Decompressive craniectomy versus craniotomy for acute subdural hematoma

Hutchinson, Peter, Adams, Hadie, Mohan, Midhun, Devi, Bhagavatula, Uff, Christopher, Hasan, Shumaila, Mee, Harry, Wilson, Mark, Gupta, Deepak, Bulters, Diederik, Zolnourian, Ardalan, McMahon, Catherine, Stovell, Matthew, Al-Tamimi, Yahia, Tewari, Manoj, Tripathi, Manjul, Thomson, Simon, Viaroli, Edoardo, Belli, Antonio, King, Andrew, Helmy, Adel, Timofeev, Ivan, Pyne, Sarah ORCID:, Shukla, Dhaval, Bhat, Dhananjaya, Maas, Andrew, Servadei, Franco, Manley, Geoffrey, Barton, Garry, Turner, Carole, Menon, David, Gregson, Barbara and Kolias, Angelos (2023) Decompressive craniectomy versus craniotomy for acute subdural hematoma. New England Journal of Medicine, 388 (24). pp. 2219-2229. ISSN 0028-4793

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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.)

Item Type: Article
Additional Information: Funding Information: Supported by the NIHR Health Technology Assessment Programme (project number 12/35/57). Dr. Hutchinson is supported by a research professorship and senior investigator award from the NIHR, the NIHR Cambridge Biomedical Research Centre, and the Royal College of Surgeons of England. Dr. Kolias is supported by a senior lectureship at the School of Clinical Medicine, University of Cambridge; the Wellcome Trust; and the Royal College of Surgeons of England. The RESCUE-ASDH trial is an “embedded study” linked with the CENTER-TBI project ( ) of the European Brain Injury Consortium. CENTER-TBI was a large-scale collaborative project, supported by the FP7 Program of the European Union (grant number 602150).
Uncontrolled Keywords: emergency medicine,emergency medicine general,head trauma,neurosurgery,neurosurgery general,surgery,surgery general,trauma,medicine(all) ,/dk/atira/pure/subjectarea/asjc/2700
Faculty \ School: Faculty of Medicine and Health Sciences > Norwich Medical School
UEA Research Groups: Faculty of Medicine and Health Sciences > Research Groups > Health Economics
Faculty of Medicine and Health Sciences > Research Groups > Health Services and Primary Care
Faculty of Medicine and Health Sciences > Research Groups > Norwich Clinical Trials Unit
Faculty of Medicine and Health Sciences > Research Groups > Public Health and Health Services Research (former - to 2023)
Faculty of Medicine and Health Sciences > Research Centres > Population Health
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Depositing User: LivePure Connector
Date Deposited: 19 Jun 2023 14:30
Last Modified: 19 Oct 2023 03:37
DOI: 10.1056/NEJMoa2214172


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