• Georgios Tsermoulas, Omid Shah, Haren Eranga Wijesinghe, SilvaAdikarige Haritha DulankaAHDDepartment of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK., Satheesh K Ramalingam, and Antonio Belli.
• Department of Neurosurgery, Queen Elizabeth Hospital, Birmingham, UK. Electronic address: georgios.tsermoulas@nhs.net.
• World Neurosurg. 2016 Apr 1; 88: 569-575.

ObjectiveIn surgery for acute subdural hematoma (ASDH), the bone flap can be fixed onto the skull, left riding to provide partial skull decompression, or removed. This study assessed whether removing the bone flap improved outcome.MethodsWe conducted an observational study on consecutive patients who were operated for ASDH in our hospital from July 2011 to June 2014. We retrospectively collected data on demographics, injury severity, and predicted and observed outcomes at 6 months. The cohort was divided into 2 groups based on whether the bone flap was replaced (fixed and riding flap craniotomy) or removed (decompressive craniectomy). The differences in functional status, postoperative control of intracranial hypertension, and number of cranial reoperations were analyzed. A subgroup analysis compared decompressive craniectomy with riding flap craniotomy alone.ResultsData were obtained for 99 patients; 69 had decompressive craniectomy, 17 had riding flap craniotomy, and 13 had fixed flap craniotomy. The decompressive craniectomy group had statistically worse injuries, more predicted poor outcomes (69% vs. 57%, P = 0.013), more observed poor outcomes (59% vs. 37%, P = 0.037), equivalent control of intracranial hypertension, and a similar number of reoperations compared with the craniotomy groups. Subgroup analysis between decompressive craniectomy and riding flap craniotomy showed no significant difference in baseline characteristics and outcomes.ConclusionsOur study concluded that removing the bone flap after ASDH evacuation was not associated with a better outcome. We recommend replacing the bone flap if brain conditions allow. Further research is required to evaluate the role of skull decompression in surgery for ASDH.Copyright © 2016 Elsevier Inc. All rights reserved.

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