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BACKGROUND Traumatic acute subdural hematomas frequently warrant surgical evacuation by means of a craniotomy (bone flap replaced) or decompressive craniectomy (bone flap not replaced). Craniectomy may prevent intracranial hypertension, but whether it is associated with better outcomes is unclear. METHODS We conducted a trial in which patients undergoing surgery for traumatic acute subdural hematoma were randomly assigned to undergo craniotomy or decompressive craniectomy. An inclusion criterion was a bone flap with an anteroposterior diameter of 11 cm or more. The primary outcome was the rating on the Extended Glasgow Outcome Scale (GOSE) (an 8-point scale, ranging from death to "upper good recovery" [no injury-related problems]) at 12 months. Secondary outcomes included the GOSE rating at 6 months and quality of life as assessed by the EuroQol Group 5-Dimension 5-Level questionnaire (EQ-5D-5L). RESULTS A total of 228 patients were assigned to the craniotomy group and 222 to the decompressive craniectomy group. The median diameter of the bone flap was 13 cm (interquartile range, 12 to 14) in both groups. The common odds ratio for the differences across GOSE ratings at 12 months was 0.85 (95% confidence interval, 0.60 to 1.18; P = 0.32). Results were similar at 6 months. At 12 months, death had occurred in 30.2% of the patients in the craniotomy group and in 32.2% of those in the craniectomy group; a vegetative state occurred in 2.3% and 2.8%, respectively, and a lower or upper good recovery occurred in 25.6% and 19.9%. EQ-5D-5L scores were similar in the two groups at 12 months. Additional cranial surgery within 2 weeks after randomization was performed in 14.6% of the craniotomy group and in 6.9% of the craniectomy group. Wound complications occurred in 3.9% of the craniotomy group and in 12.2% of the craniectomy group. CONCLUSIONS Among patients with traumatic acute subdural hematoma who underwent craniotomy or decompressive craniectomy, disability and quality-of-life outcomes were similar with the two approaches. Additional surgery was performed in a higher proportion of the craniotomy group, but more wound complications occurred in the craniectomy group. (Funded by the National Institute for Health and Care Research; RESCUE-ASDH ISRCTN Registry number, ISRCTN87370545.)

ObjectivesThis study aims to find if the incidence and pattern of traumatic brain injury (TBI) changed during the COVID-19pandemic. We also aim to build an explanatory model for change in TBI incidence using Google community mobility and alcohol sales data.DesignA retrospective time-series analysis.SettingEmergency department of a tertiary level hospital located in a metropolitan city of southern India. This centre is dedicated to neurological, neurosurgical and psychiatric care.ParticipantsDaily counts of TBI patients seen between 1 December 2019 and 3 January 2021 (400 days); n=8893. To compare the profile of TBI cases seen before and during the pandemic, a subset of these cases seen between 1 December 2019 and 31 July 2020 (244 days), n=5259, are studied in detail.ResultsAn optimal changepoint is detected on 20 March 2020 following which the mean number of TBI cases seen every day has decreased and variance has increased (mean 1=29.4, variance 1=50.1; mean 2=19.5, variance 2=59.7, loglikelihood ratio test: χ2=130, df=1, p2=58.1). A significant decrease in traffic accidents, falls, mild/moderate injuries and, an increase in assault and severe injuries is seen during the pandemic period.ConclusionsDecongestion of roads and regulation of alcohol sales can decrease TBI occurrence substantially. An increase in violent trauma during lockdown needs further research in the light of domestic violence. Acute care facilities for TBI should be maintained even during a strict lockdown as the proportion of severe TBI requiring admission increases.