英国剑桥大学Peter J. Hutchinson团队比较了开颅手术或减压颅骨切除术治疗外伤性急性硬膜下血肿对患者预后的影响。2023年4月23日出版的《新英格兰医学杂志》发表了这项成果。

外伤性急性硬膜下血肿通常需要通过开颅手术（更换骨瓣）或减压颅骨切除术（不更换骨瓣）。开颅手术可以预防颅内高压，但它是否与更好的预后有关尚不清楚。

研究组进行了一项试验，将接受外伤性急性硬膜下血肿手术的患者随机分为开颅或减压颅骨切除术。纳入标准是前后直径为11厘米或以上的骨瓣。主要结局是在12个月时根据扩展格拉斯哥结果量表（GOSE）（一种8分量表，从死亡到“恢复良好”[无损伤相关问题]）进行评分。次要结局包括6个月时的GOSE评分和EuroQol集团5维度5级问卷（EQ-5D-5L）评估的生活质量。

共有228名患者被分配到开颅手术组，222名被分配到减压颅骨切除术。两组骨瓣的中位直径均为13厘米。12个月时，GOSE评分差异的共同优势比为0.85。6个月时的结局相似。12个月时，开颅手术组30.2%的患者和减压颅骨切除术32.2%的患者死亡；两组中分别有2.3%和2.8%的患者处于植物人状态，25.6%和19.9%的患者发生较低或较高的良好恢复。两组在12个月时的EQ-5D-5L评分相似。14.6%的开颅手术组和6.9%的减压颅骨切除术组患者在随机分组后2周内进行了额外的颅骨手术。开颅手术组和减压颅骨切除术组分别有3.9%和12.2%的患者出现创伤并发症。

研究结果表明，在接受开颅手术或减压颅骨切除术的创伤性急性硬膜下血肿患者中，这两种方法的残疾和生活质量预后相似。开颅手术组中进行额外手术的比例较高，但减压颅骨切除术组发生创伤并发症较多。

附：英文原文

Title: Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma | NEJM

Author: Peter J. Hutchinson, Ph.D., F.R.C.S. (SN),, Hadie Adams, M.D.,, Midhun Mohan, M.R.E.S., M.R.C.S.,, Bhagavatula I. Devi, M.Ch.,, Christopher Uff, Ph.D., F.R.C.S. (SN),, Shumaila Hasan, M.R.C.S.,, Harry Mee, M.R.C.P.,, Mark H. Wilson, Ph.D., F.R.C.S. (SN),, Deepak K. Gupta, M.Ch., Ph.D.,, Diederik Bulters, F.R.C.S. (SN),, Ardalan Zolnourian, M.R.C.S.,, Catherine J. McMahon, Ph.D., F.R.C.S. (SN),, Matthew G. Stovell, M.R.C.S., Ph.D.,, Yahia Z. Al-Tamimi, F.R.C.S. (SN),, Manoj K. Tewari, M.Ch.,, Manjul Tripathi, M.Ch.,, Simon Thomson, F.R.C.S. (SN),, Edoardo Viaroli, M.D.,, Antonio Belli, F.R.C.S. (SN),, Andrew T. King, F.R.C.S. (SN),, Adel E. Helmy, Ph.D., F.R.C.S. (SN),, Ivan S. Timofeev, Ph.D., F.R.C.S. (SN),, Sarah Pyne, M.Sc.,, Dhaval P. Shukla, M.Ch.,, Dhananjaya I. Bhat, M.Ch.,, Andrew R. Maas, M.D., Ph.D.,, Franco Servadei, M.D.,, Geoffrey T. Manley, M.D., Ph.D.,, Garry Barton, Ph.D.,, Carole Turner, M.Sc.,, David K. Menon, F.Med.Sci.,, Barbara Gregson, Ph.D.,, and Angelos G. Kolias, Ph.D., F.R.C.S. (SN)

Issue&Volume: 2023-04-23

Abstract:

Background

Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear.

Methods

We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to “upper good recovery” [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L).

Results

A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P=0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group.

Conclusions

Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group.

DOI: 10.1056/NEJMoa2214172

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2214172