Traumatic Acute Subdural Hematoma - Should the Bone Flap Be Removed or Replaced?

Traumatic acute subdural hematomas often warrant emergency evacuation of the blood clot to avoid further cerebral compression and its sequelae. Once the subdural clot is removed, the million-dollar question in the mind of the neurosurgeon is to whether to replace the bone flap (craniotomy) or not (decompressive craniectomy). In some instances, the decision to leave the bone flap on or off is relatively straightforward, such as in older persons with atrophic brains who have a visually "relaxed" brain after clot evacuation (in whom the bone flap should be replaced) or in a patient with massively swollen brain (in whom the . . .