Surgical approaches to cerebral decompression: A meta-analysis of hinge craniotomy and decompressive craniectomy

Objectives: To assess whether hinge craniotomy (HC) offers outcomes comparable to decompressive craniectomy (DC) regarding mortality, functional recovery, complications (hydrocephalus and seizure incidence) and postoperative intracranial pressure (ICP). This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Materials and Methods: A systematic search of PubMed and a relevant scoping review were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020. Studies comparing HC with DC in non-infant patients treated for elevated ICP were included. Outcomes included favourable Glasgow Outcome Scale (GOS) scores, mortality, complications and postoperative ICP. Data were pooled using random-effects models and sensitivity analyses evaluated robustness. Results: Twelve studies (663 patients) were included. HC and DC demonstrated no significant difference in favourable GOS at discharge (Risk Ratio (RR) 1.51, 95% Confidence Interval (CI): 0.34–6.71) or six months (RR 1.23, 95% CI: 0.85–1.76). Mortality was comparable in-hospital (RR 1.20, 95% CI: 0.75–1.93) and at final follow-up (RR 0.80, 95% CI: 0.19–3.31). Postoperative ICP could not be reliably assessed due to limited and overlapping data. HC was associated with significantly lower hydrocephalus risk (RR 0.48, 95% CI: 0.36–0.65) and a non-significant effect suggesting fewer seizures (RR 0.64, 95% CI: 0.40–1.04). Conclusion: HC offers comparable mortality and functional outcomes to DC, with evidence of reduced hydrocephalus risk and a possible benefit in seizure incidence. Reliable assessment of postoperative ICP was not feasible, highlighting the need for more high-quality comparative trials.