Comparing Decompressive Craniectomy to Craniotomy for Acute subdural Hematoma: A Meta-Analysis of 1,223 Patients

Introduction: Traumatic acute subdural hematoma (ASH) is a medical emergency that requires prompt neurosurgical intervention. Surgical approaches include craniotomy(CO) , and decompressive craniectomy (DC), only in the latter the bone flap is not replaced. However, whether any of these approaches provides better surgical outcomes has not been determined. This meta-analysis aims to address this knowledge gap.

Methods: A systematic search in four databases was conducted until August 28, 2023. We identified studies comparing the efficacy of DC versus CO in patients with ASD. Outcomes included the Extended Glasgow Outcome Scale (GOSE), mortality, adverse events, and reoperation rates. Outcomes were assessed using the risk ratio (RR) using the random-effects model.

Results: Of the 764 published articles, 10 studies (9 cohorts and 1 randomized clinical trial) adding a total of 1223 cases were included. GOSE scores at 6-months were similar among DC and CO (RR=2.28[0.62-8.35],p=0.21). 12-month GOSE scores of 7-8 or “good recovery” which favored the DC-group (RR=1.37[1.05-1.80], p=0.020), but not for low scores 1-2 (RR=0.82[0.59-1.12],p=0.22). Mortality rates were similar among both groups at 30-days (RR=0.77[0.40-1.49],p=0.44), 6-months (RR=0.90[0.57-1.41],p=0.64), and at 1-year (RR=0.77[0.40-1.49],p=0.44). Procedure-related adverse events (RR=0.78[0.37-1.65],p=0.51) , including intracranial hematoma(RR=0.92[0.55-1.55],p=0.76) , were similar among interventions. Reoperation rates favored the CO-group (RR=0.68[0.46-1.00],p=0.05)

Conclusion : The present meta-analysis aligns with previous findings described in the literature as well as the first clinical trial. DC and CO may provide similar outcomes for patients with ASH. However, 12-month GOSE scores indicating "good recovery" might favor DC. Mortality rates, and procedure-associated adverse events, including intracranial hematoma, were similar among both surgical strategies, possibly indicating similar safety. Interestingly, the need for reoperations was less common in the CO-group. These findings emphasize the need for more clinical trials to draw conclusive evidence.