Elsevier

World Neurosurgery

Volume 95, November 2016, Pages 85-90
World Neurosurgery

Original Article
To Retain or Remove the Bone Flap During Evacuation of Acute Subdural Hematoma: Factors Associated with Perioperative Brain Edema

https://doi.org/10.1016/j.wneu.2016.07.067Get rights and content
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Background

The fate of the bone flap is a significant decision during surgical treatment of acute subdural hematoma (SDH). A general guideline revolves around the surgeon's concern for brain edema. Limited studies, however, have focused on the factors that contribute to perioperative brain edema.

Methods

From 2012 to 2015, 38 patients who underwent decompressive craniectomy for acute SDH were reviewed. Clinical data were extracted (age, sex, initial Glasgow Coma Scale (GCS) score, sodium level, hematocrit, and intraoperative blood loss). From the preoperative scan, SDH volume, midline shift (MLS), and volume within the skull (to estimate baseline brain volume) were measured. From the postoperative scan, brain volume (including any herniating regions) was measured. Δ% was defined as the percentage change in postoperative brain volume compared with preoperative volume. Evident contralateral injury, contusions, and intraventricular hemorrhage (IVH) were noted.

Results

Fifteen patients demonstrated negative Δ%. Univariate analysis found significant correlations between Δ% and preoperative MLS, initial GCS, presence of IVH, and presence of contralateral injury (P < 0.05). A multiple regression for Δ% elicited a significant model (F [3, 34] = 17.387, P < 0.01) with R2 0.605, where Δ% = 16.197 − 1.246*GCS − 0.986 * MLS + 3.292 * IVH (with 0 = no IVH, 1 = presence of IVH).

Conclusions

A high proportion of patients can exhibit negative Δ%, or relative brain compression after decompression of SDH. For these patients, replacement of the bone flap may be reasonable to avoid obligatory interval cranioplasty. Preoperative MLS, initial GCS, and presence of IVH can help predict whether overall brain volume will swell or compress within the normal confines of the skull. This can guide the decision to retain or remove the bone flap.

Key words

Acute subdural hematoma
Brain edema
Trauma

Abbreviations and Acronyms

Δ%
Percentage change in postoperative brain volume compared with preoperative volume
CR
Craniotomy
CT
Computed tomography
DC
Decompressive craniectomy
GCS
Glasgow Coma Scale
IVH
Intraventricular hemorrhage
MLS
Midline shift
SDH
Subdural hematoma
TBI
Traumatic brain injury

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.