Comparative Study between Bone Flap Insertion in Abdominal Wall Versus Flail Replacement in Decompressive Craniectomy of Acute Subdural Hematoma

Abstract
Background: Traumatic acute subdural hematoma remains one of the most lethal of all head injuries patients with Acute Subdural Hematomas (ASDHs) having higher mortality and lower functional recovery rates compared with those of other head-injured patients.
Decompressive Craniectomy (DC) for management of ASDH with accompanying brain edema and midline shift has become one of the standard guidelines in many centers. DC remains to be the standard of surgical modality for patients with poor clinical status.
Subcutaneous preservation of autologous bone flap is an inexpensive option that preserves the viability of the bone flap, resulting in good cosmetic results and the very low infection rate.
Aim of Study: To compare results of (ASDHs) managed with DC with consequent subcutaneous bone flap insertion in the abdominal wall vs subcutaneous hinged flail placement in the craniectomy site.
Patients and Methods: A retrospective review of 61 patients with (ASDHs) operated at the Department of Neuro-surgery, Cairo University and Beni Souf University Hospital during the period from Jan. 2012 – Dec. 2015. Patients were divided into:
Group (A): 31 patients operated upon with subcutaneous abdominal bone flap insertion, (22 males and 9 females) median age was 42 years. On admission there were 19 patients with Glasgow Coma Score (GCS) below 8, and 12 patients with GCS 8 or above 8.
Group (B): 30 patients operated upon with subcutaneous hinged flail bone flap replacement in the craniectomy site, (22 males and 8 females) median age 44 years. On admission there were 18 patients with GCS blew 8, and 12 patients with GCS 8 or above 8.
Early surgical evacuation, dural fenestration, intensive care management to monitor intra cranial pressure and follow-up CT brain were done for all patients.
Results: Group (A) 14 patients died in the hospital, 4 survived with unfavorable outcome (vegetative state), and 13 survived with favorable outcome.
Group (B) 17 patients died in the hospital, 4 survived with unfavorable outcome (vegetative state), and 9 survived with favorable outcome.
Conclusion: Analysis of the obtained data reveals that subcutaneous abdominal bone flap insertion shows a statisti-cally significant better prognosis as compared to subcutaneous hinged flail bone flap replacement at the craniectomy site which may be due to better decompression of the brain and allowing for more roomfor expansion.