Hemicraniectomy in the treatment of acute subdural hematoma: a re-appraisal.

Although acute subdural hematoma continues to be one of the more common conditions neurosurgeons are called upon to treat, mortality rates continue to be quite unsatisfactory. Hemicraniectomy with wide decompression of the swollen brain was devised for the condition in 1971 (JNS 34:70-76). Initial results were quite encouraging with a 40% overall survival rate, 28% of the patients returning to normal activity. Since this original report, an additional 50 patients have been treated with only a 10% total survival rate and a 4% functional survival rate. Retrospective analysis of our cases over the past three years reveals that patient's age, status of preoperative neurologic examination, angiographic findings and appearance of the brain at operation, all have no statistical correlation with survival. These statistics will be presented and discussed. The failure of hemicraniectomy and extensive clot removal to significantly increase the functional survival rate in this condition implies that in a majority of patients with "acute subdural hematoma," primary brain stem and possibly subcortical injury are present, neither of which is amenable to radical therapy. The operation of hemicraniectomy should be restricted to those patients who enter hospital, obtunded but without demonstrable brain stem dysfunctionn, only to deteriorate subsequently because of increasing hemispheric edema and/or subdural clot.