Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis

Objective The optimal surgical management of acute traumatic subdural hematoma (ASDH) is controversial; both craniectomy and craniotomy are performed. The purpose of this study was to determine the current management of ASDH in the United States. Methods This retrospective cohort study used the Nationwide Inpatient Sample from the years 2006-2011 to examine patients with a primary diagnosis of ASDH. All patients ≥18 years old with a primary diagnosis of ASDH were included in the analysis. Patients with procedure codes for craniectomy and craniotomy were isolated from the database. Propensity score matching based on logistic regression was used to match craniotomy to craniectomy in a 1:1 fashion. Results There were 47,911,414 hospitalizations analyzed. Of 60,435 patients with ASDH identified, 1763 underwent craniotomy and 177 underwent craniectomy. The average age of patients who underwent craniectomy was 49.5 years (SD 20.8) compared with an average age of 68.9 years (SD 17.1) of patients who underwent craniotomy (P < 0.0001). Hospital mortality was significantly higher in patients who underwent craniectomy (35.0% vs. 10.9%, P < 0.0001). Patients who underwent craniectomy had longer hospital stays compared with patients who underwent craniotomy (median duration 14.3 days [interquartile range 25] for craniectomy vs. 10.9 days [interquartile range 9] for craniotomy, P < 0.0001). Patients who underwent craniectomy were also more likely to be discharged to a skilled nursing or rehabilitation facility (79.1% vs. 63.9%, P = 0.0011). Conclusions Craniotomy is the preferred surgical technique for management of ASDH in the United States, being performed 10 times more frequently than craniectomy. Craniectomy was associated with significantly higher in-hospital mortality after propensity score matched analysis.