Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma.
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Hutchinson Peter J, Adams Hadie, Mohan Midhun, Devi Bhagavatula I, Uff Christopher, Hasan Shumaila, Mee Harry, Wilson Mark H, Gupta Deepak K, Bulters Diederik, Zolnourian Ardalan, McMahon Catherine J, Stovell Matthew G, Al-Tamimi Yahia Z, Tewari Manoj K, Tripathi Manjul, Thomson Simon, Viaroli Edoardo, Belli Antonio, King Andrew T, Helmy Adel E, Timofeev Ivan S, Pyne Sarah, Shukla Dhaval P, Bhat Dhananjaya I, Maas Andrew R, Servadei Franco, Manley Geoffrey T, Barton Garry, Turner Carole, Menon David K, Gregson Barbara, Kolias Angelos G, British Neurosurgical Trainee Research Collaborative, NIHR Global Health Research Group on Acquired Brain and Spine Injury, and RESCUE-ASDH Trial Collaborators, RESCUE-ASDH Trial Collaborators
Аннотация
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.).