From the Research
Craniotomy is indicated for subdural hematoma (SDH) when the hematoma thickness exceeds 10mm, midline shift is greater than 5mm, or the patient's Glasgow Coma Scale (GCS) score is less than 9, as supported by the most recent and highest quality study 1.
Key Considerations for Craniotomy
- For subarachnoid hemorrhage (SAH), craniotomy is typically performed when there is an associated aneurysm requiring surgical clipping, large hematomas causing significant mass effect, or hydrocephalus requiring CSF diversion.
- Urgent surgical intervention is necessary for patients with acute neurological deterioration, pupillary abnormalities, or increasing intracranial pressure (ICP) above 20-25 mmHg despite medical management.
- Medical management prior to surgery includes:
- Maintaining systolic blood pressure below 140-160 mmHg
- Elevating the head of bed to 30 degrees
- Administering mannitol (0.25-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) for increased ICP
- Seizure prophylaxis with levetiracetam (500-1000 mg IV twice daily)
Decision-Making for Craniotomy
- The decision for craniotomy must be individualized based on the patient's clinical status, comorbidities, hematoma characteristics, and potential for neurological recovery, as highlighted in a recent study 2.
- A meta-analysis comparing decompressive craniectomy and craniotomy for acute subdural hematoma found that craniotomy was associated with more favorable outcomes in terms of mortality, reoperation rate, and functional outcome 2.
- However, another study found that decompressive craniectomy was associated with a lower rate of residual subdural hematoma, but higher mortality rates compared to craniotomy 3.
Recent Evidence
- A 2023 study published in The New England Journal of Medicine found that disability and quality-of-life outcomes were similar between craniotomy and decompressive craniectomy for traumatic acute subdural hematoma, with additional surgery performed in a higher proportion of the craniotomy group, but more wound complications occurring in the craniectomy group 1.
- A 2022 study published in the Journal of Neurosurgical Sciences found that decompressive craniectomy was performed most frequently for high-energy trauma and was associated with a better neurological outcome in patients with GCS ≤ 8 at admission 4.