In-hospital mortality and length of hospital stay with craniotomy versus craniectomy for acute subdural hemorrhage: a multicenter, propensity score–matched analysis

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The optimal surgical treatment for acute subdural hemorrhage (ASDH) remains controversial. The purpose of this study was to compare outcomes in patients who underwent craniotomy with those in patients who underwent decompressive craniectomy for the treatment of ASDH.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>Using the Japan Trauma Data Bank, a nationwide trauma registry, the authors identified patients aged ≥ 18 years with ASDH who underwent surgical evacuation after blunt head trauma between 2004 and 2015. Logistic regression analysis was used to estimate a propensity score to predict decompressive craniectomy use. They then used propensity score–matched analysis to compare patients who underwent craniotomy with those who underwent decompressive craniectomy. To identify the potential benefits and disadvantages of decompressive craniectomy among different subgroups, they estimated the interactions between treatment and the subgroups using logistic regression analysis.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of 236,698 patients who were registered in the database, 1788 were eligible for propensity score–matched analysis. The final analysis included 514 patients who underwent craniotomy and 514 patients who underwent decompressive craniectomy. The in-hospital mortality did not differ significantly between the groups (41.6% for the craniotomy group vs 39.1% for the decompressive craniectomy group; absolute difference −2.5%; 95% CI −8.5% to 3.5%). The length of hospital stay was significantly longer in patients who underwent decompressive craniectomy (median 23 days [IQR 4–52 days] vs 30 days [IQR 7–60 days], p = 0.005). Subgroup analyses demonstrated qualitative interactions between decompressive craniectomy and the patient subgroups, suggesting that patients who were more severely injured (Glasgow Coma Scale score &lt; 9 and probability of survival &lt; 0.64) and those involved in high-energy injuries may be good candidates for decompressive craniectomy.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>The results of this study showed that overall, decompressive craniectomy did not appear to be superior to craniotomy in ASDH treatment in terms of in-hospital mortality. In contrast, there were significant differences in the effectiveness of decompressive craniectomy between the subgroups. Thus, future studies should prioritize the identification of a subset of patients who will possibly benefit from the performance of each of the procedures.</jats:p></jats:sec>

Functional outcome, in-hospital healthcare consumption and in-hospital costs for hospitalised traumatic brain injury patients: a Dutch prospective multicentre study

“…The large ranges are exemplary for the existing variation, that is, primarily caused by patient case-mix and treatmentrelated factors [40]. Several factors that we found to be associated with an increased total LOS were also mentioned in literature: lower GCS, higher TBI severity and the presence of extracranial injury [13,62], ICP monitoring [46,61] and decompressive craniectomy [27,53].…”

Mortality Outcome of Emergency Decompressive Craniectomy and Craniotomy in the Management of Acute Subdural Hematoma: A National Data Analysis

“…After propensity score matching, our study showed no difference in mortality, (DC, 42.7% and CO, 37.5%, P = .10), which is consistent with other studies. 8,12,13…”

“…21 Numerous studies have examined the mortality related to the DC and CO procedures, and found increased overall mortality in the DC procedure; however, in certain studies, when confounders were adjusted or expected fatal cases were excluded, the difference in mortality between the 2 procedures were evaded. 8,28 Shilahashi and colleagues 13 recently published a study comparing DC and CO using the Japan Trauma Data Base. They utilized the propensity score matching methodology to balance the baseline characteristics.…”

“…After propensity score matching, our study showed no difference in mortality, (DC, 42.7% and CO, 37.5%, P = .10), which is consistent with other studies. 8,12,13 The major issue on this subject matter is a lack of high-quality evidence of surgical treatments (DC vs CO) for acute SDH in trauma patients. Current guidelines for the management of TBI are based on limited evidence.…”

“…While the majority of studies reported a higher mortality rate following DC versus CO, few studies showed no difference in overall mortality. [7][8][9][10][11][12][13] The variation in the mortality outcome in these studies is most likely due to sample size and/or methodology. Thus, the purpose of this study is to examine the mortality outcome of all patients who sustained severe traumatic brain injury (TBI) with acute SDH and underwent either CO or DC within 4 hours of hospital arrival using the National Trauma Data Bank (NTDB) dataset.…”