Comparative effectiveness of decompressive craniectomy versus craniotomy for traumatic acute subdural hematoma (CENTER-TBI): an observational cohort study
EClinicalMedicine, vol. 63, pp. 102161
Abstract
Background Limited evidence existed on the comparative effectiveness of decompressive craniectomy (DC) versus craniotomy for evacuation of traumatic acute subdural hematoma (ASDH) until the recently published randomised clinical trial RESCUE-ASDH. In this study, that ran concurrently, we aimed to determine current practice patterns and compare outcomes of primary DC versus craniotomy. Methods We conducted an analysis of centre treatment preference within the prospective, multicentre, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (known as CENTER-TBI) and NeuroTraumatology Quality Registry (known as Net-QuRe) studies, which enrolled patients throughout Europe and Israel (2014–2020). We included patients with an ASDH who underwent acute neurosurgical evacuation. Patients with severe pre-existing neurological disorders were excluded. In an instrumental variable analysis, we compared outcomes between centres according to treatment preference, measured by the case-mix adjusted proportion DC per centre. The primary outcome was functional outcome rated by the 6-months Glasgow Outcome Scale Extended, estimated with ordinal regression as a common odds ratio (OR), adjusted for prespecified confounders. Variation in centre preference was quantified with the median odds ratio (MOR). CENTER-TBI is registered with ClinicalTrials.gov, number NCT02210221, and the Resource Identification Portal (Research Resource Identifier SCR_015582). Findings Between December 19, 2014 and December 17, 2017, 4559 patients with traumatic brain injury were enrolled in CENTER-TBI of whom 336 (7%) underwent acute surgery for ASDH evacuation; 91 (27%) underwent DC and 245 (63%) craniotomy. The proportion primary DC within total acute surgery cases ranged from 6 to 67% with an interquartile range (IQR) of 12–26% among 46 centres; the odds of receiving a DC for prognostically similar patients in one centre versus another randomly selected centre were trebled (adjusted median odds ratio 2.7, p < 0.0001). Higher centre preference for DC over craniotomy was not associated with better functional outcome (adjusted common odds ratio (OR) per 14% [IQR increase] more DC in a centre = 0.9 [95% CI 0.7–1.1], n = 200). Primary DC was associated with more follow-on surgeries and complications [secondary cranial surgery 27% vs. 18%; shunts 11 vs. 5%]; and similar odds of in-hospital mortality (adjusted OR per 14% IQR more primary DC 1.3 [95% CI (1.0–3.4), n = 200]). Interpretation We found substantial practice variation in the employment of DC over craniotomy for ASDH. This variation in treatment strategy did not result in different functional outcome. These findings suggest that primary DC should be restricted to salvageable patients in whom immediate replacement of the bone flap is not possible due to intraoperative brain swelling. Funding Hersenstichting Nederland for the Dutch NeuroTraumatology Quality Registry and the European Union Seventh Framework Program.
Authors 98
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Dalhousie University · University of Cambridge · Leiden University Medical Center · Queen Elizabeth II Health Sciences Centre · Medisch Centrum Haaglanden · Addenbrooke's Hospital · Stichting Haaglanden Medisch Centrum
Affiliation as printed
Department of Surgery, Division of Neurosurgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum
Affiliation as printed
University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Affiliation as printed
Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
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Affiliation as printed
Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Department of Neurosurgery, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
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San Francisco General Hospital · University of California, San Francisco
Affiliation as printed
Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
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Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum
Affiliation as printed
University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum
Affiliation as printed
University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Affiliation as printed
Center for Medical Decision Making, Department of Public Health, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Department of Neurosurgery, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Department of Neurosurgery, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
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Heidelberg University · University Hospital Heidelberg
Affiliation as printed
Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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Affiliation as printed
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
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Affiliation as printed
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
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Affiliation as printed
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC - University Medical Center, Rotterdam, the Netherlands
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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San Francisco General Hospital · University of California, San Francisco
Affiliation as printed
Brain and Spinal Injury Center, Department of Neurological Surgery, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, USA
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Universitair Ziekenhuis Leuven · KU Leuven
Affiliation as printed
Department of Neurosurgery, University Hospital KU Leuven, Leuven, Belgium
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Leiden University Medical Center
Affiliation as printed
Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
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University of Antwerp · Antwerp University Hospital
Affiliation as printed
Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum
Affiliation as printed
University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Leiden University Medical Center · Medisch Centrum Haaglanden · Stichting Haaglanden Medisch Centrum
Affiliation as printed
University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, HAGA, Leiden and The Hague, the Netherlands
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Affiliation as printed
Rijndam Rehabilitation and Department of Rehabilitation Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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University of Cambridge · Addenbrooke's Hospital
Affiliation as printed
Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
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Heidelberg University · University Hospital Heidelberg
Affiliation as printed
Department of Neurosurgery, University Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
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