Surgery for Acute Subdural Hematoma: Replace or Remove the Bone Flap?

World Neurosurg. 2016 Apr;88:569-575. doi: 10.1016/j.wneu.2015.10.045. Epub 2015 Oct 31.


Objective: In surgery for acute subdural hematoma (ASDH), the bone flap can be fixed onto the skull, left riding to provide partial skull decompression, or removed. This study assessed whether removing the bone flap improved outcome.

Methods: We conducted an observational study on consecutive patients who were operated for ASDH in our hospital from July 2011 to June 2014. We retrospectively collected data on demographics, injury severity, and predicted and observed outcomes at 6 months. The cohort was divided into 2 groups based on whether the bone flap was replaced (fixed and riding flap craniotomy) or removed (decompressive craniectomy). The differences in functional status, postoperative control of intracranial hypertension, and number of cranial reoperations were analyzed. A subgroup analysis compared decompressive craniectomy with riding flap craniotomy alone.

Results: Data were obtained for 99 patients; 69 had decompressive craniectomy, 17 had riding flap craniotomy, and 13 had fixed flap craniotomy. The decompressive craniectomy group had statistically worse injuries, more predicted poor outcomes (69% vs. 57%, P = 0.013), more observed poor outcomes (59% vs. 37%, P = 0.037), equivalent control of intracranial hypertension, and a similar number of reoperations compared with the craniotomy groups. Subgroup analysis between decompressive craniectomy and riding flap craniotomy showed no significant difference in baseline characteristics and outcomes.

Conclusions: Our study concluded that removing the bone flap after ASDH evacuation was not associated with a better outcome. We recommend replacing the bone flap if brain conditions allow. Further research is required to evaluate the role of skull decompression in surgery for ASDH.

Keywords: Acute subdural hematoma; Brain edema; Craniotomy; Decompressive craniectomy; Traumatic brain injury.

Publication types

  • Observational Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Causality
  • Comorbidity
  • Craniotomy / mortality*
  • Craniotomy / statistics & numerical data
  • Decompressive Craniectomy / mortality*
  • Decompressive Craniectomy / statistics & numerical data
  • Female
  • Hematoma, Subdural, Acute / mortality*
  • Hematoma, Subdural, Acute / surgery*
  • Humans
  • Intracranial Hypertension / mortality*
  • Intracranial Hypertension / surgery*
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Prevalence
  • Reoperation
  • Risk Factors
  • Skull / transplantation
  • Surgical Flaps / transplantation
  • Survival Rate
  • Treatment Outcome
  • United Kingdom / epidemiology
  • Young Adult