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Journal Club

General Neurosurgery

Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma

The New England Journal of Medicine | 2023

Rapid review note

Journal Club is a rapid, AI-assisted appraisal layer. It highlights study design, effect estimates, and practice relevance, but it is still a briefing, not a replacement for the paper.

For education only. Not medical advice.

Paper snapshot

Rapid study overview

Open paper

DOI

10.1056/NEJMoa2214172

PMID

N/A

PICO

Population

Adult patients (age >16) with traumatic acute subdural hematoma requiring surgical evacuation with a bone flap ≥11 cm

Intervention

Decompressive craniectomy (bone flap not replaced)

Comparator

Craniotomy (bone flap replaced)

Outcomes

Primary: Extended Glasgow Outcome Scale (GOSE) rating at 12 months; Secondary: GOSE at 6 months, EQ-5D-5L scores, mortality, additional cranial surgery, wound complications

Design

Type

Multicenter, randomized, controlled trial

Randomized

Yes

Multicenter

Yes

Blinded

Outcome adjudicators blinded; clinicians and patients unblinded

Follow-up

12 months

Primary endpoint

Ordinal GOSE rating at 12 months

Secondary endpoints

  • GOSE rating at 6 months
  • EQ-5D-5L utility index scores
  • Additional cranial surgery within 2 weeks
  • Wound complications

Practice impact

What this means

RESCUE-ASDH trial found no difference in 12-month GOSE outcomes between craniotomy and decompressive craniectomy for acute subdural hematoma. Craniotomy patients required more reoperations for swelling, while craniectomy patients had more wound complications. When brain allows, consider replacing bone flap to avoid second surgery for cranioplasty.

Bottom line

No significant difference in functional outcomes at 12 months between craniotomy and decompressive craniectomy for acute subdural hematoma evacuation

Strength of evidence

high

Recommendation

consider change

Why it matters

  • Craniotomy associated with higher need for additional surgery (14.6% vs 6.9%) p. 8
  • Craniectomy associated with more wound complications (12.2% vs 3.9%) p. 7
  • Similar mortality and functional outcomes support replacing bone flap when possible without brain compression p. 9

What would change my mind

  • A validated full-text appraisal with explicit effect estimates and page-linked citations.

Critical appraisal

How strong is the paper?

Methods critique

Risk of bias

Randomization and blinded outcome adjudication strengthen internal validity, but crossover between assigned procedures and surgeon discretion during decompression make the treatment contrast somewhat pragmatic rather than perfectly fixed.

Confounding

Baseline characteristics well-balanced; similar GCS scores, pupil reactivity, and CT findings between groups p. 5, 7

Missing data

5.3% missing primary outcome data; no imputation performed; post-hoc sensitivity analysis performed for missing data p. 5, 8

Multiplicity

No adjustment for secondary outcome confidence intervals; authors note no definite conclusions can be drawn from secondary results p. 8

Notes

  • Pragmatic design allows surgeon discretion for dura closure and wound management p. 3
  • Non-adherence occurred (8.8% crossover in craniotomy group, 5.4% in craniectomy group) but analyzed by intention-to-treat p. 5
  • Sample size re-estimated mid-trial based on surgeon survey about clinically meaningful effect size p. 4

Stats check

NNT

Not applicable for primary outcome (no significant difference)

Effect sizes

  • Common odds ratio for GOSE at 12 months: 0.85 (95% CI 0.60-1.18) p. 5
  • Odds ratio for additional cranial surgery: 7.60 (95% CI 0.01-0.14) p. 8
  • Difference in wound complications: 8.3 percentage points (3.9% vs 12.2%) p. 7

Absolute effects

  • Death at 12 months: 30.2% craniotomy vs 32.2% craniectomy p. 5
  • Additional cranial surgery: 14.6% craniotomy vs 6.9% craniectomy p. 8
  • Good recovery: 25.6% craniotomy vs 19.9% craniectomy p. 5

Concerns

  • Wide confidence intervals for primary outcome cross null effect
  • Secondary outcomes not adjusted for multiple comparisons
  • Post-hoc missing data analysis may not fully address attrition bias

External validity

Who it applies to

Patients similar to the study population once inclusion criteria are verified.

Who it does not

Patients outside the verified eligibility criteria.

Generalizability notes

  • External validity depends on operative workflow, center expertise, and patient selection.

Evidence trace

Source trace and metadata

Citations (5)

claim_id

methods_critique.risk_of_bias

locator

p. 5

quote

Of 228 patients in the craniotomy group, 208 underwent a craniotomy and 20 underwent a decompressive craniectomy

claim_id

methods_critique.risk_of_bias

locator

p. 5

quote

common odds ratio across outcome categories...was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32)

claim_id

methods_critique.risk_of_bias

locator

p. 7

quote

wound-related complications were reported in 4 patients in the craniotomy group and in 17 in the decompressive craniectomy group

claim_id

stats_check.concerns

locator

p. 1

claim_id

practice_impact.bottom_line

locator

p. 1

Metadata

Generated at

2026-03-09T22:31:48.002Z

Version

pdf-archive-ingest-v1