Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma.

Humans Craniotomy / adverse effects Decompressive Craniectomy / adverse effects Glasgow Outcome Scale Hematoma, Subdural, Acute / surgery Quality of Life Retrospective Studies Skull / surgery Treatment Outcome Surgical Flaps / surgery

Journal

The New England journal of medicine

ISSN: 1533-4406

Titre abrégé: N Engl J Med

Pays: United States

ID NLM: 0255562

Informations de publication

Date de publication:
15 06 2023

Historique:

medline: 16 6 2023

pubmed: 24 4 2023

entrez: 24 04 2023

Statut: ppublish

Résumé

Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear. 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). 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. 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.).

Sections du résumé

BACKGROUND

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.).

Identifiants

DOI: 10.1056/NEJMoa2214172 PMID: 37092792

pubmed: 37092792

doi: 10.1056/NEJMoa2214172

doi:

Banques de données

ISRCTN

['ISRCTN87370545']

Types de publication

Randomized Controlled Trial Journal Article

Langues

eng

Sous-ensembles de citation

Pagination

2219-2229

Subventions

Organisme : Health Technology Assessment Programme

ID : Award ID: 12/35/57. ISRCTN: 87370545

Investigateurs

Peter J Kirkpatrick (PJ)

Hadie Adams (H)

Nicola Owen (N)

Kirsty Grieve (K)

Alexis Joannides (A)

Ellie Edlmann (E)

Karen Caldwell (K)

Silvia Tarantino (S)

Francesca Hill (F)

Liz Corteen (L)

Janet Corn (J)

Matthew G Stovell (MG)

Mathew Guilfoyle (M)

Mohammad Naushahi (M)

Richard Mair (R)

Ibrahim Jalloh (I)

Mark Kotter (M)

Gary Barton (G)

Sarah Pyne (S)

David Turner (D)

Kamila Walker (K)

Tamara Tajsic (T)

Sara Venturini (S)

Selma Tülü (S)

Chris Uff (C)

Shumaila Hasan (S)

Chipo Chitsenega (C)

Geetha Boyapati (G)

Muhammad Bhatti (M)

Malik Zaben (M)

Belinda Gunning (B)

Natalia Ermalai (N)

Dmitri Shastin (D)

Mutwakil Abdulla (M)

Joseph Merola Liudmila (J)

Stuart Smith (S)

Laurence Glanz (L)

Ashwin Kumaria (A)

Lani Patterson (L)

Antonio Belli (A)

Colin Bergin (C)

Maximina Ventura (M)

Emma Toman (E)

Giles Critchley (G)

Laura Ortiz-Ruiz de Gordoa (L)

Prasanna Epaliyanage (P)

Husam Georges (H)

Peter Whitfield (P)

Sam Jeffrey (S)

Charlotte Eglinton (C)

Natasha Wilmhurst (N)

Manjunath Prasad (M)

Shahid Khan (S)

Philip Kane (P)

Emanuel Cirstea (E)

Catherine McMahon (C)

Geraint Sunderland (G)

John Kitchen (J)

Rushid Zakaria (R)

Simon Thomson (S)

Soumya Mukherjee (S)

Ian Anderson (I)

Linetty Makawa (L)

Mary Kambafwile (M)

Marios C Papadopoulos (MC)

Mathew Joseph Gallagher (MJ)

Siobhan Kearney (S)

Sarah Trippier (S)

Mark Wilson (M)

Hani Marcus (H)

Rhys Thomas (R)

Sonia Fernandez Lopez (S)

Louise Young (L)

Andrea D'Mello (A)

Jo-Anna Conyngham (JA)

Diederik Bulters (D)

Ardalan Zolnourian (A)

Patrick Holton (P)

Miriam Taylor (M)

Charlaine Reeve (C)

Jonathan Pollock (J)

Ciaran Hill (C)

Elisa Visentin (E)

Laura Parker (L)

Kismet Hossain-Ibrahim (K)

Paul Johnston (P)

Vasileios Arzoglou (V)

Emma Clarkson (E)

Arif Zafar (A)

Efosa Ukponmwan (E)

Christos Tolias (C)

Joseph Frantzias (J)

Anastasios Giamouriadis (A)

Yahia Al-Tamimi (Y)

Adam Wahba (A)

Patrick Easton (P)

Rose Clegg (R)

Grace Cole (G)

Damian Holliman (D)

Louise Finlay (L)

Daniel Holsgrove (D)

Alex Leggate (A)

Jane Perez (J)

Louise Harrison (L)

Gareth Roberts (G)

Terrie-Louise Cromie (TL)

Marianne Hare (M)

Sonia Raj (S)

Tim Lawrence (T)

Ruichong Ma (R)

Javier Magan Ventura (J)

Neil Davidson (N)

Richard Nelson (R)

Ruth Womer (R)

Beverley Fulkner (B)

Shabin Joshi (S)

Geraldine Ward (G)

Ioannis Fouyas (I)

Julie Woodfield (J)

Himanshu Shekhar (H)

Kareen Damley (K)

Emma Fleming (E)

Roddy O'Kane (R)

Michael Canty (M)

Indira Devi Bhagavatula (ID)

Dhananjaya Ishwar Bhat (DI)

Dhaval Prem Shukla (DP)

Subhas K Konar (SK)

Nagesh Shanbhag (N)

Vaishali Nl Valluru (VN)

Manoj Kumar Tewari (MK)

Manjul Tripathi (M)

Deepak Gupta (D)

Ashish Bindra (A)

Kaveri Sharma (K)

Mathew Joseph (M)

Nicole Keong (N)

Christine Lock (C)

Chen Min Wei (CM)

Julian Han (J)

Janell Kwok (J)

Nicolas Kon Kam King (NKK)

Martina Stippler (M)

Emmalin Nelton (E)

Louis Anthony Whitworth (LA)

Sonja Stutzman (S)

Christopher Madden (C)

Caryn Harper (C)

Tracey Moore (T)

Vin Shen Ban (VS)

Alice Salazar (A)

Rocco Armonda (R)

Jason J Chang (JJ)

George B Moses (GB)

Patricia Tanjucto (P)

Jamie Ullman (J)

Orseola Arapi (O)

Betsy Moclair (B)

Nrupen Baxi (N)

Erin Lewis (E)

Melvin Stone (M)

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Jamie Jones (J)

Clare Gallagher (C)

Ish Bains (I)

Kesava Reddy (K)

Paula Carroll (P)

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Ioana Moldovan (I)

Sean Christie (S)

Lisa Julien (L)

Kostas Fountas (K)

Thanasis Paschalis (T)

Sandro Krieg (S)

Sebastian Ille (S)

Maria Luisa Gandia Gomez (ML)

Alfonso Legares (A)

Ana Maria Castaño Leon (AM)

András Büki (A)

Gábor Lenzsér (G)

Tariq Khan (T)

Mukhtar Khan (M)

Franco Servadei (F)

Massimo Tomei (M)

Vairavan Narayanan (V)

Ronie Romelean Jayapalan (RR)

Martin Hunn (M)

Panagiota Gkolia (P)

Emily Galea (E)

Paula Kareclas (P)

Sridevi Nagarajan (S)

James Piercy (J)

Peter Kirkpatrick (P)

A David Mendelow (AD)

Andrew King (A)

John D Pickard (JD)

Paul Brennan (P)

Christopher Cowie (C)

Carol Davis-Wilkie (C)

Tapiwa Tungamirai (T)

Kerstin Wolf (K)

Natalia Igosheva (N)

Alicia Gore (A)

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Commentaires et corrections

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