LOS ANGELES ― A common dilemma in neurosurgery is whether to immediately replace the bone flap in the skull after surgical treatment of an acute subdural hematoma.
In a new study, outcomes were nearly alike after both craniotomy, in which the bone flap is replaced, and decompressive craniectomy, in which the bone flap is not replaced, at least not right away.
While the outcomes are similar, the findings actually favor craniotomy because it eliminates the need for a second operation to repair the skull, said lead author Peter Hutchinson, MBBS, PhD, a neurosurgeon with the University of Cambridge in the United Kingdom, in an interview. “If the brain is not excessively swollen, and you put the bone back, that’s the right thing to do.”
Hutchinson presented the findings from the Randomized Evaluation of Surgery With Craniectomy for Patients Undergoing Evacuation of Acute Subdural Hematoma (RESCUE-ASDH) trial at the annual meeting of the American Association of Neurological Surgeons (AANS) 2023. The study was published April 23 in The New England Journal of Medicine.
Traumatic subdural hematoma often requires surgical evacuation using either craniotomy or decompressive craniectomy. While craniectomy, in which the flap is not replaced, may have the advantage of reducing intracranial hypertension, the researchers note, whether it is associated with better outcomes has not been clear.
“The advantage of putting the bone back is you don’t have to take the patient back for reconstruction or bone replacement weeks or months later. You avoid that second operation,” he said. “But the disadvantage of putting the bone back is that if the brain is swollen for days after the operation, then the pressure will go up.”
The new international, multicenter, pragmatic study recruited patients with traumatic acute subdural hematomas that needed evacuation. All had bone flaps with an anteroposterior diameter of at least 11 cm.
After the clot was removed, patients were randomly assigned to undergo craniotomy or craniectomy. Those in the craniotomy group (n = 228; average age, 48 years; 78.1% men, 51.5% White, 44.1% Asian/Southeast Asian) could later undergo decompressive craniectomy if needed.
In the craniectomy group (n = 222; average age, 49 years; 80.6% men, 53.4% White, 41.1% Asian/Southeast Asian), some patients underwent surgery to replace the missing skull section with titanium, synthetic material, or the original bone flap.
At 12 months, 215 patients in the craniotomy group and 211 in the decompressive craniectomy group were evaluated. Outcomes were similar; there was no statistically significant difference in the primary outcome ― scores on the Extended Glasgow Outcome Scale, an eight-point scale ranging from death to recovery with no injury-related problems (P = .32).
“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 lower or upper good recovery occurred in 25.6% and 19.9%,” the researchers report.
Further cranial surgery within 2 weeks was performed for 14.6% of the craniotomy group and 6.9% of the craniectomy group.
“I think what’s happening is that these patients [in either group] are not getting pronounced brain swelling,” Hutchinson said. “So, whether you actually put the bone back or leave it out doesn’t actually make any difference.”
Researchers evaluated cost data, Hutchinson said. It appears likely that craniotomy will be less expensive, since it avoids the second operation to replace the missing skull section, he said.
Moving forward, he said the results suggest that neurosurgeons should replace the bone flap after the initial operation if the brain is not too swollen. But there’s a caveat. The best approach in poorer nations with less access to intensive care is not clear, he said. Ongoing research is seeking to offer more guidance.
Neurosurgeon Andrés M. Rubiano, MD, PhD, of El Bosque University in Bogotá, Colombia, praised the research in comments following the presentation at AANS 2023, calling it “an important study that will be adding more evidence to neurotrauma science.”
In a commentary that accompanies the article in The New England Journal of Medicine, neurosurgeon Shankar Gopinath, MD, of Baylor College of Medicine, wrote that the findings should reassure colleagues that “it is relatively safe to perform the quicker procedure of removal of the bone, knowing that if the bone is left in place, compression of the brain under the hematoma and the need for reoperation can largely be prevented.”
The price, he writes, “is medical complications, most of which are treatable, such as infection related to repairing or replacing the skull defect — a trade-off for fewer intracranial risks that might be considered satisfactory.”
The study was funded by the UK’s National Institute for Health and Care Research. Hutchinson discloses employment by the National Institute for Health and Care Research and the Royal College of Surgeons of England. Some of the other authors report various disclosures. Disclosures for Rubiano were not provided. Gopinath has no disclosures.
American Association of Neurological Surgeons (AANS) 2023 Annual Meeting: Presented April 23, 2023.
N Engl J Med. Published online April 23, 2023. Abstract, Editorial
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