M. H. Khan1, M. Fatima1, H. A. Maqsood2, S. F. Abid1, M. Roshaan1, T. B. Kashif1, A. H. Rashid1, S. Amir1, M. H. Faisal1, A. Z. Syeda3, S. A. Naqi1 1King Edward Medical University, Department Of Surgery, Lahore, PUNJAB, Pakistan 2Yale New Haven Health, Department Of Surgery, New Haven, CT, USA 3University Of Pennsylvania, Department Of Surgery, Philadelphia, PA, USA
Introduction:
Subdural hemorrhage (SDH) resulting from traumatic brain injury is a life-threatening situation requiring surgical intervention. Decompressive craniectomy (DC) and craniotomy (CO) are two procedures performed to evacuate the hematoma. A previous meta-analysis comparing the two surgical modalities was unable to establish conclusively which of the two procedures should be preferred for SDH evacuation. This meta-analysis is done to update the literature with newer studies and to determine the better of the two procedures for future guidelines.
Methods:
The screening and selection of studies were done after searching online databases onwards from the year 2000. Randomized controlled trials (RCTs) and retrospective cohorts were included. Forest plots were created comparing the pooled results of the two procedures. Dichotomous outcomes were compared using Odds Ratios (OR) and 95% confidence interval (CI). Continuous outcomes were compared by mean and standard deviation (SD).
Results:
There were a total of 4529 patients in 13 included studies in the meta-analysis. 2056 of them underwent DC (48.3%) versus 2203 who underwent CO (51.7%). Pooled GOS scores were compared on the basis of their means, with the CO group having better mean scores than DC (Mean Difference -0.53 95% CI -1.06 to 0.01]. Comparing the frequency of poor outcomes (severely disabled + vegetative + death) on the GOS scale, there were more poor outcomes in the DC group vs the CO group (OR 1.22, 95% CI 0.95, 1.55).
There were fewer postoperative residual SDH cases in the DC group compared to craniotomy (OR 0.40, 95% 0.22, 0.73). However, there were more reoperations in the DC group versus CO (OR 1.18, 95% CI 0.68, 2.06]. There was also a greater occurrence of both in-hospital mortality (OR 1.37 95% CI 0.77, 2.45) and mortality at the longest follow-up (OR 1.47 95% CI 0.97, 2.24) in the DC group.
Conclusion:
Our meta-analysis is the largest pooled analysis of SDH patient outcomes compared on the basis of surgery modalities. There is evidence to favor craniotomy over decompressive craniectomy. There were fewer occurrences of residual SDH with DC, however, GOS score comparisons, reoperation, and mortality analysis showed better outcomes for people undergoing craniotomy.
