Craniotomy versus decompressive craniectomy for acute subdural hematoma: systematic review and meta-analysis

Background: Acute subdural hematoma (SDH) is a major cause of morbidity after severe traumatic brain injury. Surgical evacuation of the hematoma, either via craniotomy or craniectomy, is the mainstay of treatment in patients with progressive neurologic deficits or significant mass effect. However, the decision to perform either procedure remains controversial. Methods: A literature search using major online databases and a manual search of references 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. Results: 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 than 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%, respectively; P = 0.004). Similarly, mortality rates was lower in the craniotomy group than the craniectomy group (P = 0.004). Conclusions: The safety and efficacy of craniotomy versus decompressive craniectomy in treatment of acute SDH remain controversial. In this study, craniectomy was associated with worse clinical presentation and postoperative outcome compared with craniotomy. However, craniectomy was associated with lower rate of residual SDH after treatment.