The new surgical strategy of emergency burr hole (Bh) surgery followed by large decompressive craniectomy (LDC) was proposed for the treatment of an acute subdural hematoma (ASDH) of complicated hematoma type in 1994 in Japan. The purpose of this study was to identify patient selection criteria and outcome for adult patients with an ASDH undergoing emergency Bh surgery, and to define the state of the art of this strategy.
We reviewed surgically treated 552 adult patients with an ASDH enrolled in Japan Neurotrauma Data Bank Project 1998 and Project 2004. The mean age of patients was 58 years (range, 16 – 98 years; > 65 years, 41%) and the mean GCS was 6.4 (range, 3 – 15; 3 – 5, 51%). Three surgical procedures were performed: Bh surgery alone (=Bha) in 134 patients, Bh surgery followed by craniotomy or LDC (=Bhc) in 30, and craniotomy or LDC as a primary procedure (=Crt) in 388.
Patients with a GCS score of 3 – 5 and those showing dilated fixed pupil(s) or systemic shock on admission were more frequently underwent emergency Bh surgery than did those not revealing them. The proportion of the Bhc to the Bh (=% Bhc/Bh) was lowest in patients over the age of 65 years compared to other younger age groups (p=0.021). The % Bhc/Bh in each GCS group (GCS 3 – 5, 6 – 8, 9 – 15) was 17%, 27%, and 0% respectively (not significant). The mortality and the percent of favorable outcome related to type of operation in subgroups with a GCS score of 3 – 5 were as follows: Bha = 89% / 1% ; Bhc = 45% / 5%; Crt = 54% / 14%. Of 115 cases with favorable outcome 10 cases were underwent Bh surgery (Bha = 8, Bhc = 2). Clinical characteristics of them were a younger age (mean = 33.2 years; unfavorable, 60.0, p<0.001), a higher GCS score (mean = 6.6; unfavorable, 4.6, p=0.002) and low incidence of dilated fixed pupil(s) (40%; unfavorable, 75%, p=0.026).
Emergency Bh surgery is undoubtedly effective for patients with an ASDH of simple hematoma type. The new strategy has provided little improvement in outcome of patients with an ASDH of complicated hematoma type. Nevertheless, with appropriate modifications, this strategy will improve outcome after severe ASDH.
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