Abstract Body: Background: Traumatic acute subdural hematoma (tSDH) is a life-threatening condition and frequently requires surgical evacuation via craniotomy (bone flap) or decompressive craniectomy (no bone flap). However, there are controversial data regarding this setting. We aimed to give a comprehensive assessment of craniotomy versus decompressive craniectomy in patients with tSDH.

Methods: We systematically searched PubMed, OVID, Cochrane Library, Scopus, and Web of Science for eligible comparative studies from inception until April 2024. The primary outcome of interest was the rating of the Glasgow Coma Scale (GCS). Other studied outcomes are all-cause mortality, and rate of residual SDH. STATA 18MP was used to analyze the data using the Der-Simonian Leir random effect model.

Results: A total of 16 studies comprising 6405 patients (3963 in the craniotomy, and 2442 in the craniectomy), with a mean age ranging from 34.4 to 68.9 years, and a mean follow-up of 9 months. Craniotomy was associated with a lower risk of all-cause mortality (OR: 0.74, 95% CI: 0.56 to 0.99, p= 0.004; I2= 80.66, p <0.001). Moreover, for patients with GCS scores of 13-15, there were significantly higher rates in the craniotomy group compared to the craniectomy group (OR: 1.64, 95% CI: 1.13 to 2.36, p= 0.001; I2= 0.00, p= 0.75); however, there was no significant difference in patients with the most severe GCS scores of 3-8 or those with GCS scores of 9-12.

Conclusion: Craniotomy was associated with better clinical presentation and postoperative outcomes compared to craniectomy for patients with acute SDH. However, the results are powered by the observational data, and further large-volume RCTs are warranted.