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Craniotomy Versus Decompressive Craniectomy for Acute Subdural Hematoma: Systematic Review and Meta-Analysis
Accepted Manuscript Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis Kevin Phan, Justin M. Moore, Christoph Griessenauer, Adam A. Dmytriw, Daniel B. Scherman, Sharaf Sheik-Ali, Nimer Adeeb, Christopher S. Ogilvy, Ajith Thomas, Jeffrey V. Rosenfeld PII:
S1878-8750(17)30336-4
DOI:
10.1016/j.wneu.2017.03.024
Reference:
WNEU 5393
To appear in:
World Neurosurgery
Received Date: 23 November 2016 Revised Date:
6 March 2017
Accepted Date: 7 March 2017
Please cite this article as: Phan K, Moore JM, Griessenauer C, Dmytriw AA, Scherman DB, Sheik-Ali S, Adeeb N, Ogilvy CS, Thomas A, Rosenfeld JV, Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis, World Neurosurgery (2017), doi: 10.1016/ j.wneu.2017.03.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis
Kevin Phan1, Justin M Moore2, Christoph Griessenauer2, Adam A. Dmytriw2, Daniel B
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V. Rosenfeld3
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Scherman1, Sharaf Sheik-Ali1, Nimer Adeeb2, Christopher S. Ogilvy2, Ajith Thomas2, Jeffrey
1. NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney,
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Australia.
2. Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
3. Department of Neurosurgery, Alfred Hospital; Department of Surgery, Monash
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University, Melbourne, Australia.
Keywords: craniotomy; craniectomy; subdural hematoma; decompression; traumatic brain
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injury
Correspondence: Kevin Phan, NeuroSpine Surgery Research Group (NSURG) and
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University of Sydney, Email: [email protected] Conflicts of interest: None declared Funding for this study: None Acknowledgements: None
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ACCEPTED MANUSCRIPT Abstract Introduction Acute subdural hematoma (SDH) is a major cause of morbidity following severe traumatic brain injury. Surgical evacuation of the hematoma, either via craniotomy or craniectomy, is the mainstay of treatment in patients with progressive neurological deficits or significant mass effect. However, the decision between either procedure remains controversial.
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Methods A literature search using major online databases and a manual search of reference on the topic of craniotomy and craniectomy for evacuation of subdural hematoma until September 2016 was performed. The outcome variables were analyzed which included residual SDH, revision rate, and clinical outcome.
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Results
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Six comparison studies, with a total number of 2006 craniotomy and 451 craniectomy patients, fulfilled the inclusion criteria. Patients who underwent craniectomy scored significantly lower on the Glasgow Coma Scale at the time of initial presentation. Postoperatively, the rate of residual SDH was significantly lower in the craniectomy group compared to the craniotomy group (p = 0.004), with no difference in the revision rate. The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs 60.1%, p = 0.004). Similarly, mortality rates was lower in the craniotomy group compared to craniectomy (p = 0.004). Conclusion
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The safety and efficacy of craniotomy versus decompressive craniectomy in treatment of acute SD remain controversial. In the current study, craniectomy was associated with worse clinical presentation and postoperative outcome compared to craniotomy. However, craniectomy was associated with lower rate of residual SDH following treatment.
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ACCEPTED MANUSCRIPT Introduction Acute subdural hematoma (SDH) occurs in up to one-third of patients with severe traumatic brain injury [1, 2]. Surgical evacuation is the mainstay of treatment for acute SDH in patients with progressive neurological deficits, increasing intracranial pressure (ICP), or significant
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mass effect [2-4]. According to the guidelines for surgical management of traumatic brain injury, surgical evacuation of an acute SDH is indicated if the thickness exceeds 10 mm or the midline shift 5 mm regardless of the Glasgow Coma Scale (GCS) score. In patients with a
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GCS less than 9 evacuation may be indicated even for smaller acute SDHs[4]. Acute SDH has been associated with high mortality rate ranging 40-60% and functional recovery ranging
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from 19-45% [5-7], despite rapid transportation and imaging, ICP monitoring, and intensive care management. Two types of procedures are performed for evacuation of acute SDH. Craniotomy involves elevation of a bone flap, removal and clearance of subdural hematoma, followed by replacement of the bone flap. The advantage is that this approach does not require a second procedure, with its inherent risks, to replace the bone flap. The alternative
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surgical procedure is decompressive craniectomy, which also involves elevating a bone flap, hematoma evacuation, and then storage of the bone flap, which provides room to accommodate expansion of edematous cerebral tissue and facilitates ICP management.
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However, this procedure requires a secondary cranioplasty procedure.
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Whether craniotomy or decompressive craniectomy is the preferred approach for treating an acute SDH remains controversial[8]. A number of studies have demonstrated the effectiveness of decompressive craniectomy for acute SDH, where underlying parenchymal injury is thought to contribute to postoperative swelling [9-12]. However, this theoretical advantage is limited by the fact that not all acute SDH patients have postoperative cerebral swelling. Similarly, large studies on craniectomy in the context of ICP control have shown inconsistent results relating to the benefit of the procedure [13, 14]. Decompressive craniectomy has its own set of associated complications, and if the patient survives, there is the additional risk of a subsequent cranioplasty procedure with the potential for a protracted
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ACCEPTED MANUSCRIPT hospital stay related most commonly to surgical site infection of bone flap resorption [15, 16]. While both procedures are performed worldwide, there is currently no clear guidelines or consensus on the choice of procedure and in reality the approach is usually left to the discretion of the surgeon[4]. There appears to be a general tendency for decompressive
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craniectomy to be performed in patients with more severe traumatic brain injury, as these patients are perceived as more likely to develop edema, raised ICP and secondary brain injury, and thus benefit for improved ICP control. While this technique does appear to be superior in decreasing ICP an intensive care unit (ICU) stay length, superior outcomes remain
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far from assured.
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The indications, benefits, and risks of craniotomy and decompressive craniectomy for acute SDH in traumatic brain injury also remain a source of controversy. Therefore a systematic review and meta-analysis was performed to address the relative outcomes and complications
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of craniotomy when compared to decompressive craniectomy for acute SDH.
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ACCEPTED MANUSCRIPT Methods Literature search strategy Electronic searches were performed using Ovid Medline, PubMed, the Cochrane Central Register of Controlled Trials (CCTR), the Cochrane Database of Systematic Reviews
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(CDSR), the ACP Journal Club and the Database of Abstracts of Review of Effectiveness (DARE) from their dates of inception to September 2016. To achieve maximum sensitivity of the search strategy and identify all eligible studies, we combined the terms: “subdural
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hematoma”, “subdural hemorrhage”, “craniotomy”, “craniectomy”, or “decompressive craniectomy”, as either keywords or MeSH terms. The reference lists of all retrieved articles
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were reviewed to enable further identification of potentially relevant studies. All identified articles were systematically assessed using the inclusion and exclusion criteria according to recommended guidelines [17, 18]. Selection criteria
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Eligible studies comparing outcomes of craniotomy and decompressive craniectomy for acute subdural hematoma were included. Single arm studies reporting outcomes of only craniotomy or decompressive craniectomy were excluded from analysis. When institutions published
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duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment at each time
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interval. All publications were limited to those involving human subjects and available in the English language. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. Review articles were omitted because of potential publication bias and duplication of results. Data extraction and critical appraisal All data were extracted from article texts, tables and figures. Two investigators independently reviewed each retrieved article (K.P., D.S.). Discrepancies between the two reviewers were resolved by discussion and consensus with a third reviewer (S.S.). Assessment of risk of bias
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ACCEPTED MANUSCRIPT for each selected study was performed in accordance with the most updated Cochrane statement. The final results were reviewed by the senior investigator. Statistical analysis The odds ratio (OR) was used as a summary statistic. In the present study, both fixed- and
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random-effect models were tested. In the fixed-effects model, it was assumed that treatment effect in each study was the same, whereas in a random-effects model, it was assumed that there were variations between studies. χ2 tests were used to study heterogeneity between the
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trials. The I2 statistic was used to estimate the percentage of total variation across studies, owing to heterogeneity rather than chance, with values greater than 50% considered as
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substantial heterogeneity. The I2 can be calculated as: I2 = 100% × (Q – df)/Q, with Q defined as Cochrane’s heterogeneity statistics and df defined as the degree of freedom. If there was substantial heterogeneity, the possible clinical and methodological reasons for this were explored qualitatively. In the present meta-analysis, the results using the random-effects model were presented to take into account the possible clinical diversity and methodological
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variation between studies. Specific analyses considering confounding factors were not possible because the raw data were not available. All P values were 2-sided. All statistical analysis was conducted with Review Manager Version 5.3.2. (Cochrane Collaboration,
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Software Update, Oxford, United Kingdom).
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ACCEPTED MANUSCRIPT Results A total of 1736 references were identified through six electronic database searches. After exclusion of duplicate or irrelevant references, 216 potentially relevant articles were retrieved. After detailed evaluation of these articles, 23 studies remained for assessment. A
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manual search of the reference lists yielded one new study. After applying the selection criteria, 6 comparative studies [1, 7, 19-22] were selected for analysis (Figure 1). The study characteristics of these trials are summarized in Table 1.
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Baseline preoperative characteristics
The mean age of the patients included in the decompressive craniectomy and craniotomy
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group ranged from 41.2-65.5 years and 47.4-68.9 years, respectively. The proportion of males was reported in 5 of the 6 included studies. There was a significantly lower proportion of males in the craniotomy group compared to decompressive craniectomy cohort (64.7% vs 71.9%, OR 0.67, 95% CI 0.51-0.88, I2=0%, P=0.004), with no significant heterogeneity
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detected (Figure 2).
The severity of the original traumatic injury was measured using the GCS scale. For the most severe GCS scores, ranging 3-8, there was a significantly lower proportion of such patients in
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the craniotomy group compared to decompressive craniectomy (48.1% vs 60.8%, OR 0.48, 95% CI 0.23-0.98, I2=70%, P=0.04) (Figure 3). There was no significant difference noted for
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patients with GCS 9-12 (24.7% vs 19.8%, OR 1.61, 95% CI 0.92-2.83, I2=37%, P=0.10). For patients with GCS 13-15, there was a significantly higher proportion in the craniotomy versus decompressive craniectomy group (28.3% vs 16.7%, OR 2.01, 95% CI 1.25-3.23, I2=0%, P=0.004).
No statistically significant difference was found between the groups in terms of proportion of patients with co-existing epidural hematoma (1.1% vs 3.1%, OR 0.45, 95% CI 0.04-4.63, I2=33%, P=0.50), however this variable was only reported in 2 of the included studies (Figure 4). The lack of statistical significance may be due to the inadequate patient sample sizes and
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ACCEPTED MANUSCRIPT as such, no definitive conclusion can be made with respects to operative management of acute SDH with co-existing epidural hematomas. In addition to epidural hematomas, only one other study reported other intraparenchymal injuries associated with acute SDH. Chen et al. noted that of 102 patients with acute SDH, 42.9% (n=42) of patients underwent a craniotomy while
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28.3% (n=60) of patients were treated with a decompressive craniectomy (P=0.5) [19]. A total of 37 of the 102 patients had an associated intracerebral hematoma. No statistically significant difference was determined between the groups in terms of the proportion of patients that underwent a craniotomy or a decompressive craniectomy regardless of if the intracerebral
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hematoma was originally present (31% vs 25%, P=0.77) or had developed postoperatively (11.9% vs 6.7%, P=0.65). As previously noted, the severity of the traumatic injury measured
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using GCS scores showed that a lower GCS score correlated with a higher proportion of patients undergoing decompressive craniectomy. However, with respect to acute SDH without versus acute SDH associated with intraparenchymal injuries, no correlation with the type of surgery carried out could be determined. Chen et al. noted that a higher percentage of
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patients with a pre-operative intracerebral hematoma underwent a craniotomy compared to a decompresseive craniectomy. However, like the two studies that reported co-existing epidural hematomas, no statistically significant difference was determined between the craniotomy
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and decompressive craniectomy groups (31.0% vs 26.7%, P=0.87) [19]. No difference was found between craniotomy versus decompressive craniectomy groups in
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terms of patients with unilateral mydriasis (23.4% vs 24.9%, OR 0.79, 95% CI 0.49-1.26, I2=0%, P=0.32). In terms of bilateral mydriasis, there were fewer cases found in the craniotomy group (17.7% vs 35.2%, OR 0.40, 95% CI 0.21-0.76, I2=26%, P=0.005). No difference was found between the craniotomy versus craniectomy groups in terms of extra-cranial injuries (17.7% vs 35.2%, OR 0.79, 95% CI 0.05-11.32, I2=0.86, P=0.86%). The proportion of patients with obliterated cisterns or third ventricles on CT was also comparable between craniotomy and craniectomy groups (36.7% vs 54.1%, OR 0.43, 95% 0.13-1.45, I2=77%, P=0.17).
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ACCEPTED MANUSCRIPT Outcomes Residual SDH was significantly lower in the craniectomy group compared to the craniotomy group (44.4% vs 19.6%, OR 2.43, 95% CI 1.33-4.45, I2=0%, P=0.004). Revision rates were similar between craniotomy and craniectomy groups (26.6% vs 33.5%, OR 0.86, 95% CI
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0.50-1.46, I2=15%, P=0.57) (Figure 5).
The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs 60.1%, OR 0.58, 95% CI 0.37-0.90, I2=23%, P=0.02). Similarly, mortality rates
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was lower in the craniotomy group compared to craniectomy (13.9% vs 40.5%, OR 0.41,
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95% CI 0.23-0.76, I2=64%, P=0.004).
Publication bias
Funnel plot for analysis is demonstrated in the Supplementary Figures. No significant asymmetry was detected in the forest plots, suggesting publication bias was not a significant
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influencing factor in the results presented.
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ACCEPTED MANUSCRIPT Discussion Surgical management is often the treatment option of choice for patients suffering from an acute SDH, which aims to reduce the incidence and impact of secondary brain injury [11]. Despite intervention, the morbidity and mortality for this condition remains high. Craniotomy
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and decompressive craniectomy are two common surgical approaches used, however, there is currently no universal consensus regarding the most appropriate management strategy given the lack of level I randomized evidence. Currently, the choice between the two options is
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largely at the surgeons’ discretion. A questionnaire completed by members of the The European Association of Neurosurgical Societies (EANS), NeuroCritical Care Network
Trainees' Association
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(NCCNet), The Society of British Neurological Surgeons (SBNS), and British Neurosurgical (BNTA) in 2011[23], demonstrated that in continental European
countries, 44% of neurosurgeons used decompressive craniectomy in more than half their cases[8] of acute SDH, compared 21% of British and Irish neurosurgeons. By contrast, a study of the National Surgical Quality Improvement Program (NSQIP), a large prospective
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American database, found that craniotomy was performed ten times more often than decompressive craniectomy in these patients [21]. The wide variation in practice between different continents, countries and even within departments is a reflection of the lack of high
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quality evidence and clear guidelines for this condition.
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Outcomes in the literature for craniotomy and decompressive craniectomy for acute SDH have been inconsistent, with some studies suggesting a higher complication rate with decompressive craniectomy whilst other studies suggesting no significant difference. To assess the current state of evidence for surgical management of acute SDH, we pooled preoperative factors and outcomes form the available literature. In agreement with the analysis of the American NSQIP database, we found that 82% of all included patients underwent a craniotomy, while the remaining minority (18%) underwent a decompressive craniectomy.
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ACCEPTED MANUSCRIPT There are multiple factors which are known influence the outcomes of acute SDH, including age, time from injury to treatment, pupillary abnormalities, preoperative GCS, duration of increased ICP, as well as CT features including midline shift, basal cistern compression, the size of the hematoma, and systemic abnormalities such as hypoxia and hypotension[5, 24-32].
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When comparing the preoperative and baseline characteristics of pooled craniotomy versus decompressive craniectomy cohorts, we found that decompressive craniectomy patients were more likely to be male, have poorer GCS scores (3-8), and were more likely to present with bilateral mydriasis. Clearly, the baseline preoperative characteristics of the craniotomy and
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craniectomy groups are not comparable. The significantly higher number of poor prognosis patients undergoing decompressive craniectomy strongly suggests that there is an inherent
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selection bias within the included non-randomized observational studies analyzed – as suspected, surgeons are more likely to perform a decompressive craniectomy procedure in anticipation of potential cerebral swelling and ICP management difficulties in those with a worse initial neurological presentation. Indeed, some studies have attempted to adjust for the
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initial injury severity and suggest that decompressive craniectomy outcomes are no worse when compared to craniotomy [27, 33, 34] for traumatic brain injuries. Our pooled analysis of postoperative outcomes demonstrated a significantly higher rate of
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residual hematoma within the craniotomy group. There was no significant difference in terms of revision procedures required, however the decompressive craniectomy group had a
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significantly higher proportion of patients with poor outcome at follow-up as well as higher mortality rates. These results are not surprising and suggest that the studies included in this analysis are likely to be confounded by the greater severity of the initial injury affecting patients who ultimately undergo a decompressive craniectomy. Prior retrospective comparative analyses have reported equivalent or comparable outcomes between the two surgical techniques despite the craniectomy group having more severe baseline injury, and thus it was concluded that decompressive craniectomy may in fact be the preferred option[7]. This result however, is likely a function of small sample sizes and lack of adequate power.
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Whether craniotomy or decompressive craniectomy offers superior efficacy and complication rates remains unanswered after the present meta-analysis. Rather, the present systematic review highlights the inadequacies of the current literature and an urgent need for a
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randomized controlled study with carefully-selected inclusions and exclusion criteria to ensure balanced cohorts for comparison, particularly regarding the severity of the initial injury. A large cohort analysis that is either stratified or propensity-matched based on initial
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GCS and neurological severity would also provide some guidance for clinical practice. This is an critical conundrum, as craniectomy requires a secondary procedure with associated risk
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and also requires apotentially-costly second hospital stay [15, 16], which is particularly important as health economics trends towards value-based care.
The rationale underlying decompressive craniectomy is that by keeping the skull open and not replacing the bone flap, improved ICP management can be achieved. Decompressive craniectomy was first introduced by Theodor Kocher over 100 years ago[35] and continues to
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be the option of choice by many surgeons worldwide. However, the theory underlying this practice remains controversial as not all patients who undergo this procedure go on to develop cerebral edema or raised ICP [36, 37]. Furthermore the role of ICP management itself remains
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ambiguous, as it is by no means clear whether raised ICP is a primary pathological event, or
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merely a late epiphenomenon that reflects other underlying processes which are not altered by ICP management[38]. Other studies have suggested that conversion from a closed to an open cranium and its associated abnormalities in ICP can lead to further complications [37, 39, 40]. Furthermore, decompressive craniectomy acquires additional risks from the second cranioplasty procedure[15, 16]. There are also a significant costs involved when a custommade prosthesis is required. In contrast, craniotomy involves retention of the bone flap, which may complicate ICP management and may occasionally necessitate a second operation for bone removal in an unstable patient. However, the advantages offered by this approach include the negated risks of a cranioplasty procedure. This procedure may be more suitable
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ACCEPTED MANUSCRIPT for patients who have low impact trauma mechanism, without significantly underlying cerebral parenchyma injury. The present study is constrained by multiple limitations. The included studies did not adjust outcomes for differences in baseline characteristics and severity of injury, a major confounder
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identified in the present analysis. Additionally, the outcomes of surgery for acute SDH may be affected by bone flap size, data for which was unavailable. A prospective randomized study comparing bone flaps <8cm vs >12cm have shown that large bone flaps better controls
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brain swelling, but is associated with higher complications[41, 42]. Furthermore, there was also significant differences within institutions and between studies regarding the use of
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duroplasty, the type craniotomy and the use of adjuncts such as external ventricular drains (EVDs) and drains, all factors which were not reported in the majority of studies. The retrospective nature of the included studies lends themselves susceptible to selection bias and unadjusted for cofounders. Small series or single-center studies were included, which may
trends/results.
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make it difficult to generalize results or make an interpretation regarding national
To address the questions surrounding the relative benefits and risks of craniotomy versus craniectomy for acute SDH, the Randomized Evaluation of Surgery with Craniectomy for
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Uncontrollable Elevation of Intra-Cranial Pressure (RESCUE-ASDH)[43] is a multi-center
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randomized study currently underway. This multi-center, pragmatic, parallel group randomized trial will hopefully shed further light on the optimal surgical approach for acute SDH.
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ACCEPTED MANUSCRIPT References 1. Woertgen C, Rothoerl RD, Schebesch KM, Albert R (2006) Comparison of craniotomy and craniectomy in patients with acute subdural haematoma. Journal of Clinical Neuroscience 13:718-721. doi: 10.1016/j.jocn.2005.08.019
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ACCEPTED MANUSCRIPT 13. Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ (2016) Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. New England Journal of Medicine 375:1119-1130. doi: doi:10.1056/NEJMoa1605215
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ACCEPTED MANUSCRIPT 24. d'Avella D, Servadei F, Scerrati M, Tomei G, Brambilla G, Massaro F, Stefini R, Cristofori L, Conti A, Cardali S, Tomasello F (2003) Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients. Acta Neurochir (Wien) 145:10371044; discussion 1044. doi: 10.1007/s00701-003-0150-y 25. Hatashita S, Koga N, Hosaka Y, Takagi S (1993) Acute subdural hematoma: severity of injury, surgical intervention, and mortality. Neurologia medico-chirurgica 33:13-18
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26. Hlatky R, Valadka AB, Goodman JC, Robertson CS (2007) Evolution of brain tissue injury after evacuation of acute traumatic subdural hematomas. Neurosurgery 61:249-254; discussion 254-245. doi: 10.1227/01.neu.0000279220.30633.45 27. Koc RK, Akdemir H, Oktem IS, Meral M, Menku A (1997) Acute subdural hematoma: outcome and outcome prediction. Neurosurg Rev 20:239-244
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28. Massaro F, Lanotte M, Faccani G, Triolo C (1996) One hundred and twenty-seven cases of acute subdural haematoma operated on. Correlation between CT scan findings and outcome. Acta Neurochir (Wien) 138:185-191
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29. Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC (1981) Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours. The New England journal of medicine 304:1511-1518. doi: 10.1056/nejm198106183042503 30. Shigemori M, Syojima K, Nakayama K, Kojima T, Ogata T, Watanabe M, Kuramoto S (1980) The outcome from acute subdural haematoma following decompressive hemicraniectomy. Acta Neurochir (Wien) 54:61-69
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31. Taussky P, Widmer HR, Takala J, Fandino J (2008) Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience. Swiss medical weekly 138:281-285. doi: 2008/19/smw-12056
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32. van Leeuwen N, Lingsma HF, Perel P, Lecky F, Roozenbeek B, Lu J, Shakur H, Weir J, Steyerberg EW, Maas AI, International Mission on P, Clinical Trial Design in TBISG, Corticosteroid Randomization After Significant Head Injury Trial C, Trauma A, Research N (2012) Prognostic value of major extracranial injury in traumatic brain injury: an individual patient data meta-analysis in 39,274 patients. Neurosurgery 70:811-818; discussion 818. doi: 10.1227/NEU.0b013e318235d640 33. Paci GM, Sise MJ, Sise CB, Sack DI, Shackford SR, Kureshi SA, Osler TM, Yale RS, Riccoboni ST, Peck KA, O'Reilly EB (2009) Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury? The Journal of trauma 67:531-536. doi: 10.1097/TA.0b013e3181b840e8 34. Wong GK, Hung YW, Chong C, Yeung J, Chi-Ping Ng S, Rainer T, Poon WS (2010) Assessing the neurological outcome of traumatic acute subdural hematoma patients with and without primary decompressive craniectomies. Acta neurochirurgica Supplement 106:235-237. doi: 10.1007/978-3-211-98811-4_44 35. Balestreri M, Czosnyka M, Hutchinson P, Steiner LA, Hiler M, Smielewski P, Pickard JD (2006) Impact of Intracranial Pressure and Cerebral Perfusion Pressure on Severe Disability and Mortality After Head Injury. Neurocritical Care 4:008-013. doi: 10.1385/ncc:4:1:008
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ACCEPTED MANUSCRIPT 36. Bor-Seng-Shu E, Figueiredo EG, Fonoff ET, Fujimoto Y, Panerai RB, Teixeira MJ (2013) Decompressive craniectomy and head injury: brain morphometry, ICP, cerebral hemodynamics, cerebral microvascular reactivity, and neurochemistry. Neurosurgical Review 36:361-370. doi: 10.1007/s10143-013-0453-2 37. Cooper PR, Hagler H, Clark WK, Barnett P (1979) Enhancement of experimental cerebral edema after decompressive craniectomy: implications for the management of severe head injuries. Neurosurgery 4:296-300
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38. Chesnut RM, Temkin N, Carney N, Dikmen S, Rondina C, Videtta W, Petroni G, Lujan S, Pridgeon J, Barber J, Machamer J, Chaddock K, Celix JM, Cherner M, Hendrix T (2012) A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury. New England Journal of Medicine 367:2471-2481. doi: doi:10.1056/NEJMoa1207363
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39. Akins PT, Guppy KH (2007) Sinking Skin Flaps, Paradoxical Herniation, and External Brain Tamponade: A Review of Decompressive Craniectomy Management. Neurocritical Care 9:269-276. doi: 10.1007/s12028-007-9033-z
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40. Honeybul S, Ho KM (2011) Long-Term Complications of Decompressive Craniectomy for Head Injury. Journal of Neurotrauma 28:929-935. doi: 10.1089/neu.2010.1612 41. Tagliaferri F, Zani G, Iaccarino C, Ferro S, Ridolfi L, Basaglia N, Hutchinson P, Servadei F (2012) Decompressive craniectomies, facts and fiction: a retrospective analysis of 526 cases. Acta Neurochir (Wien) 154:919-926. doi: 10.1007/s00701-012-1318-0
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42. Timofeev I, Santarius T, Kolias AG, Hutchinson PJ (2012) Decompressive craniectomy operative technique and perioperative care. Advances and technical standards in neurosurgery 38:115-136. doi: 10.1007/978-3-7091-0676-1_6
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43. Clark DJ, Kolias AG, Corteen EA, Ingham SC, Piercy J, Crick SJ, Menon DK, Hutchinson PJ (2013) Community consultation in emergency neurotrauma research: results from a preprotocol survey. Acta Neurochirurgica 155:1329-1334. doi: 10.1007/s00701-013-1748-3
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ACCEPTED MANUSCRIPT Figure Legends Figure 1. PRISMA flowchart demonstrating search strategy for the present systematic review and meta-analysis Figure 2. Forest plot comparing the proportion of males in the craniotomy group versus decompressive craniectomy group
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Figure 3. Forest plot comparing craniotomy group versus decompressive craniectomy group in terms of patients with GCS 3-8 (A), GCS 9-12 (B), and GCS 13-15 (C) Figure 4. Forest plot comparing craniotomy group versus decompressive craniectomy group in terms of proportion patients with co-existing epidural hematoma
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Figure 5. Forest plot of revision rates of the craniotomy group versus decompressive craniectomy group
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Table 1. Characteristics of studies included in the present systematic review and meta-analysis.
Year
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No No. of Average craniotomies craniectomies Follow-up (years) 111 68 5.1 30 69 NR
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Germany R, OS United R, OS Kingdom Rush 2016 United PSM, R, OS 1763 177 NR States Li 2012 United R, OS 36 49 0.5 Kingdom Chen 2011 Taiwan R, OS 42 60 ≥1 Kwon 2016 Korea R, OS 20 26 NR R, retrospective; OS, observational study; PSM, propensity-score matched; NR, not reported
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Age (mean, years) Males/Females Craniotomy Craniectomy Craniotomy Craniectomy
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It remains unclear whether craniotomy or craniectomy is better for acute SDH we performed a meta-analysis of the literature craniectomy was associated with worse clinical presentation and postoperative outcome due to selection bias craniectomy was associated with lower rate of residual SDH following treatment
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GCS score 3-8
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GCS score 9-12
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GCS 13-15
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ACCEPTED MANUSCRIPT subdural hematoma (SDH) Glasgow Coma Scale (GCS) intracranial pressure (ICP) monitoring Cochrane Central Register of Controlled Trials (CCTR) Cochrane Database of Systematic Reviews (CDSR)
confidence interval (CI) The European Association of Neurosurgical Societies (EANS) NeuroCritical Care Network (NCCNet) The Society of British Neurological Surgeons (SBNS)
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British Neurosurgical Trainees' Association (BNTA)
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odds ratio (OR)
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Database of Abstracts of Review of Effectiveness (DARE)
National Surgical Quality Improvement Program (NSQIP) external ventricular drains (EVDs)
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Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intra-Cranial Pressure (RESCUE-ASDH)
ACCEPTED MANUSCRIPT Kevin Phan1, Justin M Moore2, Christoph Griessenauer2, Adam A. Dmytriw2, Daniel B Scherman1, Sharaf Sheik-Ali1, Nimer Adeeb2, Christopher S. Ogilvy2, Ajith Thomas2, Jeffrey V. Rosenfeld3
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All authors report no conflicts of interest pertaining to the submitted article.
S1878-8750(17)30336-4
DOI:
10.1016/j.wneu.2017.03.024
Reference:
WNEU 5393
To appear in:
World Neurosurgery
Received Date: 23 November 2016 Revised Date:
6 March 2017
Accepted Date: 7 March 2017
Please cite this article as: Phan K, Moore JM, Griessenauer C, Dmytriw AA, Scherman DB, Sheik-Ali S, Adeeb N, Ogilvy CS, Thomas A, Rosenfeld JV, Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis, World Neurosurgery (2017), doi: 10.1016/ j.wneu.2017.03.024. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis
Kevin Phan1, Justin M Moore2, Christoph Griessenauer2, Adam A. Dmytriw2, Daniel B
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V. Rosenfeld3
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Scherman1, Sharaf Sheik-Ali1, Nimer Adeeb2, Christopher S. Ogilvy2, Ajith Thomas2, Jeffrey
1. NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney,
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Australia.
2. Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
3. Department of Neurosurgery, Alfred Hospital; Department of Surgery, Monash
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University, Melbourne, Australia.
Keywords: craniotomy; craniectomy; subdural hematoma; decompression; traumatic brain
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injury
Correspondence: Kevin Phan, NeuroSpine Surgery Research Group (NSURG) and
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University of Sydney, Email: [email protected] Conflicts of interest: None declared Funding for this study: None Acknowledgements: None
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ACCEPTED MANUSCRIPT Abstract Introduction Acute subdural hematoma (SDH) is a major cause of morbidity following severe traumatic brain injury. Surgical evacuation of the hematoma, either via craniotomy or craniectomy, is the mainstay of treatment in patients with progressive neurological deficits or significant mass effect. However, the decision between either procedure remains controversial.
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Methods A literature search using major online databases and a manual search of reference on the topic of craniotomy and craniectomy for evacuation of subdural hematoma until September 2016 was performed. The outcome variables were analyzed which included residual SDH, revision rate, and clinical outcome.
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Results
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Six comparison studies, with a total number of 2006 craniotomy and 451 craniectomy patients, fulfilled the inclusion criteria. Patients who underwent craniectomy scored significantly lower on the Glasgow Coma Scale at the time of initial presentation. Postoperatively, the rate of residual SDH was significantly lower in the craniectomy group compared to the craniotomy group (p = 0.004), with no difference in the revision rate. The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs 60.1%, p = 0.004). Similarly, mortality rates was lower in the craniotomy group compared to craniectomy (p = 0.004). Conclusion
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The safety and efficacy of craniotomy versus decompressive craniectomy in treatment of acute SD remain controversial. In the current study, craniectomy was associated with worse clinical presentation and postoperative outcome compared to craniotomy. However, craniectomy was associated with lower rate of residual SDH following treatment.
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ACCEPTED MANUSCRIPT Introduction Acute subdural hematoma (SDH) occurs in up to one-third of patients with severe traumatic brain injury [1, 2]. Surgical evacuation is the mainstay of treatment for acute SDH in patients with progressive neurological deficits, increasing intracranial pressure (ICP), or significant
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mass effect [2-4]. According to the guidelines for surgical management of traumatic brain injury, surgical evacuation of an acute SDH is indicated if the thickness exceeds 10 mm or the midline shift 5 mm regardless of the Glasgow Coma Scale (GCS) score. In patients with a
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GCS less than 9 evacuation may be indicated even for smaller acute SDHs[4]. Acute SDH has been associated with high mortality rate ranging 40-60% and functional recovery ranging
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from 19-45% [5-7], despite rapid transportation and imaging, ICP monitoring, and intensive care management. Two types of procedures are performed for evacuation of acute SDH. Craniotomy involves elevation of a bone flap, removal and clearance of subdural hematoma, followed by replacement of the bone flap. The advantage is that this approach does not require a second procedure, with its inherent risks, to replace the bone flap. The alternative
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surgical procedure is decompressive craniectomy, which also involves elevating a bone flap, hematoma evacuation, and then storage of the bone flap, which provides room to accommodate expansion of edematous cerebral tissue and facilitates ICP management.
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However, this procedure requires a secondary cranioplasty procedure.
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Whether craniotomy or decompressive craniectomy is the preferred approach for treating an acute SDH remains controversial[8]. A number of studies have demonstrated the effectiveness of decompressive craniectomy for acute SDH, where underlying parenchymal injury is thought to contribute to postoperative swelling [9-12]. However, this theoretical advantage is limited by the fact that not all acute SDH patients have postoperative cerebral swelling. Similarly, large studies on craniectomy in the context of ICP control have shown inconsistent results relating to the benefit of the procedure [13, 14]. Decompressive craniectomy has its own set of associated complications, and if the patient survives, there is the additional risk of a subsequent cranioplasty procedure with the potential for a protracted
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ACCEPTED MANUSCRIPT hospital stay related most commonly to surgical site infection of bone flap resorption [15, 16]. While both procedures are performed worldwide, there is currently no clear guidelines or consensus on the choice of procedure and in reality the approach is usually left to the discretion of the surgeon[4]. There appears to be a general tendency for decompressive
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craniectomy to be performed in patients with more severe traumatic brain injury, as these patients are perceived as more likely to develop edema, raised ICP and secondary brain injury, and thus benefit for improved ICP control. While this technique does appear to be superior in decreasing ICP an intensive care unit (ICU) stay length, superior outcomes remain
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far from assured.
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The indications, benefits, and risks of craniotomy and decompressive craniectomy for acute SDH in traumatic brain injury also remain a source of controversy. Therefore a systematic review and meta-analysis was performed to address the relative outcomes and complications
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of craniotomy when compared to decompressive craniectomy for acute SDH.
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ACCEPTED MANUSCRIPT Methods Literature search strategy Electronic searches were performed using Ovid Medline, PubMed, the Cochrane Central Register of Controlled Trials (CCTR), the Cochrane Database of Systematic Reviews
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(CDSR), the ACP Journal Club and the Database of Abstracts of Review of Effectiveness (DARE) from their dates of inception to September 2016. To achieve maximum sensitivity of the search strategy and identify all eligible studies, we combined the terms: “subdural
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hematoma”, “subdural hemorrhage”, “craniotomy”, “craniectomy”, or “decompressive craniectomy”, as either keywords or MeSH terms. The reference lists of all retrieved articles
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were reviewed to enable further identification of potentially relevant studies. All identified articles were systematically assessed using the inclusion and exclusion criteria according to recommended guidelines [17, 18]. Selection criteria
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Eligible studies comparing outcomes of craniotomy and decompressive craniectomy for acute subdural hematoma were included. Single arm studies reporting outcomes of only craniotomy or decompressive craniectomy were excluded from analysis. When institutions published
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duplicate studies with accumulating numbers of patients or increased lengths of follow-up, only the most complete reports were included for quantitative assessment at each time
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interval. All publications were limited to those involving human subjects and available in the English language. Abstracts, case reports, conference presentations, editorials and expert opinions were excluded. Review articles were omitted because of potential publication bias and duplication of results. Data extraction and critical appraisal All data were extracted from article texts, tables and figures. Two investigators independently reviewed each retrieved article (K.P., D.S.). Discrepancies between the two reviewers were resolved by discussion and consensus with a third reviewer (S.S.). Assessment of risk of bias
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ACCEPTED MANUSCRIPT for each selected study was performed in accordance with the most updated Cochrane statement. The final results were reviewed by the senior investigator. Statistical analysis The odds ratio (OR) was used as a summary statistic. In the present study, both fixed- and
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random-effect models were tested. In the fixed-effects model, it was assumed that treatment effect in each study was the same, whereas in a random-effects model, it was assumed that there were variations between studies. χ2 tests were used to study heterogeneity between the
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trials. The I2 statistic was used to estimate the percentage of total variation across studies, owing to heterogeneity rather than chance, with values greater than 50% considered as
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substantial heterogeneity. The I2 can be calculated as: I2 = 100% × (Q – df)/Q, with Q defined as Cochrane’s heterogeneity statistics and df defined as the degree of freedom. If there was substantial heterogeneity, the possible clinical and methodological reasons for this were explored qualitatively. In the present meta-analysis, the results using the random-effects model were presented to take into account the possible clinical diversity and methodological
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variation between studies. Specific analyses considering confounding factors were not possible because the raw data were not available. All P values were 2-sided. All statistical analysis was conducted with Review Manager Version 5.3.2. (Cochrane Collaboration,
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Software Update, Oxford, United Kingdom).
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ACCEPTED MANUSCRIPT Results A total of 1736 references were identified through six electronic database searches. After exclusion of duplicate or irrelevant references, 216 potentially relevant articles were retrieved. After detailed evaluation of these articles, 23 studies remained for assessment. A
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manual search of the reference lists yielded one new study. After applying the selection criteria, 6 comparative studies [1, 7, 19-22] were selected for analysis (Figure 1). The study characteristics of these trials are summarized in Table 1.
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Baseline preoperative characteristics
The mean age of the patients included in the decompressive craniectomy and craniotomy
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group ranged from 41.2-65.5 years and 47.4-68.9 years, respectively. The proportion of males was reported in 5 of the 6 included studies. There was a significantly lower proportion of males in the craniotomy group compared to decompressive craniectomy cohort (64.7% vs 71.9%, OR 0.67, 95% CI 0.51-0.88, I2=0%, P=0.004), with no significant heterogeneity
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detected (Figure 2).
The severity of the original traumatic injury was measured using the GCS scale. For the most severe GCS scores, ranging 3-8, there was a significantly lower proportion of such patients in
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the craniotomy group compared to decompressive craniectomy (48.1% vs 60.8%, OR 0.48, 95% CI 0.23-0.98, I2=70%, P=0.04) (Figure 3). There was no significant difference noted for
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patients with GCS 9-12 (24.7% vs 19.8%, OR 1.61, 95% CI 0.92-2.83, I2=37%, P=0.10). For patients with GCS 13-15, there was a significantly higher proportion in the craniotomy versus decompressive craniectomy group (28.3% vs 16.7%, OR 2.01, 95% CI 1.25-3.23, I2=0%, P=0.004).
No statistically significant difference was found between the groups in terms of proportion of patients with co-existing epidural hematoma (1.1% vs 3.1%, OR 0.45, 95% CI 0.04-4.63, I2=33%, P=0.50), however this variable was only reported in 2 of the included studies (Figure 4). The lack of statistical significance may be due to the inadequate patient sample sizes and
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ACCEPTED MANUSCRIPT as such, no definitive conclusion can be made with respects to operative management of acute SDH with co-existing epidural hematomas. In addition to epidural hematomas, only one other study reported other intraparenchymal injuries associated with acute SDH. Chen et al. noted that of 102 patients with acute SDH, 42.9% (n=42) of patients underwent a craniotomy while
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28.3% (n=60) of patients were treated with a decompressive craniectomy (P=0.5) [19]. A total of 37 of the 102 patients had an associated intracerebral hematoma. No statistically significant difference was determined between the groups in terms of the proportion of patients that underwent a craniotomy or a decompressive craniectomy regardless of if the intracerebral
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hematoma was originally present (31% vs 25%, P=0.77) or had developed postoperatively (11.9% vs 6.7%, P=0.65). As previously noted, the severity of the traumatic injury measured
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using GCS scores showed that a lower GCS score correlated with a higher proportion of patients undergoing decompressive craniectomy. However, with respect to acute SDH without versus acute SDH associated with intraparenchymal injuries, no correlation with the type of surgery carried out could be determined. Chen et al. noted that a higher percentage of
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patients with a pre-operative intracerebral hematoma underwent a craniotomy compared to a decompresseive craniectomy. However, like the two studies that reported co-existing epidural hematomas, no statistically significant difference was determined between the craniotomy
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and decompressive craniectomy groups (31.0% vs 26.7%, P=0.87) [19]. No difference was found between craniotomy versus decompressive craniectomy groups in
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terms of patients with unilateral mydriasis (23.4% vs 24.9%, OR 0.79, 95% CI 0.49-1.26, I2=0%, P=0.32). In terms of bilateral mydriasis, there were fewer cases found in the craniotomy group (17.7% vs 35.2%, OR 0.40, 95% CI 0.21-0.76, I2=26%, P=0.005). No difference was found between the craniotomy versus craniectomy groups in terms of extra-cranial injuries (17.7% vs 35.2%, OR 0.79, 95% CI 0.05-11.32, I2=0.86, P=0.86%). The proportion of patients with obliterated cisterns or third ventricles on CT was also comparable between craniotomy and craniectomy groups (36.7% vs 54.1%, OR 0.43, 95% 0.13-1.45, I2=77%, P=0.17).
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ACCEPTED MANUSCRIPT Outcomes Residual SDH was significantly lower in the craniectomy group compared to the craniotomy group (44.4% vs 19.6%, OR 2.43, 95% CI 1.33-4.45, I2=0%, P=0.004). Revision rates were similar between craniotomy and craniectomy groups (26.6% vs 33.5%, OR 0.86, 95% CI
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0.50-1.46, I2=15%, P=0.57) (Figure 5).
The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs 60.1%, OR 0.58, 95% CI 0.37-0.90, I2=23%, P=0.02). Similarly, mortality rates
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was lower in the craniotomy group compared to craniectomy (13.9% vs 40.5%, OR 0.41,
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95% CI 0.23-0.76, I2=64%, P=0.004).
Publication bias
Funnel plot for analysis is demonstrated in the Supplementary Figures. No significant asymmetry was detected in the forest plots, suggesting publication bias was not a significant
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influencing factor in the results presented.
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ACCEPTED MANUSCRIPT Discussion Surgical management is often the treatment option of choice for patients suffering from an acute SDH, which aims to reduce the incidence and impact of secondary brain injury [11]. Despite intervention, the morbidity and mortality for this condition remains high. Craniotomy
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and decompressive craniectomy are two common surgical approaches used, however, there is currently no universal consensus regarding the most appropriate management strategy given the lack of level I randomized evidence. Currently, the choice between the two options is
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largely at the surgeons’ discretion. A questionnaire completed by members of the The European Association of Neurosurgical Societies (EANS), NeuroCritical Care Network
Trainees' Association
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(NCCNet), The Society of British Neurological Surgeons (SBNS), and British Neurosurgical (BNTA) in 2011[23], demonstrated that in continental European
countries, 44% of neurosurgeons used decompressive craniectomy in more than half their cases[8] of acute SDH, compared 21% of British and Irish neurosurgeons. By contrast, a study of the National Surgical Quality Improvement Program (NSQIP), a large prospective
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American database, found that craniotomy was performed ten times more often than decompressive craniectomy in these patients [21]. The wide variation in practice between different continents, countries and even within departments is a reflection of the lack of high
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Outcomes in the literature for craniotomy and decompressive craniectomy for acute SDH have been inconsistent, with some studies suggesting a higher complication rate with decompressive craniectomy whilst other studies suggesting no significant difference. To assess the current state of evidence for surgical management of acute SDH, we pooled preoperative factors and outcomes form the available literature. In agreement with the analysis of the American NSQIP database, we found that 82% of all included patients underwent a craniotomy, while the remaining minority (18%) underwent a decompressive craniectomy.
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ACCEPTED MANUSCRIPT There are multiple factors which are known influence the outcomes of acute SDH, including age, time from injury to treatment, pupillary abnormalities, preoperative GCS, duration of increased ICP, as well as CT features including midline shift, basal cistern compression, the size of the hematoma, and systemic abnormalities such as hypoxia and hypotension[5, 24-32].
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When comparing the preoperative and baseline characteristics of pooled craniotomy versus decompressive craniectomy cohorts, we found that decompressive craniectomy patients were more likely to be male, have poorer GCS scores (3-8), and were more likely to present with bilateral mydriasis. Clearly, the baseline preoperative characteristics of the craniotomy and
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craniectomy groups are not comparable. The significantly higher number of poor prognosis patients undergoing decompressive craniectomy strongly suggests that there is an inherent
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selection bias within the included non-randomized observational studies analyzed – as suspected, surgeons are more likely to perform a decompressive craniectomy procedure in anticipation of potential cerebral swelling and ICP management difficulties in those with a worse initial neurological presentation. Indeed, some studies have attempted to adjust for the
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initial injury severity and suggest that decompressive craniectomy outcomes are no worse when compared to craniotomy [27, 33, 34] for traumatic brain injuries. Our pooled analysis of postoperative outcomes demonstrated a significantly higher rate of
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residual hematoma within the craniotomy group. There was no significant difference in terms of revision procedures required, however the decompressive craniectomy group had a
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significantly higher proportion of patients with poor outcome at follow-up as well as higher mortality rates. These results are not surprising and suggest that the studies included in this analysis are likely to be confounded by the greater severity of the initial injury affecting patients who ultimately undergo a decompressive craniectomy. Prior retrospective comparative analyses have reported equivalent or comparable outcomes between the two surgical techniques despite the craniectomy group having more severe baseline injury, and thus it was concluded that decompressive craniectomy may in fact be the preferred option[7]. This result however, is likely a function of small sample sizes and lack of adequate power.
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Whether craniotomy or decompressive craniectomy offers superior efficacy and complication rates remains unanswered after the present meta-analysis. Rather, the present systematic review highlights the inadequacies of the current literature and an urgent need for a
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randomized controlled study with carefully-selected inclusions and exclusion criteria to ensure balanced cohorts for comparison, particularly regarding the severity of the initial injury. A large cohort analysis that is either stratified or propensity-matched based on initial
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GCS and neurological severity would also provide some guidance for clinical practice. This is an critical conundrum, as craniectomy requires a secondary procedure with associated risk
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and also requires apotentially-costly second hospital stay [15, 16], which is particularly important as health economics trends towards value-based care.
The rationale underlying decompressive craniectomy is that by keeping the skull open and not replacing the bone flap, improved ICP management can be achieved. Decompressive craniectomy was first introduced by Theodor Kocher over 100 years ago[35] and continues to
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be the option of choice by many surgeons worldwide. However, the theory underlying this practice remains controversial as not all patients who undergo this procedure go on to develop cerebral edema or raised ICP [36, 37]. Furthermore the role of ICP management itself remains
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ambiguous, as it is by no means clear whether raised ICP is a primary pathological event, or
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merely a late epiphenomenon that reflects other underlying processes which are not altered by ICP management[38]. Other studies have suggested that conversion from a closed to an open cranium and its associated abnormalities in ICP can lead to further complications [37, 39, 40]. Furthermore, decompressive craniectomy acquires additional risks from the second cranioplasty procedure[15, 16]. There are also a significant costs involved when a custommade prosthesis is required. In contrast, craniotomy involves retention of the bone flap, which may complicate ICP management and may occasionally necessitate a second operation for bone removal in an unstable patient. However, the advantages offered by this approach include the negated risks of a cranioplasty procedure. This procedure may be more suitable
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identified in the present analysis. Additionally, the outcomes of surgery for acute SDH may be affected by bone flap size, data for which was unavailable. A prospective randomized study comparing bone flaps <8cm vs >12cm have shown that large bone flaps better controls
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brain swelling, but is associated with higher complications[41, 42]. Furthermore, there was also significant differences within institutions and between studies regarding the use of
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To address the questions surrounding the relative benefits and risks of craniotomy versus craniectomy for acute SDH, the Randomized Evaluation of Surgery with Craniectomy for
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Uncontrollable Elevation of Intra-Cranial Pressure (RESCUE-ASDH)[43] is a multi-center
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ACCEPTED MANUSCRIPT References 1. Woertgen C, Rothoerl RD, Schebesch KM, Albert R (2006) Comparison of craniotomy and craniectomy in patients with acute subdural haematoma. Journal of Clinical Neuroscience 13:718-721. doi: 10.1016/j.jocn.2005.08.019
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7. Li LM, Kolias AG, Guilfoyle MR, Timofeev I, Corteen EA, Pickard JD, Menon DK, Kirkpatrick PJ, Hutchinson PJ (2012) Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy. Acta Neurochirurgica 154:1555-1561. doi: 10.1007/s00701-012-1428-8
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ACCEPTED MANUSCRIPT 13. Hutchinson PJ, Kolias AG, Timofeev IS, Corteen EA, Czosnyka M, Timothy J, Anderson I, Bulters DO, Belli A, Eynon CA, Wadley J, Mendelow AD, Mitchell PM, Wilson MH, Critchley G, Sahuquillo J, Unterberg A, Servadei F, Teasdale GM, Pickard JD, Menon DK, Murray GD, Kirkpatrick PJ (2016) Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. New England Journal of Medicine 375:1119-1130. doi: doi:10.1056/NEJMoa1605215
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ACCEPTED MANUSCRIPT 24. d'Avella D, Servadei F, Scerrati M, Tomei G, Brambilla G, Massaro F, Stefini R, Cristofori L, Conti A, Cardali S, Tomasello F (2003) Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients. Acta Neurochir (Wien) 145:10371044; discussion 1044. doi: 10.1007/s00701-003-0150-y 25. Hatashita S, Koga N, Hosaka Y, Takagi S (1993) Acute subdural hematoma: severity of injury, surgical intervention, and mortality. Neurologia medico-chirurgica 33:13-18
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ACCEPTED MANUSCRIPT 36. Bor-Seng-Shu E, Figueiredo EG, Fonoff ET, Fujimoto Y, Panerai RB, Teixeira MJ (2013) Decompressive craniectomy and head injury: brain morphometry, ICP, cerebral hemodynamics, cerebral microvascular reactivity, and neurochemistry. Neurosurgical Review 36:361-370. doi: 10.1007/s10143-013-0453-2 37. Cooper PR, Hagler H, Clark WK, Barnett P (1979) Enhancement of experimental cerebral edema after decompressive craniectomy: implications for the management of severe head injuries. Neurosurgery 4:296-300
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39. Akins PT, Guppy KH (2007) Sinking Skin Flaps, Paradoxical Herniation, and External Brain Tamponade: A Review of Decompressive Craniectomy Management. Neurocritical Care 9:269-276. doi: 10.1007/s12028-007-9033-z
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43. Clark DJ, Kolias AG, Corteen EA, Ingham SC, Piercy J, Crick SJ, Menon DK, Hutchinson PJ (2013) Community consultation in emergency neurotrauma research: results from a preprotocol survey. Acta Neurochirurgica 155:1329-1334. doi: 10.1007/s00701-013-1748-3
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ACCEPTED MANUSCRIPT Figure Legends Figure 1. PRISMA flowchart demonstrating search strategy for the present systematic review and meta-analysis Figure 2. Forest plot comparing the proportion of males in the craniotomy group versus decompressive craniectomy group
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Figure 3. Forest plot comparing craniotomy group versus decompressive craniectomy group in terms of patients with GCS 3-8 (A), GCS 9-12 (B), and GCS 13-15 (C) Figure 4. Forest plot comparing craniotomy group versus decompressive craniectomy group in terms of proportion patients with co-existing epidural hematoma
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Figure 5. Forest plot of revision rates of the craniotomy group versus decompressive craniectomy group
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Table 1. Characteristics of studies included in the present systematic review and meta-analysis.
Year
Study type
No No. of Average craniotomies craniectomies Follow-up (years) 111 68 5.1 30 69 NR
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Germany R, OS United R, OS Kingdom Rush 2016 United PSM, R, OS 1763 177 NR States Li 2012 United R, OS 36 49 0.5 Kingdom Chen 2011 Taiwan R, OS 42 60 ≥1 Kwon 2016 Korea R, OS 20 26 NR R, retrospective; OS, observational study; PSM, propensity-score matched; NR, not reported
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Woetgan 2006 Tsermoulas 2016
Country
Age (mean, years) Males/Females Craniotomy Craniectomy Craniotomy Craniectomy
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57.2 48
52 44
NR 22:8
NR 57:12
68.9
49.5
1150:613
127:50
59
45
18:18
33:16
47.4 63.4
41.2 65.5
21:21 12:8
41:19 16:10
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It remains unclear whether craniotomy or craniectomy is better for acute SDH we performed a meta-analysis of the literature craniectomy was associated with worse clinical presentation and postoperative outcome due to selection bias craniectomy was associated with lower rate of residual SDH following treatment
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GCS score 3-8
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GCS score 9-12
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GCS 13-15
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Residual SDH
ACCEPTED MANUSCRIPT subdural hematoma (SDH) Glasgow Coma Scale (GCS) intracranial pressure (ICP) monitoring Cochrane Central Register of Controlled Trials (CCTR) Cochrane Database of Systematic Reviews (CDSR)
confidence interval (CI) The European Association of Neurosurgical Societies (EANS) NeuroCritical Care Network (NCCNet) The Society of British Neurological Surgeons (SBNS)
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Database of Abstracts of Review of Effectiveness (DARE)
National Surgical Quality Improvement Program (NSQIP) external ventricular drains (EVDs)
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Randomized Evaluation of Surgery with Craniectomy for Uncontrollable Elevation of Intra-Cranial Pressure (RESCUE-ASDH)
ACCEPTED MANUSCRIPT Kevin Phan1, Justin M Moore2, Christoph Griessenauer2, Adam A. Dmytriw2, Daniel B Scherman1, Sharaf Sheik-Ali1, Nimer Adeeb2, Christopher S. Ogilvy2, Ajith Thomas2, Jeffrey V. Rosenfeld3
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All authors report no conflicts of interest pertaining to the submitted article.