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Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy

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Abstract

Objective

Acute subdural hematoma (ASDH) stands as a significant contributor to morbidity after severe traumatic brain injuries (TBI). The primary treatment approach for patients experiencing progressive neurological deficits or notable mass effects is the surgical removal of the hematoma, which can be achieved through craniotomy (CO) or decompressive craniectomy (DC). Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy.

Materials and methods

We conducted a comprehensive literature review, utilizing prominent online databases and manually searching references related to craniotomy and craniectomy for subdural hematoma evacuation up to November 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes.

Results

We included a total of 11 comparative studies in our analysis, encompassing 4269 patients, with 2979 undergoing craniotomy and 1290 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale (GCS) during their initial presentation. Following surgery, the DC group exhibited a significantly reduced rate of residual subdural (P = 0.009). Additionally, the likelihood of a poor outcome during follow-up was lower in the CO group. Likewise, the mortality rate was lower in the CO group compared to the craniectomy group (OR 0.63, 95% CI 0.41–0.98, I2 = 84%, P = 0.04).

Conclusion

Our study found that CO was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome while DC was associated with less likelihood of residual subdural hematoma. Upon further investigation of patient characteristics who underwent into either of these interventions, it was very clear that patients in DC cohort have more serious and low pre-op characteristics than the CO group. Nonetheless, brain herniation and advanced age act as independent factor for predicting the outcome irrespective of the intervention.

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Data availability

Data available within the article and supplementary file. The authors confirm that the data supporting the findings of this study are available within the article and supplementary file.

Abbreviations

ASDH:

Acute subdural hematoma

GCS:

Glasgow coma score

CO:

Craniotomy

DC:

Decompressive craniectomy

ICP:

Intracranial pressure

RCTs:

Randomized control trials

CT:

Computed tomography

MR:

Magnetic resonance

MMA:

Middle meningeal artery

CSDH:

Chronic subdural hematoma

RCT:

Randomized controlled trial

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Authors and Affiliations

  1. Department of Neurosurgery, Jinnah Sindh Medical University, Rafiqi H J Shaheed Road, Karachi, 75510, Pakistan

    Muhammad Ashir Shafique, Muhammad Saqlain Mustafa, Burhanuddin Sohail Rangwala & Abdul Haseeb

  2. Department of Neurosurgery, University of Florida, Gainesville, FL, USA

    Brandon Luke-Wold

  3. Department of Neurosurgery, Shaheed Mohtarma Benazir Bhutto Medical College, Lyari Hospital Rd, Rangiwara Karachi, Karachi, 75010, Pakistan

    Aashish Kumar

  4. Department of Neurosurgery, Rai Medical College, Lahore Road, Sargodha City, 40100, Punjab, Pakistan

    Muhammad Abdullah

  5. Department of Neurosurgery, Liaquat National Hospital and Medical College, National Stadium Rd, Karachi, 74800, Pakistan

    Syed Muhammad Sinaan Ali

  6. Department of Neurosurgery, King Edward Medical University, Lahore, Pakistan

    Javed Iqbal

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Contributions

M.A.S and B.L.W did the conceptualization. S.M.S.A and A.H conducted the literature search and screening. Drafting of the manuscript was done by J.I, M.A, B.S.R, A.K, and M.S.M. M.A.S performed the editing and supervision. All authors have read and agreed to the final version of the manuscript.

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Correspondence to Muhammad Ashir Shafique.

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Shafique, M.A., Mustafa, M.S., Luke-Wold, B. et al. Surgical strategies in acute subdural hematoma: a meta-analysis of decompressive craniectomy vs. craniotomy. Acta Neurochir 166, 121 (2024). https://doi.org/10.1007/s00701-024-06013-1

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