Surgical Strategies in Acute Subdural Hematoma: A Meta-Analysis of Decompressive Craniectomy vs. Craniotomy

doi:10.21203/rs.3.rs-3335457/v1

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Surgical Strategies in Acute Subdural Hematoma: A Meta-Analysis of Decompressive Craniectomy vs. Craniotomy

https://doi.org/10.21203/rs.3.rs-3335457/v1

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INTRODUCTION

Acute subdural hematoma (SDH) stands as a significant contributor to morbidity after severe traumatic brain injuries. 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 or craniectomy. Nevertheless, the choice between these two procedures remains a subject of ongoing debate and controversy.

METHOD

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 July 2023. Our analysis focused on outcome variables such as the presence of residual subdural hematoma, the need for revision procedures, and overall clinical outcomes.

RESULT

We included a total of 10 comparative studies in our analysis, encompassing 3,933 patients, with 2,734 undergoing craniotomy and 1,199 undergoing craniectomy, meeting the inclusion criteria. Patients who underwent craniectomy displayed significantly lower scores on the Glasgow Coma Scale during their initial presentation. Following surgery, the craniectomy group exhibited a significantly reduced rate of residual subdural hematoma (p = 0.004), with no notable difference in the revision rate. Additionally, the likelihood of a poor outcome during follow-up was lower in the craniotomy group (33.1% vs. 42.7%, p = 0.001). Likewise, the mortality rate was lower in the craniotomy group compared to the craniectomy group, with an odds ratio of 0.65 (95% CI: 0.40-1.07, p = 0.004).

CONCLUSION

The debate over the safety and effectiveness of craniotomy versus decompressive craniectomy for treating acute subdural hematoma (SDH) persists. In our recent investigation, we observed that craniectomy was linked to a more unfavorable clinical presentation and postoperative outcomes when compared to craniotomy. Nonetheless, it is worth noting that craniectomy demonstrated a lower incidence of residual SDH after treatment.

craniotomy

craniectomy

subdural hematoma

decompression

traumatic brain Injury

Intracranial pressure

Acute subdural hematoma (ASDH) is a critical condition often resulting from severe head trauma, and it stands as a leading cause of both disability and mortality(1, 2). The primary recommended intervention for individuals with ASDH, especially when it involves a significant mass effect, is the immediate surgical evacuation of the hematoma(3, 4). However, the decision on which surgical approach to employ remains a subject of ongoing debate. For cases with specific characteristics such as thickness greater than 10 mm, midline shift less than 5 mm, initial Glasgow Coma Score (GCS) less than 9, GCS decline of 2 from admission GCS, or abnormal pupil changes, the surgical evacuation is endorsed by Bullock et al(1).

ASDH is associated with a high mortality rate, ranging from 40 to 60 percent, with functional recovery rates varying from 19 to 45 percent(5–7). The surgical management of ASDH primarily involves two procedures: craniotomy (CO) and decompressive craniectomy (DC). However, determining which procedure offers a superior neurological prognosis following traumatic ASDH has been a focal point of research. We aimed to investigate and compare the outcomes of these surgical methods. Decompressive craniectomy (DC) involves the removal of a bone flap to create space for brain expansion, without immediate replacement of the bone. An expansile duroplasty is often employed to further support brain expansion. This procedure is frequently favored, especially in young patients, to mitigate the risk of rising intracranial pressure (ICP) post-ASDH evacuation. The bone flap is typically reinserted several weeks later during a cranioplasty procedure, which carries its own set of risks and challenges(8, 9).

On the other hand, craniotomy (CO) involves immediate replacement of the bone flap after the removal of the clot. The choice between DC and CO as the optimal surgical treatment for ASDH remains contentious(10, 11). Proponents of DC argue that it provides better control over ICP and postoperative swelling(12, 13). However, this rationale is not universally applicable, as not all patients develop postoperative cerebral edema, and some studies report inconsistent results regarding ICP control(14, 15). Furthermore, DC introduces its own set of complications, notably those associated with cranioplasty(16). In cases of high-energy trauma with GCS8 at admission, many neurosurgeons tend to lean towards decompressive craniectomy, even though it may not be directly linked to an improved survival rate(17). Ultimately, the choice between DC and CO often falls to the discretion of the treating surgeon (1). At present, no established guidelines or consensus exist to dictate the preferred approach.

The indications, benefits, and risks of decompressive craniectomy and craniotomy for ASDH in traumatic brain injury remain subjects of active discussion. To shed light on this matter and to provide a comprehensive assessment of the relative outcomes and complications associated with craniotomy versus decompressive craniectomy for acute SDH, a thorough review and meta-analysis have been conducted.

SEARCH STRATEGY

Electronic Searched was performed using PubMed, Google Scholar, Medline, and Scopus from March 07, 2023, to up to date. The entire MeSH word is contained in a separate file Observe Additional File 1. The MeSH phrases " (Acute Subdural Hematoma) OR (Acute subdural Hematoma) AND (craniotomy) AND (Craniectomy) OR (Decompressive Craniectomy)" were used in the search to ensure the highest level of sensitivity and the inclusion of all studies that were determined to be eligible. The topic (humans) and not the date of publication guided the search criteria and selection of the papers. Similarly, for the data search, only English was used. Previous assessments and the bibliographies of relevant publications were consulted for any research that was discovered to be lacking.

PROTOCOL

The recommended methods for doing systemic reviews and meta-analyses were taken from the Cochrane Handbook of Systemic Review and Intervention, and the PRISMA principles were also used throughout the process.

STUDY SELECTION CRITERIA

The following Criteria were used for inclusion of studies: Studies that included the results of a craniotomy or decompressive craniectomy for an acute subdural hematoma were considered eligible. Studies that showed the use of Craniectomy or Decompressive craniectomy for acute subdural hematoma were also included as a control group. Plans for the research included using quasi-RCTS or randomized control trials (RCTs) on adults. Adult population greater than 18 years was included and other populations were excluded. Similarly, case reports, Case series, and Single arm studies were excluded.

OUTCOME MEASURES

Primary outcomes that were analyzed were whether craniotomy or craniectomy was better in the Acute SDH population having GCS 3–8, GCS 9–12, and GCS 13–15. The secondary outcome assessed was revision rates among the craniotomy and craniectomy groups.

DATA COLLECTION AND SCREENING

Two authors separately chose whether or not to include the abstracts and titles that the search produced for a thorough examination. Studies that were deemed eligible for the systematic review were included. The publication year, author, research caliber, findings, and demographic data( sample size, intervention used, outcome measured) of the subjects were obtained from the included studies.

STATISTICAL ANALYSIS

We utilized Review Manager 5.4.1 to perform a statistical analysis. The same program, Revman 5.4, was used in the initial analysis to examine trial heterogeneity. A random effect model was applied, and considerable between-study heterogeneity was taken into account if I2 was greater than 50%. Both primary and secondary outcomes were reported. The odds ratios (OR) and a 95% confidence interval were used in the study to compare the revision rates of craniotomy against decompressive craniectomy in GCS 3–8, GCS 9–12, and GCS 12–15. The influence of publications was investigated using funnel plots. The outcomes are in Additional File 1.

QUALITY ASSESSMENT AND RISK OF BIAS

According to the most recent Cochrane declaration, the risk of bias was evaluated for each included study by using the OTAWA tool for risk of bias, taking into account a lack of outcome data participant blinding, random sequence generation, outcome assessment, and other potential validity concerns. Studies were assigned low risk, uncertain risk, and high risk for each variable. To assist in settling any differences of opinion, a third author was consulted. To resolve all disagreements, an understanding was reached.

Study Selections

In the initial phase of our study, we conducted a thorough database search across various platforms, including PubMed, Google Scholar, and SCOPUS, which yielded a combined total of 29,881 results. These results underwent a meticulous review process to eliminate duplicate entries, ultimately resulting in a refined pool of 1,069 unique citations. From this curated list, we embarked on a diligent examination of titles and abstracts to determine their relevance to our research inquiry. This stringent screening process led to the exclusion of 112 citations that were found to be unrelated to the specific topic of investigation. Subsequently, the remaining 957 citations were subjected to a comprehensive evaluation of their full papers. Our primary objective was to identify studies containing pertinent data for the comparative analysis of Craniotomy versus Depressive Craniectomy in the context of acute subdural hematoma. Employing this strict inclusion criterion, we identified that 85 studies were not aligned with our research goals and were thus excluded from further analysis. In the end, our final analysis comprised a total of 10 studies that met the rigorous inclusion criteria, thereby providing valuable insights into the subject matter at hand.

Baseline preoperative characteristics

Within the study's patient population, the mean age exhibited a range of years in the decompressive craniectomy group, whereas in the craniotomy group, the mean age ranged from years. Out of the total 10 studies in our pooled analysis 8 of them reported the proportion of males. The proportion of males was significantly lower in the craniotomy group in contrast to the decompressive craniectomy group (OR 0.73, 95% CI 0.56–0.95, I² = 36%, P = 0.02). No significant heterogeneity was present (Fig. 2).

The GCS scale was used as a measurement for the severity of the original traumatic injury. 7 studies reported on the population with the most severe GCS scores, spanning the range of 3 to 8. The patient population was significantly higher in the decompressive craniectomy group compared to the craniotomy group (OR 0.58, 95% CI 0.36–0.94, I² = 67%, P = 0.03). While in the 5 studies that reported GCS scores of about 9–12, there was no difference in the 2 groups (OR 1.61, 95% CI 0.92–2.83, I² = 27.8%, P = 0.1). The 4 studies which had patients with GCS 13–15, there was a significantly lower population in the decompressive craniectomy group in comparison to craniotomy (OR 2.01, 95% CI 1.25–3.23, I² = 0%, P = 0.004) (Fig. 3).

Although there was no statistically significant difference between the groups regarding the percentage of patients with co-existing epidural hematoma (1.1% vs 3.1%, with an odds ratio of 0.45 and a 95% confidence interval of 0.04–4.63), the available data on this variable were limited to only two of the studies included in the analysis (Fig. 4), contributing to an I² value of 33% and a p-value of 0.5. Apart from epidural hematomas, there was just one more study that provided information about intraparenchymal injuries linked to acute subdural hematomas (SDH). Chen et al. observed that out of 102 patients with acute SDH, 42.9% (42 patients) underwent a craniotomy, while 28.3% (60 patients) received treatment through decompressive craniectomy. The comparison of these treatment methods resulted in a p-value of 0.5[1]. Out of the 102 patients, a total of 37 had an intracerebral hematoma in addition. Regardless of whether the intracerebral hematoma was present from the start or developed after the operation, there was no significant difference between the groups in terms of the percentage of patients who underwent a craniotomy or a decompressive craniectomy (31% vs 25%, P = 0.77 for pre-existing hematoma; 11.9% vs 6.7%, P = 0.65 for postoperative hematoma). While the severity of the traumatic injury, as indicated by GCS scores, was linked to a higher likelihood of patients undergoing decompressive craniectomy, the type of surgery did not show a clear correlation concerning acute SDH alone versus SDH associated with intraparenchymal injuries. Chen et al. stated that a greater proportion of patients with a pre-operative intracerebral hematoma received a craniotomy rather than a decompressive craniectomy. However, similar to the two studies that reported concurrent epidural hematomas, there was no statistically significant difference between the craniotomy and decompressive craniectomy groups (31.0% vs 26.7%, P = 0.87) [1].

4 studies had reported patients with unilateral Mydriasis accompanying SDH and those studies also had reported patients with a bilateral Mydriasis along with SDH. In terms of unilateral mydriasis there was statistically no significance shown between the craniotomy versus decompressive craniectomy groups (OR 0.79, 95% CI 0.49–1.26, I² = 0%, P = 0.32). In contrast to patients with bilateral mydriasis where there was a significantly lower population undergoing craniotomy (OR 0.40, 95% CI 0.21–0.76, I² = 26%, P = 0.005) (Fig. 4).

Of the 3 studies that reported Extra cranial injuries, there was an insignificant difference between the two groups of patients who had extra-cranial injuries (OR 0.79, 95% CI 0.05–11.32, I² = 86%, P = 0.86). 5 studies were showing that patients who had obliterated cisterns or third ventricles on CT were less in the craniotomy group. However, on analysis it was proven that this was not significant and there was no difference (OR 0.59, 95% CI 0.31–1.09, I² = 67%, P = 0.09) (Fig. 4).

Outcomes

In our combined analysis of the 2 studies that had reported residual subdural hematoma, there was a significantly lower population in the decompressive craniectomy group (OR 2.43, 95% CI 1.33–4.45, I² = 0%, P = 0.004). A total of 6 studies stated Reoperation for IC hematoma. Our analysis showed that statically there was no difference amongst the groups (OR 1.03, 95% CI 0.57–1.85, I² = 50%, P = 0.92) (Fig. 5).

It was observed on analysis that the chances of poor outcome at follow-up were significantly lower in the population who underwent craniotomy (OR 0.62, 95% CI 0.46–0.82, I² = 5%, P = 0.001). Correspondingly, the same trend was not observed in Morality and there was no observed difference between the 2 groups (OR 0.65, 95% CI 0.40–1.07, I² = 86%, P = 0.09) (Fig. 5).

Publication bias

The funnel plot analysis, upon careful examination, did not exhibit any substantial signs of imbalance. This observation strongly suggests that the findings being presented were not notably impacted by the presence of publication bias. Furthermore, it's noteworthy that the OTAWA SCALE FOR risk of bias assessment tool was meticulously employed in our study, revealing a nuanced evaluation that leans towards a favourable assessment of moderate to low risk of bias in the research conducted.

Surgical surgery is frequently the recommended therapeutic choice for persons suffering from acute subdural hematoma (SDH), with the primary goal of reducing the occurrence and effect of subsequent brain damage (18, 19). Despite these medical measures, the morbidity and fatality rates linked with this illness remain catastrophically high. Craniotomy and decompressive craniectomy are two common surgical procedures. However, there is currently no agreement on the best management technique. As a result, the decision between these two surgical approaches is primarily at the discretion of the attending surgeons.

The reported results for craniotomy and decompressive craniectomy for acute SDH in the extant literature have been inconsistent. Some studies have found that decompressive craniectomy has a greater complication rate, whereas others have found no significant differences. We did an analysis of preoperative variables and outcomes from the available literature to assess the current state of evidence on the surgical therapy of acute SDH. Our findings are consistent with the analysis done using the American NSQIP database, which revealed that 82% of the patients included in our study had a craniotomy, with the remaining minority (18%) undergoing a decompressive craniectomy(20). Some other surveys consistently reveals that the selection between craniotomy and craniectomy is predominantly at the discretion of surgeons, showcasing a liberal approach to their choice of surgical procedure(11, 21). A variety of variables have been found as having an impact on the outcomes of acute subdural hematoma (SDH). Age, the time elapsed between injury and treatment, abnormalities in pupillary response, the initial Glasgow Coma Scale (GCS) score, the duration of elevated intracranial pressure (ICP), and various computed tomography (CT) characteristics such as midline shift, compression of basal cisterns, hematoma size, and systemic issues such as hypoxia and hypotension are among these factors(5, 22–26).

Distinctions occurred from our examination of preoperative and baseline variables in mixed groups of patients having craniotomy and decompressive craniectomy. Decompressive craniectomy patients were more likely to be male, had lower GCS scores (range from 3 to 8), and were more likely to have bilateral mydriasis. The preoperative features of the two groups, those having craniotomy and those receiving craniectomy, were clearly not equal. The much larger proportion of patients with a poor prognosis who choose decompressive craniectomy clearly suggests that the non-randomized observational studies included in our analysis have a built-in bias. This shows that in instances with a poor prognosis, surgeons may be more prone to do decompressive craniectomy. As anticipated, surgeons tend to opt for a decompressive craniectomy procedure when they foresee the possibility of cerebral swelling and challenges in managing intracranial pressure (ICP) in cases with a more severe initial neurological condition. In fact, certain studies have made efforts to account for the initial injury severity and have proposed that outcomes following decompressive craniectomy are not inherently inferior when compared to craniotomy in the context of traumatic brain injuries(25, 27, 28). Our thorough postoperative outcome analysis indicated a significantly greater frequency of residual hematoma in the craniotomy group. Although there was no significant difference in the requirement for revision surgeries, patients with poor outcomes during follow-up were much lower in the craniotomy group. These findings are consistent with predictions, implying that the studies included in this analysis were most likely impacted by the higher initial injury severity reported in patients who eventually had decompressive craniectomy(7). Previous retrospective comparison studies found equal or identical results across the two surgical methods, despite the craniectomy group originally presenting with more serious injuries. As a result, some people believe that decompressive craniectomy is the best choice(7). However, it is important to emphasise that this finding is likely impacted by small sample sizes and insufficient statistical power.

Both craniotomy and decompressive craniectomy surgeries also carry notable postoperative complications, each specific to its respective procedure. In the case of craniotomy, some studies have documented the occurrence of tension pneumocephalus, a condition characterized by the buildup of air within the cranial cavity, leading to mass effect and midline shift. This condition can be radiologically identified as the "Mount Fuji sign" and necessitates immediate medical attention. Additionally, like any surgical procedure, both interventions pose a risk of wound infection after surgery. A comprehensive retrospective analysis conducted in 2017, involving more than 5000 patients, revealed an overall incidence of post-craniotomy intracranial infection at 6.8%(29, 30). Other contributing risk factors for such infections include prior radiation therapy and repeated surgeries(31). Typically, initial signs of infection manifest in the skin and superficial fascia at the incision site. Computed tomography (CT) and magnetic resonance (MR) imaging may show skin thickening and superficial edema, underscoring the importance of correlating these findings with physical examinations to identify developing cellulitis. If not promptly treated, cellulitis can progress to abscess formation. Furthermore, although less frequently reported, complications such as extradural abscesses and subdural empyema can occur. Infections of the bone flap, although relatively rare, pose the risk of meningitis and potential brain damage. Besides cosmetic disfigurement, the necessity for repeated surgeries to remove or replace the bone flap can be not only costly but also increase the risk of further injury and infection. Typically, bone flap infections commence as cellulitis at the surgical site and, if left untreated, may progress over weeks to months following the surgery(32). It's important to acknowledge that some degree of hemorrhage is anticipated in any surgical procedure. When hemorrhages become substantial, they can have clinically significant consequences, leading to signs of clinical deterioration in patients(33, 34). Postsurgical intracranial hemorrhage can manifest in various forms, including subdural or extradural hematomas, intraparenchymal hemorrhages, and cerebellar hemorrhages. Key risk factors for extensive postoperative hemorrhage encompass metabolic syndrome (involving hypertension, diabetes, and coronary artery disease), anticoagulation therapy, and the extent of surgical excision(35–38).

In our current meta-analysis, the question of whether craniotomy or decompressive craniectomy offers higher efficacy and complication rates remains unclear. This is partly owing to the lack of statistical differences reported in numerous outcomes, most notably death, where no changes were discovered despite a large sample size.

LIMITATIONS

Our systematic review highlights the limitations of the current pool of research and highlights the critical need for a well-designed randomized controlled trial. Research of this type should use strict inclusion and exclusion criteria to reduce confounding variables and ensure balanced comparison groups, especially in terms of the severity of the original injury. A large-scale cohort study that is stratified or propensity-matched based on initial Glasgow Coma Scale (GCS) scores and neurological severity might provide useful therapeutic insights.

This issue is of critical importance as decompressive craniectomy involves a subsequent procedure with associated risks and potentially incurs additional hospital costs [15, 16]. This consideration is particularly pertinent given the current trend in healthcare economics towards value-based care.

In conclusion, our comprehensive analysis of the available literature up to July 2023 suggests that the choice between craniotomy and craniectomy for the evacuation of acute subdural hematoma (SDH) remains a complex decision. While craniectomy was associated with a higher likelihood of an unfavorable clinical presentation and postoperative outcomes, it did demonstrate a lower incidence of residual SDH after treatment. These findings highlight the importance of individualized patient assessment and careful consideration of the specific clinical circumstances when determining the surgical approach for acute SDH. Further research and updated data are needed to provide more conclusive insights into the optimal surgical management of this challenging condition.

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Competing interests

The authors declare that they have no competing interests

Authors Contributions

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

Acknowledgments

Not applicable.

Funding

The authors received no extramural funding for the study

Availability of Data and Material

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Table

AUTHOR	YEAR	COUNTRY	DESIGN	CRANIOTOMY NUMBER Males: females	CRANIECTOMY NUMBER Males: females	PATIENTS	OUTCOME
CHEN	2012	TAIWAN	ROS	42 21:21	60 41:19	ASDH, patients with GCS 3-8, epidural hematoma, obliterated cisterns and reoperated for SDH and ICH	DC group had greater mortality
KWON	2016	KOREA	ROS	20 12:8	26 16:10	ASDH, patients with GCS 3-8, mydriasis, extracranial injuries and obliterated cisterns and reoperated for ICH.	CO can be an alternative to DC
LI	2012	UNITED KINGDOM	ROS	36 18:18	49 33:16	ASDH, patients with GCS 3-8, mydriasis, extracranial injuries, and obliterated cisterns and reoperated for SDH.	No significant difference between the two groups
RUSH	2016	UNITED STATES	ROS	1763 1150:613	177 127:50	ASDH,	CO is preferred more than DC
TSERMOULAS	2016	UNITED KINGDOM	ROS	30 22:8	69 57:12	ASDH, mydriasis, extracranial injuries and reoperated for ICH.	No significant difference between the two groups
WOETGAN	2006	GERMANY	ROS	111 N/A	69 N/A	ASDH, patients with GCS 3-8, mydriasis, residual SDH and reoperated for ICH.	No significant difference between the two groups
Ruggeri	2022	ROME	ROS	55 N/A	44 N/A	ASDH,	DC patients had slightly better outcomes
HUTCHINSON	2023	UNITED KINGDOM	RCT	228 178:50	222 179:43	ASDH, patients with GCS 3-8, obliterated cisterns and reoperated for SDH.	DC patients had more wound-related complicationss.
ANIS	2022	N/A	N/A	87 73:14	78 72:6	ASDH, patients had obliterated cisterns and were reoperated for ICH.	Favors CO
AHMED	2021	N/A	N/A	518 395:123	518 387:131	ASDH.	Favors DC

No competing interests reported.

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Surgical Strategies in Acute Subdural Hematoma: A Meta-Analysis of Decompressive Craniectomy vs. Craniotomy

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Abstract

Figures

INTRODUCTION

METHOD

SEARCH STRATEGY

PROTOCOL

STUDY SELECTION CRITERIA

OUTCOME MEASURES

DATA COLLECTION AND SCREENING

STATISTICAL ANALYSIS

QUALITY ASSESSMENT AND RISK OF BIAS

RESULTS

Study Selections

Baseline preoperative characteristics

Outcomes

Publication bias

DISCUSSION

LIMITATIONS

CONCLUSIONS

Declarations

References

Tables

Additional Declarations

Supplementary Files

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