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Surgery for acute subdural hematoma: the value of decompressive craniectomy by propensity score analysis
EANS Academy. Castaño-Leon A. Sep 27, 2019; 275957; EP05043
Dra Ana Castaño-Leon
Dra Ana Castaño-Leon

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Abstract
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Background: Acute subdural haematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are still considered the most lethal type of traumatic mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy (CR) or decompressive craniectomy (DC), remains controversial.
Methods: We reviewed a prospectively collected series of 453 moderate to severe TBI patients in whom ASDH was the main lesion. We selected ASDH with volumes above 10 cc and any midline shift. Bilateral ASDH that required evacuation or the presence of intracerebral/ epidural haematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 207 were managed conservatively, 75 underwent ASDH evacuation by CR and 170 by DC (65 elective and 105 obligatory). We defined obligatory DC when intraoperative brain swelling did not allow bone replacement. We calculated the probability to receive one type of treatment among conservative, CR, elective DC and obligatory DC by Propensity score (PS) analysis (WEIGHTIT R package). The risk of elective DC was modelled using the following covariates: age, year, hypoxia, shock, pupils, Major extracranial injury (MEI), admission motor GCS, midline shift >5mm, ASDH volume, intraventricular and subarachnoid haemorrhage. Then, multivariable logistic regression and ordinal logistic regression were performed to estimate associations between predictors and mortality and 12 months after TBI GOS respectively. The patients' estimated propensity scores were included as an independent variable in the logistic regression model).
Results: The variables associated with outcome were age, hypoxia, shock, year, pupils, CT classification and treatment with conservative treatment and craniotomy revealed worse results.
Conclusions: When differences in patients characteristics are balanced, DC is associated with better outcome in patients with ASDH.
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