Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: Systematic Review and Meta-Analysis

Craniotomy versus Decompressive Craniectomy in Acute Subdural Hematoma Management: A Systematic Review and Meta-Analysis

BACKGROUND

 This study aimed to compare the clinical outcomes of decompressive craniectomy (DC) and craniotomy in treating acute subdural hematoma (ASDH) to provide a more precise assessment of the procedures' outcomes.

METHODS

 We searched for relevant articles in PubMed, Web of Science, Embase, Scopus, and Cochrane till August 2023, including cohort studies and randomized controlled trials comparing craniotomy and DC for ASDH. The analysis was conducted using "Review Manager" software, using the risk ratio along with a 95% confidence interval (CI) for categorical data, whereas continuous data were analyzed using the mean difference (MD) and 95% CI.

RESULTS

 Our analysis included 13 studies with a total of 4,689 patients, of whom 1,910 (40.7%) underwent DC and 2,779 (59.3%) underwent craniotomy. The results revealed a statistically significant difference in favor of craniotomy concerning good recovery in delayed GOS (risk ratio [RR] = 1.42; 95% CI [1.12, 1.81]), postoperative mortality (RR = 0.81; 95% CI [0.71, 0.94]), mortality at last follow-up (RR = 0.75; 95% CI [0.62, 0.91]), and hospital stay (MD = -3.71; 95%CI [-5.82, -1.60]). A nonsignificant difference (RR = 1.06; 95% CI [0.52, 2.17]; p = 0.87) was found between the two interventions concerning seizures.

CONCLUSION

 Despite craniotomy's favorable clinical outcomes and mortality rates, the significant baseline differences between DC and craniotomy make these data inconclusive. To establish solid evidence regarding the use of DC versus craniotomy in ASDH, it is necessary to conduct well-controlled randomized studies with large sample sizes.

Surgical Management of Acute Subdural Hematoma: A Meta-Analysis

BACKGROUND AND OBJECTIVE

Traumatic acute subdural hematoma (ASDH) is a medical emergency that requires prompt neurosurgical intervention. Urgent surgical evacuation may be performed with craniotomy (CO) and decompressive craniectomy (DC). However, a meta-analysis evaluating confounders, pooled functional outcomes, and mortality analyses at different time points has not been performed.

METHODS

A systematic search was conducted until August 28, 2023. We identified studies performing ASDH evacuation with CO or DC. Outcomes included Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), GOS-Extended, mortality, procedure-related complications, and reoperation. Variables were assessed using risk ratio (RR) and mean difference.

RESULTS

Among 684 published articles, we included the Randomized Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation of ASDH (RESCUE-ASDH) trial, 4 propensity score-matched (PSM) cohorts, and 13 observational cohort studies. A total of 8886 patients underwent CO or DC. GCS at admission in unmatched cohorts was significantly worse in the DC group (mean difference = 2.20 [95% CI = 1.86-2.55], P < .00001). GOS-Extended scores were similar among CO and DC (RR = 1.10 [95% CI = 0.85-1.42], P = .49), including the RESCUE-ASDH trial. GOS at the last follow-up in unmatched cohorts significantly favored CO (RR = 1.66 [95% CI = 1.02-2.70], P = .04). Similarly, while short-term mortality favored CO over DC (RR = 0.69 [95% CI = 0.51-0.93], P = .02), both the RESCUE-ASDH trial and the PSM-cohorts yielded similar mortality rates among groups (P > .05). Mortality at the last follow-up in unmatched patients favored CO (RR = 0.60 [95% CI = 0.47-0.77], P < .0001). Procedure-related complications (RR = 0.74 [0.50-1.09], P = .12) and reoperation rates (RR = 0.74 [0.50-1.09], P = .12) were similar.

CONCLUSION

Patients with ASDH undergoing DC across unmatched cohorts had a worse GCS at admission. Although ASDH mortality was lower in the CO group, these findings are derived from unmatched cohorts, potentially confounding previous analyses. Notably, population-matched studies, such as the RESCUE-ASDH trial and PSM cohorts, showed similar effectiveness in mortality and functional outcomes between CO and DC. Reoperation and complication rates were comparable among surgical approaches. Considering the prevalence of unmatched cohorts, our findings highlight the need of future clinical trials to validate the findings of the RESCUE-ASDH trial.

Decompressive craniectomy in trauma: What you need to know

ABSTRACT

Decompressive craniectomy (DC) is a surgical procedure in which a large section of the skull is removed, and the underlying dura mater is opened widely. After evacuating a traumatic acute subdural hematoma, a primary DC is typically performed if the brain is bulging or if brain swelling is expected over the next several days. However, a recent randomized trial found similar 12-month outcomes when primary DC was compared with craniotomy for acute subdural hematoma. Secondary removal of the bone flap was performed in 9% of the craniotomy group, but more wound complications occurred in the craniectomy group. Two further multicenter trials found that, whereas early neuroprotective bifrontal DC for mild to moderate intracranial hypertension is not superior to medical management, DC as a last-tier therapy for refractory intracranial hypertension leads to reduced mortality. Patients undergoing secondary last-tier DC are more likely to improve over time than those in the standard medical management group. The overall conclusion from the most up-to-date evidence is that secondary DC has a role in the management of intracranial hypertension following traumatic brain injury but is not a panacea. Therefore, the decision to offer this operation should be made on a case-by-case basis. Following DC, cranioplasty is warranted but not always feasible, especially in low- and middle-income countries. Consequently, a decompressive craniotomy, where the bone flap is allowed to "hinge" or "float," is sometimes used. Decompressive craniotomy is also an option in a subgroup of traumatic brain injury patients undergoing primary surgical evacuation when the brain is neither bulging nor relaxed. However, a high-quality randomized controlled trial is needed to delineate the specific indications and the type of decompressive craniotomy in appropriate patients.

Indications and scientific support for supratentorial unilateral decompressive craniectomy for different subgroups of patients: A scoping review

CONTEXT

Even though supratentorial unilateral decompressive craniectomy (DC) has become the gold standard neurosurgical procedure aiming to provide long term relief of intractable intracranial hypertension, its indication has only been validated by high-quality evidence for traumatic brain injury and malignant middle cerebral artery infarction. This scoping review aims to summarize the available evidence regarding DC for these two recognized indications, but also for less validated indications that we may encounter in our daily clinical practice.

MATERIALS AND METHODS

A scoping review was conducted on Medline / Pubmed database from inception to present time looking for articles focused on 7 possible indications for DC indications. Studies' level of evidence was assessed using Oxford University level of evidence scale. Studies' quality was assessed using Newcastle-Ottawa scale for systematic reviews of cohort studies and Cochrane Risk of Bias Tool for randomized controlled trials.

RESULTS

Two randomized trials (level 1b) reported the possible efficacy of unilateral DC and the mitigated efficiency of bifrontal DC in the trauma setting. Five systematic reviews meta-analyses (level 2a) supported DC for severely injured young patients with acute subdural hematoma probably responsible for intraoperative brain swelling, while one randomized controlled trial (level 1b) showed comparable efficacy of DC and craniotomy for ASH with intraoperative neutral brain swelling. Three randomized controlled trials (level 1b) and two meta-analyses (level 1a and 3a) supported DC efficacy for malignant ischemic stroke. One systematic review (level 3a) supported DC efficacy for malignant meningoencephalitis. One systematic review meta-analysis (level 3a) supported DC efficacy for malignant cerebral venous thrombosis. The mitigated results of one randomized trial (level 1b) did not allow to conclude for DC efficacy for intracerebral hemorrhage. One systematic review (level 3a) reported the possible efficacy of primary DC and the mitigated efficacy of secondary DC for aneurysmal subarachnoid hemorrhage. Too weak evidence (level 4) precluded from drawing any conclusion for DC efficacy for intracranial tumors.

CONCLUSION

To date, there is some scientific background to support clinicians in the decision making for DC for selected cases of severe traumatic brain injury, acute subdural hematoma, malignant ischemic stroke, malignant meningoencephalitis, malignant cerebral venous thrombosis, and highly selected cases of aneurysmal subarachnoid hemorrhage.

Comparison of Decompressive Craniectomy Versus Craniotomy for Evacuation of Subdural Hemorrhage: A Systematic Review and Meta-Analysis

INTRODUCTION

Acute subdural hemorrhage (ASDH) from traumatic brain injury is a life-threatening situation, often requiring surgical intervention. This meta-analysis is done to update the literature regarding the choice of procedure for the treatment of ASDH.

METHODS

PubMed, Scopus, and Cochrane were searched from the year 2000 up to September 2023. Randomized controlled trials and observational studies were included. The odds ratio with 95% confidence interval (CI) mean difference and standardized mean difference were calculated for dichotomous and continuous outcomes, respectively.

RESULTS

A total of 14 studies comprising 4686 patients were included in the analysis. Pooled Glasgow Outcome Scale/Extended Glasgow Outcome Scale scores were compared based on their means, with the craniotomy (CO) group having better mean scores than decompressive craniectomy (DC) (standardized mean difference -0.37, 95% CI -0.68 to -0.06, P = 0.02). The risk for poor outcomes was statistically greater in the DC group compared to the CO group (1.32, 95% CI 1.05-1.66, P value = 0.02). There were fewer residual subdural hematoma cases in the DC group as compared to CO (odds ratio 0.40, 95% CI 0.22-0.73, P value < 0.005).

CONCLUSIONS

Our meta-analysis showed that the ASDH patients had better functional outcomes when treated with CO as compared to DC. However, there were fewer odds of residual subdural hematoma with DC.

Comparison of craniotomy and decompressive craniectomy for acute subdural hematoma: a meta-analysis of comparative study

BACKGROUND

Acute subdural hematoma (ASDH) necessitates urgent surgical intervention. Craniotomy (CO) and decompressive craniectomy (DC) are the two main surgical procedures for ASDH evacuation. This meta-analysis is to compare the clinical outcomes between the CO and DC procedures.

MATERIALS AND METHODS

The authors performed a meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C513 , Supplemental Digital Content 2, http://links.lww.com/JS9/C514 ) Statement protocol and assessing the methodological quality of systematic reviews (AMSTAR) (Supplemental Digital Content 3, http://links.lww.com/JS9/C515 ) guideline. The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Comparative studies reporting the outcomes of the CO and DC procedures in patients with ASDH were included.

RESULTS

A total of 15 articles with 4853 patients [2531 (52.2%) receiving CO and 2322 (47.8%) receiving DC] were included in this meta-analysis. DC was associated with higher mortality [31.5 vs. 40.6%, odds ratio (OR)=0.58, 95% CI: 0.43-0.77] and rate of patients with poorer neurological outcomes (54.3 vs. 72.7%; OR=0.43, 95% CI: 0.28-0.67) compared to CO. The meta-regression model identified the comparability of preoperative severity as the only potential source of heterogeneity. When the preoperative severity was comparable between the two procedures, the mortality (CO 35.5 vs. DC 38.1%, OR=0.80, 95% CI: 0.62-1.02) and the proportion of patients with poorer neurological outcomes (CO 64.8 vs. DC 66.0%; OR=0.82, 95% CI: 0.57-1.16) were both similar. Reoperation rates were similar between the two procedures (CO 16.1 vs. DC 16.0%; OR=0.95, 95% CI: 0.61-1.48).

CONCLUSION

Our meta-analysis reveals that DC is associated with higher mortality and poorer neurological outcomes in ASDH compared to CO. Notably, this difference in outcomes might be driven by baseline patient severity, as the significance of surgical choice diminishes after adjusting for this factor. Our findings challenge previous opinions regarding the superiority of CO over DC and underscore the importance of considering patient-specific characteristics when making surgical decisions. This insight offers guidance for surgeons in making decisions tailored to the specific conditions of their patients.

Comparison of Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: A Systematic Review and Meta-Analysis

OBJECTIVE

Acute subdural hematoma (ASDH) is a common critical neurosurgical condition, often requiring immediate surgical intervention. Craniotomy and decompressive craniectomy are the 2 mainstay surgical approaches. This comprehensive review and meta-analysis aims to summarize the existing evidence and compare the outcomes of these 2 procedures.

METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, and CINAHL electronic databases were searched for relevant studies, published between inception of databases till June 2023. Eligible studies reported data of patients diagnosed with ASDH who underwent craniotomy or decompressive craniectomy for ASDH. Outcome measures included the Glasgow Coma Scale score, residual subdural hematoma, requirement of revision surgery, poorer outcomes, and mortality. Data were presented as pooled odds ratios with 95% confidence intervals. Quality assessment and risk of bias were performed for each study.

RESULTS

Fourteen studies with a total of 3095 patients were included. The results showed that patients who underwent craniotomy had significantly lower mortality, lower odds of poorer outcomes, and a higher rate of residual subdural hematoma, compared to patients who underwent decompressive craniectomy. There was no significant difference in the requirement of revision surgery between the 2 groups. Heterogeneity was high for most outcomes, and the quality of evidence ranged from moderate to low.

CONCLUSION

Our findings suggest that craniotomy is associated with better clinical outcomes and lower mortality compared to decompressive craniectomy for ASDH, but a higher rate of residual subdural hematoma. Further high-quality randomized controlled trials are needed to validate our findings.

Decompressive craniectomy versus craniotomy for acute subdural hematoma: Updated meta-analysis of real-world clinical outcome after RESCUE-ASDH trial

INTRODUCTION

The Randomized Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation of Acute Subdural Hematoma trial found that disability and quality-of-life outcomes were similar between craniotomy and decompressive craniectomy for traumatic acute subdural hematoma (ASDH), contrasting previous literature. This meta-analysis aimed to validate the applicability of RESCUE-ASDH results using real-world data in ASDH patients.

METHODS

We searched Chocrane, Embase, and MEDLINE for relevant articles reporting clinical outcomes of craniotomy and decompressive craniectomy. Meta-analysis used R software (Ross Ihaka and Robert Gentleman at the University of Auckland, New Zealand) with the restricted maximum likelihood method for random-effects meta-analyses, presenting odds ratios (ORs) and 95% confidence intervals (CIs) with Hartung-Knapp-Sidik-Jonkman adjustment for heterogeneity.

RESULTS

Besides RESCUE-ASDH, five retrospective studies were included, spanning 2006 to 2016. A total of 961 patients with traumatic ASDH were included in this study (craniotomy, 467; decompressive craniotomy, 494). The pooled analysis of retrospective studies showed no significant difference in poor clinical outcomes between the two groups (OR, 0.59; 95% CI, 0.32-1.10). These findings align with the RESCUE-ASDH trial (OR, 0.84; 95% CI, 0.58-1.23). Mortality rate was significantly higher in patients undergoing craniectomy in pooled result of retrospective studies (OR, 0.59; 95% CI, 0.32-1.10). In RESCUE-ASDH trial, reoperation rate was higher in the craniotomy group, but the pooled result of retrospective did not show significant difference between the craniotomy and craniectomy group.

CONCLUSION

This real-world evidence confirms the RESCUE-ASDH trial results. Both craniotomy and decompressive craniectomy yielded similar disability and quality-of-life outcomes for traumatic ASDH patients.

LEVEL OF EVIDENCE

Systematic Review/Meta-Analysis; Level III.

A ten-year retrospective analysis of decompressive craniectomy or craniotomy after severe brain injury and its implications for donation after brain death

Craniotomy or decompressive craniectomy are among the therapeutic options to prevent or treat secondary damage after severe brain injury. The choice of procedure depends, among other things, on the type and severity of the initial injury. It remains controversial whether both procedures influence the neurological outcome differently. Thus, estimating the risk of brain herniation and death and consequently potential organ donation remains difficult. All patients at the University Hospital Münster for whom an isolated craniotomy or decompressive craniectomy was performed as a treatment after severe brain injury between 2013 and 2022 were retrospectively included. Proportion of survivors and deceased were evaluated. Deceased were further analyzed regarding anticoagulants, comorbidities, type of brain injury, potential and utilized donation after brain death. 595 patients were identified, 296 patients survived, and 299 deceased. Proportion of decompressive craniectomy was higher than craniotomy in survivors (89% vs. 11%, p < 0.001). Brain death was diagnosed in 12 deceased and 10 donations were utilized. Utilized donations were comparable after both procedures (5% vs. 2%, p = 0.194). Preserved brain stem reflexes as a reason against donation did not differ between decompressive craniectomy or craniotomy (32% vs. 29%, p = 0.470). Patients with severe brain injury were more likely to survive after decompressive craniectomy than craniotomy. Among the deceased, potential and utilized donations did not differ between both procedures. This suggests that brain death can occur independent of the previous neurosurgical procedure and that organ donation should always be considered in end-of-life decisions for patients with a fatal prognosis.

Comparing surgical outcomes: Craniotomy versus decompressive craniectomy in acute subdural hematoma - A systematic review and meta-analysis

Introduction

Acute subdural hematomas (SDH) pose a significant health risk, often resulting from traumatic head injuries. The choice between surgical interventions, craniotomy, and decompressive craniectomy, remains a subject of debate. This meta-analysis aims to compare outcomes and guide clinical decision-making.

Methods

Following PRISMA guidelines, a comprehensive literature search was conducted in databases such as Ovid Medline, PubMed, and Cochrane, up to December 2023. Selection criteria included studies comparing craniotomy and decompressive craniectomy for acute SDH. Data extraction utilized the Newcastle-Ottawa Quality Assessment Tool, and statistical analysis employed the random-effects model.

Results

The meta-analysis included 17 studies and 6848 patients. Craniotomy demonstrated a significant reduction in mortality rates (RR 0.80, 95% CI 0.73-0.89, P < 0.0001). GCS scores favored craniotomy for severe cases. GOS outcomes showed a trend favoring craniotomy, particularly in good recovery (RR 1.34, 95% CI 1.04-1.74, P = 0.03). Additional factors explored included co-existing sub-epidural hematoma, mydriasis, extracranial injuries, residual SDH, revision rates, and intracranial pressure.

Conclusion

The meta-analysis suggests that craniotomy may be a favorable surgical strategy for acute SDH, displaying a significant decrease in mortality rates and a lower risk of raised intracranial pressure. However, the nuanced nature of outcomes emphasizes the need for a tailored approach, considering broader clinical contexts. Future research should address limitations and provide a basis for well-informed clinical decision-making.

Cost-effectiveness of craniotomy versus decompressive craniectomy for UK patients with traumatic acute subdural haematoma

OBJECTIVE

To estimate the cost-effectiveness of craniotomy, compared with decompressive craniectomy (DC) in UK patients undergoing evacuation of acute subdural haematoma (ASDH).

DESIGN

Economic evaluation undertaken using health resource use and outcome data from the 12-month multicentre, pragmatic, parallel-group, randomised, Randomised Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation-ASDH trial.

SETTING

UK secondary care.

PARTICIPANTS

248 UK patients undergoing surgery for traumatic ASDH were randomised to craniotomy (N=126) or DC (N=122).

INTERVENTIONS

Surgical evacuation via craniotomy (bone flap replaced) or DC (bone flap left out with a view to replace later: cranioplasty surgery).

MAIN OUTCOME MEASURES

In the base-case analysis, costs were estimated from a National Health Service and Personal Social Services perspective. Outcomes were assessed via the quality-adjusted life-years (QALY) derived from the EuroQoL 5-Dimension 5-Level questionnaire (cost-utility analysis) and the Extended Glasgow Outcome Scale (GOSE) (cost-effectiveness analysis). Multiple imputation and regression analyses were conducted to estimate the mean incremental cost and effect of craniotomy compared with DC. The most cost-effective option was selected, irrespective of the level of statistical significance as is argued by economists.

RESULTS

In the cost-utility analysis, the mean incremental cost of craniotomy compared with DC was estimated to be -£5520 (95% CI -£18 060 to £7020) with a mean QALY gain of 0.093 (95% CI 0.029 to 0.156). In the cost-effectiveness analysis, the mean incremental cost was estimated to be -£4536 (95% CI -£17 374 to £8301) with an OR of 1.682 (95% CI 0.995 to 2.842) for a favourable outcome on the GOSE.

CONCLUSIONS

In a UK population with traumatic ASDH, craniotomy was estimated to be cost-effective compared with DC: craniotomy was estimated to have a lower mean cost, higher mean QALY gain and higher probability of a more favourable outcome on the GOSE (though not all estimated differences between the two approaches were statistically significant).

ETHICS

Ethical approval for the trial was obtained from the North West-Haydock Research Ethics Committee in the UK on 17 July 2014 (14/NW/1076).

TRIAL REGISTRATION NUMBER

ISRCTN87370545.

Comparative efficacy of craniotomy versus craniectomy in surgical management of acute subdural hematoma: A systematic review and meta-analysis

INTRODUCTION

Acute subdural hematoma (ASDH), a predominantly lethal neurosurgical emergency in the settings of traumatic brain injury, requires surgical evacuation of hematoma, via craniotomy or craniectomy. The clinical practices vary, with no consensus over the superiority of either procedure.

AIM

To evaluate whether craniotomy or craniectomy is the optimal approach for surgical evacuation of ASDH.

METHODS

After a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) up to January 2024, to identify relevant studies, a meta-analysis was performed using a random-effects model, and risk ratios were calculated with 95% confidence intervals (CIs). For quality assessment, the Cochrane risk of bias tool and Newcastle-Ottawa Scale were applied.

RESULTS

Out of 2143 potentially relevant studies, 1875 were deemed suitable for screening. Eighteen studies were included in the systematic review. Thirteen studies, in which 1589 patients underwent craniotomy and 1452 patients underwent craniectomy, allowed meta-analysis. Pooled estimates showed that there was no significant correlation of mortality at 6 months (RR 1.14;95 % CI; 0.94-1.38 P = 0.18) and 12 months (RR 1.17; 95 % CI; 0.84-1.63 P = 0.36) with the two surgical modalities. A positive association was observed between improved functional outcomes at 6-months and craniotomy (RR 0.76; 95 % CI; 0.62-0.93 P = 0.008), however, no significant difference was observed between the two treatment groups at 12 months follow-up (RR 0.89; 95 % CI; 0.72-1.09 P = 0.26). Craniotomy reported a significantly higher proportion of patients discharged to home (RR 0.63; 95 % CI; 0.49-0.83 P = 0.0007), whereas incidence of residual subdural hematoma was significantly lower in the craniectomy group (RR 0.70; 95 % CI; 0.52-0.94 P = 0.02).

CONCLUSION

Craniectomy is associated with poor clinical outcomes. However, with long-term follow-up, no difference in mortality and functional outcomes is observed in either of the patient populations. On account of equivocal evidence regarding the efficacy of craniectomy over craniotomy in the realm of long-term outcomes, utmost preference shall be directed toward craniotomy as it is less invasive and associated with fewer complications.

Delayed Burr Hole Evacuation Compared With Acute Craniotomy for Acute Subdural Hematoma in Older Patients With Low-Energy Trauma

Background Acute subdural hematomas commonly require emergent surgical decompression by craniotomy. There is currently limited research on alternative surgical strategies in the elderly population. This study investigates delayed surgical intervention for stable patients with low-energy trauma presenting with acute subdural hematomas. Methodology In this retrospective chart review, 45 patients over the age of 55 presenting with acute subdural hematomas with a Glasgow Coma Scale score greater than or equal to 13 in the setting of low-energy trauma were selected. Additionally, included patients had a maximal hematoma thickness of >10 mm and/or a midline shift size of >5 mm per the current Brain Trauma Foundations guidelines for surgical intervention of subdural hematomas. The study was performed at a large tertiary care center, with records being examined from 1995 to 2020. Comparison groups were immediate craniotomy (within 24 hours) or delayed burr hole (minimum of 48 hours passing since the initial presentation). Primary outcomes included minor complications, major complications, any complications, and any complications with mortality excluded. There was no significant difference in mortality between the two cohorts. Results The immediate craniotomy group consisted of 16 patients, while the delayed burr hole group consisted of 29 patients. The results demonstrated a statistically significant increase in the incidence of any complication including mortality (relative risk (RR) = 3.17, 95% confidence interval (CI) = 1.71-5.88, p < 0.0001), major complications (RR = 2.33, 95% CI = 1.07-5.07, p = 0.031), and minor complications (RR = 2.42, 95% CI = 1.02-5.74, p = 0.041) in the immediate craniotomy group compared to the delayed burr hole group. Conclusions Our study demonstrates the decreased risk of major and minor complications for delayed burr hole evacuation in stable patients >55 years old presenting with low-energy trauma and subdural hematoma. The results suggest that for this population of patients, it appears to be beneficial to delay surgery if the patient's clinical situation allows.

Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma

INTRODUCTION

The pathogenesis of chronic subdural hematoma (CSDH) has not been completely understood. However, different mechanisms can result in space-occupying subdural fluid collections, one pathway can be the transformation of an original trauma-induced acute subdural hematoma (ASDH) into a CSDH.

MATERIALS AND METHODS

All patients with unilateral CSDH, requiring burr hole trephination between 2018 and 2023 were included. The population was distributed into an acute-to-chronic group (group A, n = 41) and into a conventional group (group B, n = 282). Clinical and radiographic parameters were analyzed. In analysis A, changes of parameters after trauma within group A are compared. In analysis B, parameters between the two groups before surgery were correlated.

RESULTS

In group A, volume and midline shift increased significantly during the progression from acute-to-chronic (p < 0.001, resp.). Clinical performance (modified Rankin scale, Glasgow Coma Scale) dropped significantly (p = 0.035, p < 0.001, resp.). Median time between trauma with ASDH and surgery for CSDH was 12 days. Patients treated up to the 12th day presented with larger volume of ASDH (p = 0.012). Before burr hole trephination, patients in group A presented with disturbance of consciousness (DOC) more often (p = 0.002), however less commonly with a new motor deficit (p = 0.014). Despite similar midline shift between the groups (p = 0.8), the maximal hematoma width was greater in group B (p < 0.001).

CONCLUSION

If ASDH transforms to CSDH, treatment may become mandatory early due to increase in volume and midline shift. Close monitoring of these patients is crucial since DOC and rapid deterioration is common in this type of SDH.

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

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.

A comprehensive systematic review and meta-analysis study in comparing decompressive craniectomy versus craniotomy in patients with acute subdural hematoma

There are two controversial surgery methods which are traditionally used: craniotomy and decompressive craniectomy. The aim of this study was to evaluate the efficacy and complications of DC versus craniotomy for surgical management in patients with acute subdural hemorrhage (SDH) following traumatic brain injury (TBI). We conducted a comprehensive search on PubMed, Scopus, Web of Science, and Embase up to July 30, 2023, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Relevant articles were reviewed, with a focus on studies comparing decompressive craniectomy to craniotomy techniques in patients with SDH following TBI. Ten studies in 2401 patients were reviewed. A total of 1170 patients had a craniotomy, and 1231 had decompressive craniectomy. The mortality rate was not significantly different between the two groups (OR: 0.46 [95% CI: 0.42-0.5] P-value: 0.07). The rate of revision surgery was insignificantly different between the two groups (OR: 0.59 [95% CI: 0.49-0.69] P-value: 0.08). No significant difference was found between craniotomy and decompressive craniectomy regarding unilateral mydriasis (OR: 0.46 [95% CI: 0.35-0.57] P-value < 0.001). However, the craniotomy group had significantly lower rates of non-pupil reactivity (OR: 0.27 [95% CI: 0.17-0.41] P-value < 0.001) and bilateral mydriasis (OR: 0.59 [95% CI: 0.5-0.66] P-value: 0.04). There was also no significant difference in extracranial injury between the two groups, although the odds ratio of significant extracranial injury was lower in the craniotomy group (OR: 0.58 [95% CI: 0.45-0.7] P-value: 0.22). Our findings showed that non-pupil and bilateral-pupil reactivity were significantly more present in decompressive craniectomy. However, there was no significant difference between the two groups regarding mortality rate, extracranial injury, revision surgery, and one-pupil reactivity.

A dynamic nomogram for predicting intraoperative brain bulge during decompressive craniectomy in patients with traumatic brain injury: a retrospective study

OBJECTIVE

The aim of this paper is to investigate the risk factors associated with intraoperative brain bulge (IOBB), especially the computed tomography (CT) value of the diseased lateral transverse sinus, and to develop a reliable predictive model to alert neurosurgeons to the possibility of IOBB.

METHODS

A retrospective analysis was performed on 937 patients undergoing traumatic decompressive craniectomy. A total of 644 patients from Fuzong Clinical Medical College of Fujian Medical University were included in the development cohort, and 293 patients from the First Affiliated Hospital of Shantou University Medical College were included in the external validation cohort. Univariate and multifactorial logistic regression analyses identified independent risk factors associated with IOBB. The logistic regression models consisted of independent risk factors, and receiver operating characteristic curves, calibration, and decision curve analyses were used to assess the performance of the models. Various machine learning models were used to compare with the logistic regression model and analyze the importance of the factors, which were eventually jointly developed into a dynamic nomogram for predicting IOBB and published online in the form of a simple calculator.

RESULTS

IOBB occurred in 93/644 (14.4%) patients in the developmental cohort and 47/293 (16.0%) in the validation cohort. Univariate and multifactorial regression analyses showed that age, subdural hematoma, contralateral fracture, brain contusion, and CT value of the diseased lateral transverse sinus were associated with IOBB. A logistic regression model (full model) consisting of the above risk factors had excellent predictive power in both the development cohort [area under the curve (AUC)=0.930] and the validation cohort (AUC=0.913). Among the four machine learning models, the AdaBoost model showed the best predictive value (AUC=0.998). Factors in the AdaBoost model were ranked by importance and combined with the full model to create a dynamic nomogram for clinical application, which was published online as a practical and easy-to-use calculator.

CONCLUSIONS

The CT value of the diseased lateral transverse is an independent risk factor and a reliable predictor of IOBB. The online dynamic nomogram formed by combining logistic regression analysis models and machine learning models can more accurately predict the possibility of IOBBs in patients undergoing traumatic decompressive craniectomy.

Challenges in Coagulation Management in Neurosurgical Diseases: A Scoping Review, Development, and Implementation of Coagulation Management Strategies

Bleeding and thromboembolic (TE) complications in neurosurgical diseases have a detrimental impact on clinical outcomes. The aim of this study is to provide a scoping review of the available literature and address challenges and knowledge gaps in the management of coagulation disorders in neurosurgical diseases. Additionally, we introduce a novel research project that seeks to reduce coagulation disorder-associated complications in neurosurgical patients. The risk of bleeding after elective craniotomy is about 3%, and higher (14-33%) in other indications, such as trauma and intracranial hemorrhage. In spinal surgery, the incidence of postoperative clinically relevant bleeding is approximately 0.5-1.4%. The risk for TE complications in intracranial pathologies ranges from 3 to 20%, whereas in spinal surgery it is around 7%. These findings highlight a relevant problem in neurosurgical diseases and current guidelines do not adequately address individual circumstances. The multidisciplinary COagulation MAnagement in Neurosurgical Diseases (COMAND) project has been developed to tackle this challenge by devising an individualized coagulation management strategy for patients with neurosurgical diseases. Importantly, this project is designed to ensure that these management strategies can be readily implemented into healthcare practices of different types and with sustainable integration.

Classification of subdural hematomas: proposal for a new system improving the ICD Coding Tools

Background

The International Statistical Classification of Diseases (ICD) classifies subdural hematoma (SDH) as traumatic or non-traumatic. In clinical settings, however, SDH is typically described as either acute or chronic.

Objective

The goal of this study was to assess how the ICD Coding Tools captures the clinical terminology and propose an improved classification that would increase the system's usefulness in administrative, statistical and research applications.

Methods

We performed a retrospective analysis of patients who presented to our center with an ICD diagnostic code for either traumatic or non-traumatic SDH. A qualitative analysis of patients' charts was performed to identify elements relevant to management and prognosis, following which a meeting between expert investigators was held to elaborate a new classification of SDH. Imaging from all patients was then reviewed and cases were reclassified according to our proposed system.

Results

A total of 277 SDH cases were included. Themes documented in the charts included chronicity, etiology, side, and symptoms. We created a new classification which distinguishes acute SDH (aSDH) from membrane-associated SDH (mSDH). aSDH were further divided into traumatic aSDH (taSDH) and non-traumatic aSDH (ntaSDH), while mSDH were divided into acute on chronic (a/cSDH), subacute (sSDH) and chronic (cSDH) categories.

Conclusion

The ICD coding system correctly identifies taSDH and ntaSDH. However, it remains non-specific for mSDH. We propose this new SDH classification system to better capture chronicity and etiology - factors felt to impact management and prognosis.

Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study

Background

Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy.

Methods

We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014-2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582).

Findings

Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12-26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7-1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0-3.4), n = 200]).

Interpretation

We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling.

Funding

Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.

Functional outcome in patients with traumatic or hemorrhagic brain injuries undergoing decompressive craniectomy versus craniotomy and 6-month rehabilitation

Decompressive craniectomy (DC) and craniotomy (CT) to treat increased intracranial pressure after brain injury are common but controversial choices in clinical practice. Studying a large cohort of patients with traumatic brain injury (TBI) and hemorrhagic stroke (HS) on rehabilitation pathways, we aimed to determine the impact of DC and CT on functional outcome/mortality, and on seizures occurrence. This observational retrospective study included patients with either TBI, or HS, who underwent DC or CT, consecutively admitted to our unit for 6-month neurorehabilitation programs between January 1, 2009 and December 31, 2018. Neurological status using Glasgow Coma Scale (GCS), and rehabilitation outcome with Functional Independence Measure, both assessed at baseline and on discharge, post-DC cranioplasty, prophylactic antiepileptic drug use, occurrence of early/late seizures, infectious complications, and death during hospitalization were evaluated and analyzed with linear and logistic regression models. Among 278 patients, DC was performed in 98 (66.2%) with HS, and in 98 (75.4%) with TBI, whilst CT in 50 (33.8%) with HS, and in 32 (24.6%) with TBI. On admission, GCS scores were lower in patients treated with CT than in those with DC (HS, p = 0.016; TBI, p = 0.024). Severity of brain injury and older age were the main factors affecting functional outcome, without between-group differences, but DC associated with worse functional outcome, independently from severity or type of brain injury. Unprovoked seizures occurred post-DC cranioplasty more frequently after HS (OR = 5.142, 95% CI 1.026-25.784, p = 0.047). DC and CT shared similar risk of mortality, which associated with sepsis (OR = 16.846, 95% CI 5.663-50.109, p < 0.0001), or acute symptomatic seizures (OR = 4.282, 95% CI 1.276-14.370, p = 0.019), independently from the neurosurgery procedures. Among CT and DC, the latter neurosurgical procedure is at major risk of worse functional outcome in patients with mild-to-severe TBI, or HS undergoing an intensive rehabilitation program. Complications with sepsis or acute symptomatic seizures increase the risk of death.

Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma

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.).

Burr hole as a management for extra axial hematomas in a low-resource setting

INTRODUCTION AND IMPORTANCE

In a low-resource setting, the availability of neurosurgeons and neurosurgical equipment for neurosurgery has proved to be a challenge for the management of extra-axial hematomas hence general surgeons perform burr hole surgeries for emergencies.

CASE PRESENTATION

We share our experience with three patients who presented with extra-axial hematomas and managed successfully in our institute with craniostomy as the surgical approach.

CLINICAL DISCUSSION

Traumatic brain injury is a major global health burden as it is a leading cause of death among the middle-aged population. Mortality associated with brain injury is highest in low- and middle-income countries. From our experience, we had good outcome in terms of improved Glasgow Coma Scale and overall clinical status in those who underwent burr hole surgery for extra axial hematoma.

CONCLUSION

The need for neurosurgeons in sub-Saharan Africa is high but training comes at a cost hence general surgeons can perform life-saving emergency procedures with good outcomes.

Acute subdural haematoma exacerbates cerebral blood flow disorder and promotes the development of intraoperative brain bulge in patients with severe traumatic brain injury

BACKGROUND

Decompressive craniectomy (DC) is a routine procedure used for the treatment of severe traumatic brain injury (TBI) with concomitant acute subdural haematoma (SDH). However, certain patients are prone to developing malignant brain bulge during DC, which prolongs the operative time and worsens patient outcomes. Previous studies have shown that malignant intraoperative brain bulge (IOBB) may be associated with excessive arterial hyperaemia caused by cerebrovascular system disorders. Through a clinical retrospective analysis and prospective observations, we found that the cerebral blood flow of patients who possessed risk factors manifested high resistance and low flow velocity, which severely affected brain tissue perfusion and resulted in the occurrence of malignant IOBB. In the current literature, rat models of severe brain injury-associated brain bulge have rarely been reported.

METHODS

To gain an in-depth understanding of cerebrovascular changes and the cascade of responses related to brain bulge, we introduced acute SDH into the Marmarou model for the preparation of a rat model of high intracranial pressure (ICP) to simulate the pathological conditions experienced by patients with severe brain injury.

RESULTS

With the introduction of a 400-µL haematoma, significant dynamic changes occurred in ICP, mean arterial pressure, and relative blood perfusion rate of the cerebral cortical vessels. ICP increased to 56.9 ± 2.3 mmHg, mean arterial pressure showed reactive decrease, and the blood flow of cerebral cortical arteries and veins on the non-SDH-affected side decreased to < 10%. These changes could not fully recover even after DC. This resulted in generalised damage to the neurovascular unit and a lag effect to the venous blood reflux, which triggered malignant IOBB formation during DC.

CONCLUSION

An excessive increase in ICP causes cerebrovascular dysfunction and brings about a cascade of damage to brain tissue, which forms the basis for the development of diffuse brain swelling. The subsequent heterogeneous responses of the cerebral arteries and veins during craniotomy may be the main cause of primary IOBB. Clinicians should pay particular attention to the redistribution of CBF to various vessels when performing DC in patients with severe TBI.

Craniotomy or Craniectomy for Acute Subdural Hematoma? Difference in Patient Characteristics and Outcomes at a Tertiary Care Hospital

Objective  This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC). Methods  In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient. Results  Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) ( p  = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) ( p  = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group ( p  = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group ( p  < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups ( p  = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group ( p  = 0.14). Conclusion  The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma.

The Characteristics of Withdrawal or Withholding of Life-Sustaining Treatment in Severe Traumatic Brain Injury: A Single Japanese Institutional Study

OBJECTIVES

There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution.

METHODS

A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST.

RESULTS

Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24 h of admission. The mean duration between WLST and death was 2 days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24 h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST.

CONCLUSIONS

The decisions of almost all WLST cases were made within 24 h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients' religious and cultural backgrounds.

Closure intracranial pressure is an objective intraoperative determinant of the adequacy of surgical decompression in traumatic acute subdural haematoma: a multicentre observational study

PURPOSE

Acute subdural haematoma (ASDH) is associated with severe traumatic brain injury and poor outcomes. Although guidelines exist for the decompression of ASDH, the question of adequate decompression remains unanswered. The authors examined the relationship of intracranial pressure (ICP) on closure with outcomes to determine its utility in the determination of adequate ASDH decompression.

METHODS

A multicentre retrospective review of 105 consecutive patients with ASDH who underwent decompressive surgery was performed. Receiver operating characteristic (ROC) analysis with internal validation was performed to determine an ICP threshold for the division of patients into the inadequate and good ICP groups. Multivariable analyses were performed for both inpatient and long-term outcomes.

RESULTS

An ICP threshold of 10 mmHg was identified with a 91.5% specificity, 45.7% sensitivity, and a positive and negative predictive value of 80.8% and 68.4%. There were 26 patients (24.8%) and 79 patients (75.2%) in the inadequate and good ICP groups, respectively. After adjustment, the inadequate ICP group was associated with increased postoperative usage of mannitol (OR 14.2, p < 0.001) and barbiturates (OR 150, p = 0.001). Inadequate ICP was also associated with increased inpatient mortality (OR 24.9, p < 0.001), and a lower rate of favourable MRS at 1 year (OR 0.08, p = 0.008). The complication rate was similar amongst the groups.

CONCLUSIONS

Closure ICP is a novel, objective, and actionable intraoperative biomarker that correlates with inpatient and long-term outcomes in ASDH. Various surgical manoeuvres can be undertaken to achieve this target safely. Large-scale prospective studies should be performed to validate this ICP threshold.

Primary Decompressive Craniectomy After Traumatic Brain Injury: A Literature Review

Traumatic brain injuries (TBIs) still put a high burden on public health worldwide. Medical and surgical treatment strategies are continuously being studied, but the role and indications of primary decompressive craniectomy (DC) remain controversial. In medically refractory intracranial hypertension after severe traumatic brain injury, secondary decompressive craniectomy is a last resort treatment option to control intracranial pressure (ICP). Randomized controlled studies have been extensively performed on secondary decompressive craniectomy and its role in the management of severe traumatic brain injuries. Indications, prognostic factors, and long-term outcomes in primary decompressive craniectomy during the evacuation of an epidural, subdural, or intracerebral hematoma in the acute phase are still a matter of ongoing research and controversy to this day. Prospective trials have been designed, but the results are yet to be published. In isolated epidural hematoma without underlying brain injury, osteoplastic craniotomy is likely to be sufficient. In acute subdural hematoma (ASDH) with relevant brain swelling and preoperative CT signs such as effaced cisterns, overly proportional midline-shift compared to a relatively small acute subdural hematoma, and accompanying brain contusions as well as pupillary abnormalities, intraventricular hemorrhage, and coagulation disorder, primary decompressive craniectomy is more likely to be of benefit for patients with traumatic brain injury. The role of intracranial pressure monitoring after primary decompressive craniectomy is recommended, but prospective trials are pending. More refined guidelines and hopefully class I evidence will be established with the ongoing trials: randomized evaluation of surgery with craniectomy for patients undergoing evacuation of acute subdural hematoma (RESCUE-ASDH), prospective randomized evaluation of decompressive ipsilateral craniectomy for traumatic acute epidural hematoma (PREDICT-AEDH), and pragmatic explanatory continuum indicator summary (PRECIS).

Does the Timing of the Surgery Have a Major Role in Influencing the Outcome in Elders with Acute Subdural Hematomas?

BACKGROUND

The incidence of traumatic acute subdural hematomas (ASDH) in the elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays no clear role as a predictor. We investigated whether the timing of surgery had a major role in influencing the outcome in these patients.

METHODS

We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 year period in five Italian hospitals. Patients were divided into three surgical timing groups from hospital arrival: ultra-early (within 6 h); early (6-24 h); and delayed (after 24 h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at the Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.

RESULTS

We included 136 patients. About 33% died as a result of the consequences of ASDH and among the survivors, only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting the Glasgow Outcome Scale (GCS), which was on average lower in the ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared to be neither associated with survival nor with functional outcome, also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor.

CONCLUSIONS

An earlier surgery was offered to patients with worse clinical-radiological findings. Additionally, after stratification for GCS, it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.

Magnetic Resonance Imaging Features under Deep Learning Algorithms in Evaluated Cerebral Protection of Craniotomy Evacuation of Hematoma under Propofol Anesthesia

This study aimed to explore the value of magnetic resonance imaging (MRI) features based on deep learning super-resolution algorithms in evaluating the value of propofol anesthesia for brain protection of patients undergoing craniotomy evacuation of the hematoma. An optimized super-resolution algorithm was obtained through the multiscale network reconstruction model based on the traditional algorithm. A total of 100 patients undergoing craniotomy evacuation of hematoma were recruited and rolled into sevoflurane control group and propofol experimental group. Both were evaluated using diffusion tensor imaging (DTI) images based on deep learning super-resolution algorithms. The results showed that the fractional anisotropic image (FA) value of the hind limb corticospinal tract of the affected side of the internal capsule of the experimental group after the operation was 0.67 ± 0.28. The National Institute of Health Stroke Scale (NIHSS) score was 6.14 ± 3.29. The oxygen saturation in jugular venous (SjvO₂) at T4 and T5 was 61.93 ± 6.58% and 59.38 ± 6.2%, respectively, and cerebral oxygen uptake rate (CO₂ER) was 31.12 ± 6.07% and 35.83 ± 7.91%, respectively. The difference in jugular venous oxygen (Da-jvO₂) at T3, T4, and T5 was 63.28 ± 10.15 mL/dL, 64.89 ± 13.11 mL/dL, and 66.03 ± 11.78 mL/dL, respectively. The neuron-specific enolase (NSE) and central-nerve-specific protein (S100β) levels at T5 were 53.85 ± 12.31 ng/mL and 7.49 ± 3.16 ng/mL, respectively. In terms of the number of postoperative complications, the patients in the experimental group were better than the control group under sevoflurane anesthesia, and the differences were substantial (P < 0.05). In conclusion, MRI images based on deep learning super-resolution algorithm have great clinical value in evaluating the degree of brain injury in patients anesthetized with propofol and the protective effect of propofol on brain nerves.

Escalation therapy in severe traumatic brain injury: how long is intracranial pressure monitoring necessary?

Traumatic brain injury frequently causes an elevation of intracranial pressure (ICP) that could lead to reduction of cerebral perfusion pressure and cause brain ischemia. Invasive ICP monitoring is recommended by international guidelines, in order to reduce the incidence of secondary brain injury; although rare, the complications related to ICP probes could be dependent on the duration of monitoring. The aim of this manuscript is to clarify the appropriate timing for removal and management of invasive ICP monitoring, in order to reduce the risk of related complications and guarantee adequate cerebral autoregulatory control. There is no universal consensus concerning the duration of invasive ICP monitoring and its related complications, although the pertinent literature seems to show that the longer is the monitoring maintenance, the higher is the risk of technical issues. Besides, upon 72 h of normal ICP values or less than 72 h if the first computed tomography scan is normal (none or minimal signs of injury) and the neurological exam is available (allowing to observe variations and possible occurrence of new-onset pathological response), the removal of invasive ICP monitoring can be justified. The availability of non-invasive monitoring systems should be considered to follow up patients' clinical course after invasive ICP probe removal or for substituting the invasive monitoring in case of contraindication to its placement. Recently, optic nerve sheath diameter and straight sinus systolic flow velocity evaluation through ultrasound methods showed a good correlation with ICP values, demonstrating their potential role in place of invasive monitoring or in the early weaning phase from the invasive ICP monitoring.

Delayed Treatment of Acute Subdural Hematomas: Retrospective Outcome Analysis of 215 Patients

BACKGROUND: The preferred treatment method for acute subdural hematoma (aSDH) is surgical intervention. AIM: We aimed to show that, regardless of the good results of surgical treatment, conventional delayed treatment might be very useful in some situations and might lead to chronicity of hematoma as well as reduction of surgical intervention scope and reduce risk of anesthesia. It might also give rise to spontaneous resorption of hematoma. METHODS: In the period March 1, 2013–March 1, 2020, we retrospectively examined 215 aSDH patients. The basic result of the outcome analysis was evaluated on the basis of the Glasgow Outcome Scale (GOS) at discharge after 3-month and 6-month follow-up. RESULTS: A total of 215 patients with aSDH and minor or moderate brain injury were examined, while applying conventional delayed treatment, the following results were obtained: large craniotomy was carried out in 123 patients (57.2%) on the 2nd–3rd day of observation, small craniotomy with drainage was applied in 29 patients (13.5%) and spontaneous resorption of subdural hematoma occurred in 63 patients (29.3%). The median score as per the Glasgow Coma Scale at admission to the hospital was 11.4. CONCLUSION: This study showed that conventional delayed treatment applied in patients with aSDH and minor or moderate craniocerebral injury might lead to chronicity and resorption of aSDH. The outcomes as per the GOS scale also showed good data three and 6 months after hospitalization.

Surgical Site Infection After Autologous Cranioplasty for Decompressive Craniectomy in Traumatic Brain Injury: A Retrospective Review of Two Level 1 Trauma Centers

OBJECT

Surgical site infection (SSI) after cranioplasty can result in unnecessary morbidity. This analysis was designed to determine the risk factors of SSI after cranioplasty in patients who received a decompressive craniectomy with the autologous bone for traumatic brain injury (TBI).

METHODS

A retrospective review was performed at two level 1 academic trauma centers for adult patients who underwent autologous cranioplasty after prior decompressive craniectomy for TBI. Demographic and procedural variables were collected and analyzed for associations with an increased incidence of surgical site infection with two-sample independent t tests and Mann Whitney U tests, and with a Bonferroni correction applied in cases of multiple comparisons. Statistical significance was reported with a P value of < 0.05.

RESULTS

A total of 71 patients were identified. The mean interval from craniectomy to cranioplasty was 99 days (7-283), and 3 patients developed SSIs after cranioplasty (4.2%). Postoperative drain placement (P > 0.08) and administration of intrawound vancomycin powder (P = 0.99) were not predictive of infection risk. However, a trend was observed suggesting that administration of prophylactic preoperative IV vancomycin is associated with a reduced infection rate.

CONCLUSIONS

The SSI rate after autologous cranioplasty in TBI patients is lower than previously reported for heterogeneous groups and indications, and the infection risk is comparable to other elective neurosurgical procedures. As such, the authors recommend attempting to preserve native skull and perform autologous cranioplasty in this population whenever possible.

Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases

BACKGROUND

Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time.

OBJECTIVE

To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study.

METHODS

We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018.

RESULTS

The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3).

CONCLUSION

Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.

Transcranial direct current stimulation in patients after decompressive craniectomy: a finite element model to investigate factors affecting the cortical electric field

Objective

To simulate the process of transcranial direct current stimulation (tDCS) on patients after decompressive craniectomy (DC), and to model cortical electric field distributions under different electrode montages, we constructed a finite element model that represented the human head at high resolution.

Methods

Using computed tomography images, we constructed a human head model with high geometrical similarity. The removed bone flap was simplified to be circular with a diameter of 12 cm. We then constructed finite element models according to bioelectrical parameters. Finally, we simulated tDCS on the finite element models under different electrode montages.

Results

Inward current had a linear relationship with peak electric field value, but almost no effect on electric field distribution. If the anode was not over the skull hole (configuration 2), there was almost no difference in electric field magnitude and focality between the circular and square electrodes. However, if the anode was right over the hole (configuration 1), the circular electrodes led to higher peak electric field values and worse focality. In addition, configuration 1 significantly decreased focality compared with configuration 2.

Conclusion

Our results might serve as guidelines for selecting current and electrode montage settings when performing tDCS on patients after DC.

Predictive factors of 30-day mortality in patients with traumatic subdural hematoma

In the present study, we aimed to assess and analyze the predictive factors of 30-day mortality in patients with acute subdural hematoma (ASDH) who underwent surgical intervention after traumatic brain injury (TBI). We conducted a retrospective study, which included a cohort of 135 consecutive patients diagnosed with ASDH who required surgical evacuation. We assessed the demographic and clinical data, the imaging data of the hematoma described by preoperative computed tomography (CT) and the type of neurosurgical intervention for hematoma evacuation via either craniectomy or craniotomy. The patients were followed up for 30 days after head trauma and the occurrence of death was noted. Death was recorded in 63 (46.6%) patients at 30 days after TBI. There was a significant number of deceased patients who underwent craniectomy (71.4%). The Glasgow Coma Scale (GCS) was statistically significantly lower in patients who died (P<0.001), with a cut-off value of ≤12, under which the probability of death increased [AUC 0.830 (95% CI, 0.756-0.889); Se 90.48% (95% CI, 80.4-96.4); Sp 66.7% (95% CI, 54.6-77.3); P<0.001]. The midline shift was statistically significantly higher in deceased patients (P=0.005), with a cut-off value of >7 mm, over which the probability of death increased [AUC 0.637 (95% CI, 0.550-0.718); Se 38.1% (95% CI, 26.1-51.2); Sp 86.1% (95% CI, 75.9-93.1); P=0.003]. There were significantly more deceased patients with intracranial hypertension, brain herniation, brain swelling, intraparenchymal hematoma and cranial fracture. In multivariate analysis only a Glasgow score ≤12 and a midline shift >7 mm were independently linked to mortality. Brain herniation and intraparenchymal hematoma were associated with a higher probability of dying, but the statistical threshold was slightly exceeded. The type of neurosurgery performed for patients with ASDH was not an independent predictive factor for 30-day mortality. However, craniectomy was associated with a higher mortality in patients with ASDH.

The construction of an improved model of acute subdural hematoma in rats

BACKGROUND

To construct a new and improved model of acute subdural hematoma in rats.

NEW METHOD

30 male adult Sprague-Dawley rats(SD rats) were selected and randomly divided into two groups. The traditional model group was based on Miller's model construction method, and the improved model group was based on improved needle, injection site and operation method. The improved model was evaluated by comparing the physiological indicators, behavioral scores, magnetic resonance performance and HE staining results of the two groups of rats.

RESULTS

The physical signs of the rats in the two groups were similar. The survival rate of the improved group was higher than that of the traditional group. The hematoma in the improved model was thicker and concentrated in the ipsilateral side, as revealed by HE staining and MRI. The improved method has less intrusions on the cortex around the injection site and is more stable than the traditional model.

COMPARISON WITH EXISTING METHOD(S)

The operation difficulty of the improved model is reduced and easier. The survival rate of the improved group was higher than that of the traditional group. And the improved model will have more research possibilities.

CONCLUSION

The improved model is based on the traditional model. Although it has some shortcomings, it can also be used in different research fields of the traditional model. The operation for the improved model is easier to perform. And the improved model has more applications in research.

Clinical management and outcome of adult patients with extracorporeal life support device-associated intracerebral hemorrhage-a neurocritical perspective and grading

Intracerebral hemorrhage (ICH) is a devastating complication in patients treated with extracorporeal membrane oxygenation (ECMO) due to respiratory or cardiac issues. Neurosurgical evaluation and management of such cases has only insufficiently been studied. We conducted a retrospective, cohort study of adult patients treated with ECMO between January 2007 and January 2017 in a tertiary healthcare center. Demographics, clinical data, coagulation status, ICH characteristics, and treatment modalities were analyzed. The primary outcome parameter was defined as mortality caused by ICH during ECMO. 525 patients with ECMO therapy were eligible for analysis. An overall incidence for any type of intracranial bleeding of 12.3% was found. Small hemorrhages accounted for 6.4% and acute subdural and epidural hematoma for 1.2%. Twenty-four (4.6%) patients developed ICH, and 11 patients (46%) died due to the ICH. Mortality was significantly higher in patients with larger ICH volumes (86.8 ± 34.8 ml vs 9.9 ± 20.3 ml, p < 0.001), intraventricular hemorrhage (83% vs 8%, p = 0.01), and a fluid level inside the ICH (75% vs 31%, p = 0.04). All patients were classified according to the bleeding pattern on the initial CT scan into 3 types. Patients with type 1 bleeding were statistically more likely to die (p < 0.001). In 15 out of 24 patients (63%), correction of the coagulation status was possible within 12 h after ICH onset. Seven out of 9 patients (78%) without early coagulation correction died compared to 2 out of 15 patients (13%), in whom early coagulation correction was successful (p = 0.01). This is the first study evaluating the course and management of patients experiencing an ICH under ECMO therapy and establishing an ICH classification based on the bleeding patterns. Early correction of the coagulation is of paramount importance in the treatment of these patients.

Random Forest-Based Prediction of Outcome and Mortality in Patients with Traumatic Brain Injury Undergoing Primary Decompressive Craniectomy

BACKGROUND

Various prognostic models are used to predict mortality and functional outcome in patients after traumatic brain injury with a trend to incorporate machine learning protocols. None of these models is focused exactly on the subgroup of patients indicated for decompressive craniectomy. Evidence regarding efficiency of this surgery is still incomplete, especially in patients undergoing primary decompressive craniectomy with evacuation of traumatic mass lesions.

METHODS

In a prospective study with a 6-month follow-up period, we assessed postoperative outcome and mortality of 40 patients who underwent primary decompressive craniectomy for traumatic brain injuries during 2018-2019. The results were analyzed in relation to a wide spectrum of preoperatively available demographic, clinical, radiographic, and laboratory data. Random forest algorithms were trained for prediction of both mortality and unfavorable outcome, with their accuracy quantified by area under the receiver operating curves (AUCs) for out-of-bag samples.

RESULTS

At the end of the follow-up period, we observed mortality of 57.5%. Favorable outcome (Glasgow Outcome Scale [GOS] score 4-5) was achieved by 30% of our patients. Random forest-based prediction models constructed for 6-month mortality and outcome reached a moderate predictive ability, with AUC = 0.811 and AUC = 0.873, respectively. Random forest models trained on handpicked variables showed slightly decreased AUC = 0.787 for 6-month mortality and AUC = 0.846 for 6-month outcome and increased out-of-bag error rates.

CONCLUSIONS

Random forest algorithms show promising results in prediction of postoperative outcome and mortality in patients undergoing primary decompressive craniectomy. The best performance was achieved by Classification Random forest for 6-month outcome.

Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury

Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.

Delayed Surgical Intervention in Acute Subdural Hematoma

Background Current guidelines recommend an acute subdural hematoma (ASDH) with a thickness greater than or equal to 10 mm or a midline shift greater than or equal to 5 mm be evacuated regardless of Glasgow Coma Scale (GCS). A large craniotomy versus craniectomy is the preferred surgical treatment for ASDH. A subset of patients who are typically older if not elderly meet the above criteria but have a monitorable neurologic exam. These patients can be followed and taken in a delayed manner allowing the ASDH to become chronic. The delay in treatment allows for a smaller surgery in regards to size of incision, size of craniotomy, and duration of anesthesia.  Methods Between February 2013 and July 2019, we retrospectively identified 19 patients who underwent delayed evacuation of an ASDH, with the primary outcome being Glasgow Outcome Score (GOS) at discharge and three-month follow-up. Results Eight patients (42%) were female and 11 patients (58%) were male. The median age was 77 years, with a range from 49 to 93 years. Sixteen patients (84%) were 60 years of age or older. Mechanism of injury was a fall for 10 patients (53%). Median number of days from initial evaluation and surgical evacuation was 11 days with a range from 6 to 31 days. Thirteen patients (68%) had a GOS of 4-5 at three-month follow-up. Six patients (32%) had a GOS 1-3 at three-month follow-up. Two mortalities (11%) recorded in the postoperative period. Conclusion Surgically evacuated ASDH in the elderly population is known to carry a significant mortality and morbidity. With close neuromonitoring, delayed intervention in older patients with an ASDH, initially meeting surgical criteria with a good neurologic exam, is a safe practice. Delayed treatment allows for smaller surgery, decreased operative time, and decreased surgical risk which affects older patients even more than younger patients.

Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review

PURPOSE OF REVIEW

The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers.

RECENT FINDINGS

To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.

Outcomes of patients undergoing craniotomy and decompressive craniectomy for severe traumatic brain injury with brain herniation: A retrospective study

The treatment of severe traumatic brain injury (TBI) with brain herniation is challenging because outcomes are often associated with high mortality and morbidity. Our aim was to identity factors contributing to decompressive craniectomy (DC) and evaluate treatment outcomes in patients with severe TBI with brain herniation.In this retrospective study, we analyzed medical records of severe TBI with brain herniation from May 2009 to December 2013. We reviewed their demographic data, mechanism of injury, Glasgow Coma Scale (GCS) score, pupil status, computed tomography findings, surgical treatment methods, time interval between brain herniation and surgery, as well as outcomes. GCS and pupil status are clinical parameters for detecting increase intracranial pressure while brain parenchyma bulged above the inner plate of the skull during operation indicated brain swelling as well as increased intracranial pressure on which basis the decision to perform DC or craniotomy was determined intraoperatively.One hundred ninety-four patients were included in the study. We performed DC in 143 of the patients while 51 of them we performed craniotomy. There were no statistically significant differences in the age, gender, or injury mechanism between the 2 groups. GCS, pupillary dilation, midline shift, hematoma type and timing of surgery were associated with DC. Nevertheless, logistic regression analysis revealed that hematoma type and timing of surgery were significantly associated with favorable DC outcomes (P < .001 and P = .023). Subdural hematoma and timing of surgery >1 hour were both identified as risk factors for DC. Six months after TBI, 34.0% of patients exhibited favorable outcomes. Overall mortality rate was 30.4%. Age, GCS, pupil dilation, hematoma type, and timing of surgery were all associated with patient outcomes. Further logistic regression analysis revealed that, lower GCS, bilateral pupil dilation, timing of surgery >1 hour, and advanced age were independent risk factors for poor outcomes (P = .001, P = .037, P = .028, and P = .001, respectively).Our study revealed that, DC is not mandatory for all TBI patients with brain herniation. Nevertheless, DC decreases mortality rate in severe TBI patients with brain herniation. Subdural hematoma and timing of surgery >1 hour are key indicators for DC. Lower GCS, bilateral pupil dilation, delayed timing of surgery and advance age are indicators of poor outcomes.

Neurocritical Management of Traumatic Acute Subdural Hematomas

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Mortality Outcome of Emergency Decompressive Craniectomy and Craniotomy in the Management of Acute Subdural Hematoma: A National Data Analysis

BACKGROUND

The purpose of the study is to evaluate the in-hospital mortality of patients who presented with acute subdural hematoma (SDH) and underwent emergency decompressive craniectomy (DC) or craniotomy (CO) within 4 hours of hospital arrival.

METHOD

The National Trauma Data Bank (NTDB) dataset of the calendar year of 2007 through 2010 was accessed for the study. All blunt severe head injury patients who presented with acute SDH were included in the study. Severe head injury is defined as a head Abbreviated Injury Scale (AIS) score ≥3 and a Glasgow Coma Scale (GCS) score ≤8. Univariate followed by propensity-matched analyses were performed to compare the two procedure groups: DC and CO.

RESULTS

Out of 2370 patients, 518, (21.9%) patients underwent DC. There were significant differences found in the univariate analysis between the DC and CO groups for median age (38 (IQR: 22.0, 55.0) vs 49 (IQR: 27, 67), P < .001), mechanism of injury (fall: 33.2% vs 50.7%; motor vehicle crashes: 58.3% vs 40.9%, P < .001), and median injury severity score (ISS: 26.0 (IQR: 25, 38) vs 26 (IQR: 25.0, 33.0), P < .001). After propensity score matching and pair-matched analysis, no differences were found with any of the above characteristics. The pair-matched analysis also showed no significant difference in in-hospital mortality (42.7% vs 37.5%, P = .10) between the DC vs CO groups.

CONCLUSION

The overall in-hospital mortality for emergency CO or DC for the evacuation of SDH remains high. The preference of one operative procedure over the other did not impact overall mortality.

Craniectomy size for subdural haematomas and the impact on brain shift and outcomes

BACKGROUND

Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported.

METHOD

A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement.

RESULTS

Thirty-six patients with mean age of 36.1 ± 12.5 (range 16-62) were included, with a median follow-up of 23.5 months (range 2.2-109.6). The median craniectomy size was 88.7 cm² and the median subtemporal decompression was 15.0 mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R² < 0.05).

CONCLUSIONS

This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.

In-hospital mortality and length of hospital stay with craniotomy versus craniectomy for acute subdural hemorrhage: a multicenter, propensity score-matched analysis

OBJECTIVE

The optimal surgical treatment for acute subdural hemorrhage (ASDH) remains controversial. The purpose of this study was to compare outcomes in patients who underwent craniotomy with those in patients who underwent decompressive craniectomy for the treatment of ASDH.

METHODS

Using the Japan Trauma Data Bank, a nationwide trauma registry, the authors identified patients aged ≥ 18 years with ASDH who underwent surgical evacuation after blunt head trauma between 2004 and 2015. Logistic regression analysis was used to estimate a propensity score to predict decompressive craniectomy use. They then used propensity score-matched analysis to compare patients who underwent craniotomy with those who underwent decompressive craniectomy. To identify the potential benefits and disadvantages of decompressive craniectomy among different subgroups, they estimated the interactions between treatment and the subgroups using logistic regression analysis.

RESULTS

Of 236,698 patients who were registered in the database, 1788 were eligible for propensity score-matched analysis. The final analysis included 514 patients who underwent craniotomy and 514 patients who underwent decompressive craniectomy. The in-hospital mortality did not differ significantly between the groups (41.6% for the craniotomy group vs 39.1% for the decompressive craniectomy group; absolute difference -2.5%; 95% CI -8.5% to 3.5%). The length of hospital stay was significantly longer in patients who underwent decompressive craniectomy (median 23 days [IQR 4-52 days] vs 30 days [IQR 7-60 days], p = 0.005). Subgroup analyses demonstrated qualitative interactions between decompressive craniectomy and the patient subgroups, suggesting that patients who were more severely injured (Glasgow Coma Scale score < 9 and probability of survival < 0.64) and those involved in high-energy injuries may be good candidates for decompressive craniectomy.

CONCLUSIONS

The results of this study showed that overall, decompressive craniectomy did not appear to be superior to craniotomy in ASDH treatment in terms of in-hospital mortality. In contrast, there were significant differences in the effectiveness of decompressive craniectomy between the subgroups. Thus, future studies should prioritize the identification of a subset of patients who will possibly benefit from the performance of each of the procedures.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65 years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.

Role of surgical modality and timing of surgery as clinical outcome predictors following acute subdural hematoma evacuation

Background & Objective:

A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma.

Methods:

A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed.

Results:

Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87).

Conclusion:

In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.