The Association of Surgical Method with Outcomes of Acute Subdural Hematoma Patients: Experience with 643 Consecutive Patients

OBJECTIVE: We investigated the association of decompressive craniectomy (DC) and osteoplastic craniotomy (OC) with outcomes in consecutive patients undergoing surgical evacuation of acute subdural hematoma (ASDH) and analyzed prognostic indicators to determine optimal surgical management strategy for patients with ASDH. METHODS: We performed a prospective review of all adult patients with ASDH operated on by craniotomy from January 2009 to January 2016. Mortality and discharge outcomes (Glasgow Outcome Scale) were analyzed as a function of surgical method adjusting for age, admission Glasgow Coma Scale score, ASDH thickness and midline shift. RESULTS: OC was performed in 394 (61%) patients, and DC was performed in 249 (39%) patients. Patients undergoing DC were younger, with lower Glasgow Coma Scale score, greater ASDH thickness, and greater midline shift (P < 0.001). Mortality rate (54% vs. 20%; P < 0.001) and proportion of patients with poor discharge outcomes (85% and 45%; P < 0.001) were greater in DC patients versus OC patients. Glasgow Outcome Scale score was lower and mortality rate was greater (P <= 0.048) in DC patients versus OC patients across all patient subgroups. Outcomes were similar between the 2 groups in patients with Glasgow Coma Scale score of 3 and midline shift of >= 2 cm. Adjusting for disease severity, DC remained associated with greater risk for in-hospital mortality (odds ratio = 3.442 [95% confidence interval 2.196-5.396], P < 0.001) and unfavorable discharge outcome (odds ratio [5.277 [95% confidence interval 3.030-9.191], P < 0.001). CONCLUSIONS: DC was performed more often in younger and more severely injured patients. DC is associated with greater mortality and handicap rates independent of disease severity. Clinical trials investigating optimal surgical management strategy of patients with ASDH are needed.