Quantified standardized individualized small craniotomy vs. conventional large craniotomy for cerebral herniation secondary to acute supratentorial epidural hematoma: a propensity score-matched study for emergency and battlefield trauma care

Background Acute supratentorial epidural hematoma (EDH) with uncal transtentorial herniation is a fatal emergency for civilian and battlefield trauma. Conventional large craniotomy causes excessive surgical damage inconsistent with damage control surgery (DCS). Current minimally invasive EDH approaches lack standardized bone window metrics, rarely enroll patients with definite brain herniation, and lack battlefield-adapted evidence. This 1:1 propensity score-matched (PSM) study compared perioperative trauma and long-term neurological outcomes between a stratified quantitative small craniotomy and traditional decompressive surgery. Methods This single-center retrospective cohort included patients with isolated acute EDH and preoperative uncal herniation (2012–2018). Confounders such as age, admission GCS, hematoma volume and anisocoria were balanced via PSM. A five-step CT-guided quantified small craniotomy workflow with tiered 4.0–6.0 cm bone windows was applied. Primary outcomes were operative time and intraoperative blood loss; secondary outcomes covered reoperation risk, hematoma clearance, soft tissue complications, wound healing and 6-month GOS. Results Twenty-two matched pairs (44 patients) were analyzed. Small craniotomy was associated with a 31.1% reduction in operative duration and 71.7% reduction in intraoperative blood loss (both p < 0.001). It lowered persistent scalp numbness and accelerated suture removal (both p < 0.05). No reoperations occurred in either group. No statistically significant intergroup differences in residual hematoma, clearance efficiency and 6-month neurological recovery were detected, although the cohort size limits our capacity to exclude small-to-moderate clinically meaningful differences. Subgroup exploratory analyses are reported in Supplementary Table S1 . Conclusion CT-guided quantified individualized small craniotomy represents a DCS-compliant minimally-invasive surgical option for patients with herniated acute EDH in this selected cohort. No statistically significant between-group differences in hematoma evacuation efficacy or 6-month neurological functional recovery were detected, though our analysis is limited by modest sample size and cannot definitively rule-out small-to-moderate clinically meaningful differences between procedures. The procedure was associated with reduced surgical trauma metrics. This standardized rapid decompression protocol possesses hypothetical translational value for civilian emergency treatment and resource-limited casualty-care scenarios.