Introduction: Approximately two-thirds of TBI patients undergoing emergency cranial surgery have an acute subdural haematoma (ASDH) evacuated. These haematomas are frequently associated with underlying parenchymal injury which further exacerbates brain swelling. Therefore, even though craniotomy (CR) and evacuation is the established primary treatment for ASDH, leaving the bone flap out [i.e. primary decompressive craniectomy (DC)] is an option.
Methods: All patients who underwent evacuation of a traumatic ASDH from August 2005 to August 2010 were included in this single-centre retrospective review of prospectively collected data. We compared the observed clinical outcomes (assessed by Glasgow Outcome Scale at 6 months) with those predicted by the CRASH-CT prognostic model.
Results: We identified 91 patients (40 CR and 51 DC). The group undergoing DC was younger (median age 45 years in DC vs 59 years in CR, p=0.015) and had a higher proportion of comatose patients (78% in DC vs 39% in CR, p=0.001), significant extracranial injuries (33% in DC vs 3% in CR, p=0.001) and obliterated basal cisterns (59% in DC vs 18% in CR, p=0.001). The mean predicted risk of mortality at 14 days (mean +/- SEM; 0.5 +/- 0.04 in DC vs 0.33 +/- 0.04 in CR, p=0.004) and unfavourable outcome at 6 months (0.76 +/- 0.03 in DC vs 0.65 +/- 0.04 in CR, p=0.016) differed significantly. However, no differences were observed in the 6-month mortality (38% in DC vs 32% in CR; p=0.65) or favourable outcome rate (42% in DC vs 45% in CR; p=0.83). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95% CI: 0.51-1.07) for DC and 0.90 (95% CI: 0.57-1.35) for CR.
Conclusions: Primary DC, in itself, is not detrimental to outcome following ASDH. A randomised trial of primary DC versus CR for patients with ASDH is justified and required.
Patient Care: We are proposing a randomised trial of primary decompressive craniectomy versus craniotomy for patients with Acute Subdural Haematomas.
Learning Objectives: By the conclusion of this session, participants should be able to describe the different options in the management of Acute Subdural Haematomas.
References: The management of patients with intradural post-traumatic mass lesions: a multicenter survey of current approaches to surgical management in 729 patients coordinated by the European Brain Injury Consortium. Compagnone C, Murray GD, Teasdale GM, Maas AI, Esposito D, Princi P, D'Avella D, Servadei F. Neurosurgery. 2005 Dec;57(6):1183-92
Acknowledgements: AGK is supported by a Royal College of Surgeons of England Research Fellowship, an NIHR Academic Clinical Fellowship and a Raymond and Beverly Sackler Studentship. PJH is supported by an Academy of Medical Sciences/Health Foundation Senior Surgical Scientist Fellowship.