Elsevier

World Neurosurgery

Volume 88, April 2016, Pages 25-31
World Neurosurgery

Original Article
Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis

https://doi.org/10.1016/j.wneu.2015.12.034Get rights and content

Objective

The optimal surgical management of acute traumatic subdural hematoma (ASDH) is controversial; both craniectomy and craniotomy are performed. The purpose of this study was to determine the current management of ASDH in the United States.

Methods

This retrospective cohort study used the Nationwide Inpatient Sample from the years 2006–2011 to examine patients with a primary diagnosis of ASDH. All patients ≥18 years old with a primary diagnosis of ASDH were included in the analysis. Patients with procedure codes for craniectomy and craniotomy were isolated from the database. Propensity score matching based on logistic regression was used to match craniotomy to craniectomy in a 1:1 fashion.

Results

There were 47,911,414 hospitalizations analyzed. Of 60,435 patients with ASDH identified, 1763 underwent craniotomy and 177 underwent craniectomy. The average age of patients who underwent craniectomy was 49.5 years (SD 20.8) compared with an average age of 68.9 years (SD 17.1) of patients who underwent craniotomy (P < 0.0001). Hospital mortality was significantly higher in patients who underwent craniectomy (35.0% vs. 10.9%, P < 0.0001). Patients who underwent craniectomy had longer hospital stays compared with patients who underwent craniotomy (median duration 14.3 days [interquartile range 25] for craniectomy vs. 10.9 days [interquartile range 9] for craniotomy, P < 0.0001). Patients who underwent craniectomy were also more likely to be discharged to a skilled nursing or rehabilitation facility (79.1% vs. 63.9%, P = 0.0011).

Conclusions

Craniotomy is the preferred surgical technique for management of ASDH in the United States, being performed 10 times more frequently than craniectomy. Craniectomy was associated with significantly higher in-hospital mortality after propensity score matched analysis.

Introduction

An estimated 1.7 million traumatic brain injuries (TBIs) occur each year in the United States, which are responsible for approximately 55,000 deaths.1, 2 The direct cost of treating patients with TBI is projected at >$9 billion per year.1 The frequency of acute subdural hemorrhage (ASDH) in patients with TBI is 10%–30%.3, 4, 5 Furthermore, patients with ASDH often present with intracranial hypertension or neurologic dysfunction that requires emergent surgical decompression.3 At the time of surgery, provided that there is no extracranial herniation, it is often unclear if the bone flap should be removed (decompressive craniectomy [DC]) or replaced (craniotomy). There is wide variation in the clinical practice of neurosurgeons around the world.6, 7

Several small single-center retrospective cohort studies have attempted to address this equipoise.5, 8, 9, 10, 11, 12, 13 These studies usually represent the practice patterns of a small number of neurosurgeons and contain data from a limited number of cases, limiting their generalizability. National trends and estimates of the proportion of patients receiving craniotomy or DC for ASDH in the United States are unknown. Given the paucity of data, the goal of this retrospective cohort study was to characterize the surgical management of ASDH in the United States. In addition, we sought to determine the independent association with hospital mortality of DC versus craniotomy for ASDH.

Section snippets

Materials and Methods

We report our study in accordance with the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) statement.14

Results

There were 47,911,414 (weighted national projection 235,911,271) admissions examined from the NIS for the years 2006–2011. We isolated a cohort of 60,435 (weighted projection 298,896) patients with a primary diagnosis of traumatic subdural hematoma. From this cohort, we identified 1763 patients who underwent craniotomy and 177 patients who underwent craniectomy; these represent 8786 craniotomies and 883 craniectomies when weighted for national projections. There were 21 patients who had

Discussion

In our retrospective cohort study using data from the NIS, we demonstrated that craniotomy is performed approximately 10 times more frequently than DC in patients with ASDH in the United States. Patients who undergo DC are younger and have more acute comorbid conditions and higher severity indices but are less likely to have a neurologic comorbid condition. When adjusting for all identifiable variables, patients who undergo craniectomy have a 1.7-fold higher risk of dying in the hospital.

Conclusions

In the United States, craniotomy is performed 10 times more frequently than DC in patients with ASDH. Patients who undergo craniectomy are younger, have significantly longer hospitalizations, and are more likely to be discharged to a skilled nursing or rehabilitation facility or to die in the hospital. Although the optimal management of these patients is highly debated, surgical management in most of these patients in the United States involves performing a craniotomy.

Acknowledgments

The authors thank Dr. Ellen McCarthy at the Harvard School of Public Health for her guidance and assistance.

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    Conflict of interest statement: This study was funded in part by the National Library of Medicine Grant No. T15LM007092. D.G. is funded by the VGH & UBC Hospital Foundation Best of Health Fund. The remaining authors have no conflicts to report.

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