the Cochrane Library,Web of science,CNKI,Wan Fang Data,and CBM databases were electronically searched to collect the studies about Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma from inception to June 12,2018.For the two categorical variables,the odds ratio(OR)and its 95% confidence interval(95% CI)are used.Two researchers independently screened the literature,extracted the data,and evaluated the quality of the included studies.The meta-analysis was performed using Stata/SE 12.0 software.ResultsA total of 8 studies were included in the meta-analysis,of which 828 patients underwent craniotomy,and 663 patients underwent decompressive craniectomy.Analysis of preoperative baseline characteristics of two groups of patients.Metaanalysis results showed that the proportion of male patients in the decompressive craniectomy group is higher(72% vs.64%;P = 0.05);Analysis of GCS scores(3-8 points),the proportion of patients in the decompressive craniectomy group were significantly higher(63% vs.48%;P=0.017);Analysis of GCS scores(9-12 points),there was no significant difference between the two groups;Analysis of GCS scores(9-12 points),the proportion of patients in the craniotomy group were higher(16.7% vs.28.3%;P=0.004);No statistically significant difference was found between the groups in terms of proportion of patients with coexisting epidural hematoma;No difference was found between craniotomy versus decompressive craniectomy groups in terms of patients with unilateral mydriasis;In terms of bilateral mydriasis,there were higher cases found in the decompressive craniectomy group(35% vs.18%;P = 0.001);No difference was found between the craniotomy versus craniectomy groups in terms of extracranial injuries.Analysis of postoperative outcomes in the two groups of patients,Meta-analysis results showed that residual subdural hematoma was significantly lower in the craniectomy group than the craniotomy group(22% vs.43%;P = 0.015);There was no difference in the revision rates between the two groups.The odds of a poor outcome at follow-up were found to be higher in the decompressive craniectomy group(60% vs.50%;P=0.003);Similarly,mortality rates was higher in the decompressive craniectomy group than the craniectomy group(45% vs.25%;P=0.002).ConclusionThe safety and efficacy of craniotomy versus decompressive craniectomy in treatment of acute subdural hematoma remains controversial.In this study,compared with the craniotomy group,the Patients in the decompression craniectomy group had higher preoperative injury,higher poor outcomes and higher mortality rates,but the residual subdural hematoma in the decompressive craniectomy group was significantly lower.