APR 23, 2023 12:31 PM PDT

Brain Surgery Debate Settled: To Replace or Not to Replace the Skull Flap?

WRITTEN BY: Amielle Moreno

Rest assured, we know how we'll crack open your skull now.

Image Credit Rama, via Creative Commons Attribution-ShareAlike 3.0 France

The New England Journal of Medicine has reported the results from a multicenter study involving 11 countries on the outcome of the two primary approaches to acute subdural hematoma.

An acute subdural hematoma occurs when blood seeps into the space between the brain and the skull; a site only filtered cerebral spinal fluid should flow. To treat, doctors open up the skull to remove the clot, relieving pressure on the brain. But then, what do you do with that chunk of the removed skull?

This was the question of their clinical trial, explained Peter Hutchinson, Professor of Neurosurgery at Cambridge and the trial's Chief Investigator, "which technique is optimal for removing an acute subdural hematoma – a craniotomy (putting the bone back) or a decompressive craniectomy (leaving the bone out)?"

At the end of the large trial, patient recovery, complication, and mortality rates were compared between the two approaches. Though results were similar, consultant neurosurgeon and Cambridge Professor Angelos Kolias explained that "based on the trial findings, we recommend that after removing the blood clot, if the bone flap can be replaced without compression of the brain, surgeons should do so, rather than performing a pre-emptive decompressive craniectomy." One clear benefit to a craniotomy is that these patients don't need skull reconstruction later.



Surgeons have been opening human skulls since 3000 BCE. A surgical procedure called trepanation was performed prehistorically. Hippocrates described trepanation in text, and it remained a practice of Western medicine until the Middle Ages. Trepanation involves cutting the scalp and drilling an opening into the cranium to relieve the swelling associated with traumatic head injuries.

Anthropologists and doctors from today have examined the still open trepanation holes of ancient Peruvians. Evidence of bone healing around the drill sites suggests up to 91% survival rates once techniques were refined in 1000-1400 ACE. This exceeded rates during the American Civil War (46%-56%). But to be fair, wartime surgery is a more chaotic operating environment.

In the present day, and after this definitive study, medical doctors will likely replace any surgically removed skull with a craniotomy technique. However, in various spaces where brain surgeries are performed, pre-emptive decompressive craniectomy might be used in cases of limited resources or front-line settings.

Sources:  Hutchinson, PJ et al. Decompressive Craniectomy versus Craniotomy for Acute Subdural Hematoma. NEJM; 23 Apr 2023, World Neurosurgery, Science

About the Author
Doctorate (PhD)
Amielle Moreno earned her doctorate in neuroscience from Emory University and has dedicated her career to science communication, news coverage, and academic writing/editing. She is a published researcher who has branched out to author articles for various science websites. She recently published an original research article detailing her findings on how sensory areas of the brain respond to social sound. When she's not writing or editing, you can find her spinning the latest neuroscience news into comedy gold, hosting her podcast "Miss Behavior Journal Club." This fortnightly humorous podcast features the latest in behavioral research. Her goal in life is to defend and discover scientific truths.
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