Among patients undergoing evacuation of a traumatic acute subdural haematoma, decompressive craniectomy did not result in better outcomes than craniotomy and was not considered to represent value for money.
There was no statistically significant difference in functional outcomes at 12 months between decompressive craniectomy and craniotomy for acute subdural haematoma evacuation.
Mortality rates at 12 months were similar between the craniotomy and decompressive craniectomy groups.
Additional surgery was required in a higher proportion of patients in the craniotomy group, while more wound complications occurred in the decompressive craniectomy group.
In the observational (non-randomised) cohort, patients who underwent decompressive craniectomy had significantly worse outcomes at 6 and 12 months, but had worse baseline characteristics.
There was intraoperative non-adherence with allocation in both arms of the randomised trial.
Craniotomy was estimated to offer better value for money than decompressive craniectomy in UK patients.
The trial identified unanswered questions regarding long-term outcomes following decompressive craniectomy, including timing and impact of cranial reconstruction on rehabilitation.
This research compared two surgical techniques used to remove dangerous blood clots from the brain (acute subdural haematomas): craniotomy, where the piece of skull removed during surgery is replaced at the end, and decompressive craniectomy, where the skull piece is left out to allow the brain to swell. In a randomised trial of 450 patients across multiple hospitals in the UK and internationally, the study found no significant difference in patient outcomes one year after surgery between the two approaches. Around 30% of patients in both groups died, and good recovery rates were broadly similar (25.6% for craniotomy vs. 19.9% for craniectomy), though the overall difference was not statistically significant. The two procedures did differ in their complication profiles: patients who had craniotomy were more likely to need additional surgery, while patients who had decompressive craniectomy experienced more wound complications. In a separate group of patients who were not randomised but observed, those receiving decompressive craniectomy appeared to do worse — but these patients already had worse conditions before surgery, which likely explains the difference. The economic analysis, based on UK patients, estimated that craniotomy was associated with lower costs and higher quality of life, suggesting better value for money. This research suggests that for most patients needing emergency surgery to remove an acute subdural haematoma, craniotomy (replacing the skull) performs as well as decompressive craniectomy (leaving the skull out) in terms of survival and functional recovery, while also being more cost-effective. This is important because decompressive craniectomy is a more complex procedure that requires a second surgery to replace the skull later, and it was previously thought it might reduce dangerous brain swelling and improve outcomes. The findings indicate that surgeons may be able to choose craniotomy as the default approach without compromising patient outcomes, though further research is needed on the longer-term effects of each procedure and how skull reconstruction affects patient rehabilitation.
Hutchinson P, Mee H, Adams H, Mohan M, Devi B, Uff C, et al.. (2026). Decompressive craniectomy versus craniotomy for patients undergoing surgical evacuation of an acute subdural hematoma: RESCUE-ASDH RCT and cost effectiveness.. Health technology assessment (Winchester, England). https://doi.org/10.3310/GJPH0512