Correspondence
Treatment of acute decompressive craniectomy, despite
subdural haematoma
In their Article, Thomas A van Essen
and colleagues compared emergency
surgery with initial conservative
treatment for traumatic acute
subdural haematoma, regardless of
associated traumatic brain injuries.1
They concluded that emergency
surgical evacuation of acute subdural
haematoma was not associated with
better functional outcome on the
Glasgow Outcome Scale Extended at
6 months. However, the study had
broad inclusion criteria and patients
were enrolled from many centres
across Europe, which makes the
findings difficult to interpret. Several
points also merit discussion.
First, van Essen and colleagues cited
Brain Trauma Foundation guidelines,2
which recommend surgical evacuation
of acute subdural haematoma based
on radiological criteria. Surprisingly,
the authors added that, in emergency
situations, neurosurgeons must use
intuition, experience, and regional
training to justify decision making.
Yet, the Brain Trauma Foundation
guidelines also state that comatose
patients (ie, with a Glasgow Coma
Scale [GCS] score <9), who have either
a drop of at least 2 points on the GCS
between prehospital care and hospital
admission, asymmetric or fixed dilated
pupils, intracranial pressure higher than
20 mm Hg, or a combination of these
criteria, warrant surgical evacuation of
acute subdural haematoma.
Second, of 1318 patients in the
study, 336 (25%) had emergency
surgery and constituted the surgical
group. Therefore, the conservative
treatment group comprised 982 (75%)
patients. However, 107 (11%) patients
in this conservative group underwent
“delayed” surgical evacuation at
a median of 19 h (IQR 8–85) after
admission, which seems an early
procedure and might have affected the
results.
Third, only 91 (27%) patients in the
surgical group underwent primary
1080 www.thelancet.com/neurology Vol 21 December 2022
1 van Essen TA, Lingsma HF, Pisică D, et al.
their relatively young age (median
56 years [IQR 40–67]); this preference
for craniotomy over decompressive
craniectomy might have affected the
study findings. Indeed, surgery was
associated with a worse outcome in
patients younger than 65 years,1 which
contradicts previous findings showing
that older patients with acute subdural
haematoma usually have a more
dismal prognosis.3,4 In young people
who are at high risk of brain swelling
after acute subdural haematoma,
decompressive craniectomy might
be preferred over craniotomy. 5
Furthermore, of 107 patients in the
conservative treatment group who
underwent delayed surgery, 52 (49%)
had decompressive craniectomy,
which might also have affected the
results.
Finally, baseline characteristics were
unbalanced between groups, with
patients in the surgical group having
a lower GCS and larger haematoma
volume compared with those in
the conservative treatment group.1
Previous work in patients older
than 65 years with acute subdural
haematoma (ie, with a Subdural
Hematoma in the Elderly [SHE] score
of 3 or 4) showed that a low GCS score
upon admission and a haematoma
volume greater than 50 cm³ were
strong predictors of 30-day mortality,
regardless of the treatment strategy.3
Patients with fewer risk factors
(ie, with a SHE score of 1 or 2) might,
therefore, be ideal candidates for
emergency surgical evacuation.
Unfortunately, the SHE score is not
in widespread use yet. Future studies
of emergency surgical evacuation of
acute subdural haematoma should
carefully consider inclusion criteria.
I declare no competing interests.
Nathan Beucler
nathan.beucler@neurochirurgie.fr
Neurosurgery Department, Sainte-Anne Military
Teaching Hospital, 83800 Toulon, France; Ecole du
Val-de-Grâce, French Military Health Service
Academy, Paris, France
Surgery versus conservative treatment for
traumatic acute subdural haematoma:
a prospective, multicentre, observational,
comparative effectiveness study. Lancet Neurol
2022; 21: 620–31.
2 Bullock MR, Chesnut R, Ghajar J, et al. Surgical
management of acute subdural hematomas.
Neurosurgery 2006; 58: S16–24.
3 Alford EN, Rotman LE, Erwood MS, et al.
Development of the Subdural Hematoma in
the Elderly (SHE) score to predict mortality.
J Neurosurg 2019; 132: 1616–22.
4 Baucher G, Troude L, Pauly V, Bernard F,
Zieleskiewicz L, Roche P-H. Predictive factors
of poor prognosis after surgical management
of traumatic acute subdural hematomas:
a single-center series. World Neurosurg 2019;
126: e944–52.
5 Ruggeri AG, Cappelletti M, Tempestilli M,
Fazzolari B, Delfini R. Surgical management of
acute subdural hematoma: a comparison
between decompressive craniectomy and
craniotomy on patients treated from 2010 to
the present in a single center. J Neurosurg Sci
2022; 66: 22–27.
Authors’ reply
We appreciate the comments of
Nathan Beucler on our Article,1 which
might reflect concerns shared also by
other neurosurgeons.
In response to the first point, we
stated the Brain Trauma Foundation
guidelines regarding when to operate
when a patient is not comatose. These
guidelines recommend to operate
on patients with a large haematoma
(ie, clot >10 mm thick or causing
>5 mm midline shift) regardless of
their Glasgow Coma Scale score.
Nevertheless, uncertainty about the
best approach remains.
Second, Beucler suggests that
delayed surgery could be regarded as
acute surgery and should not have been
analysed in the conservative treatment
group. Our research question was
whether to immediately operate
on a patient with an acute subdural
haematoma (as assessed on CT). This
question reflects clinical reality. Some
patients will deteriorate and have
surgery later which—obviously—is
not known at the time of planning.
Comparison of all early (<24 h) surgical
procedures with all conservatively
treated patients would be erroneous
and probably show that surgery
leads to a worse outcome compared
with conservative treatment, due