1
|
Li H, Yao Y, Jiang Y, Su Y, Wang H, Zhu C, Gan W. Comparison of craniotomy and decompressive craniectomy for acute subdural hematoma: a meta-analysis of comparative study. Int J Surg 2024; 110:5101-5111. [PMID: 38884600 PMCID: PMC11326010 DOI: 10.1097/js9.0000000000001590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/25/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Acute subdural hematoma (ASDH) necessitates urgent surgical intervention. Craniotomy (CO) and decompressive craniectomy (DC) are the two main surgical procedures for ASDH evacuation. This meta-analysis is to compare the clinical outcomes between the CO and DC procedures. MATERIALS AND METHODS The authors performed a meta-analysis according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C513 , Supplemental Digital Content 2, http://links.lww.com/JS9/C514 ) Statement protocol and assessing the methodological quality of systematic reviews (AMSTAR) (Supplemental Digital Content 3, http://links.lww.com/JS9/C515 ) guideline. The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched. Comparative studies reporting the outcomes of the CO and DC procedures in patients with ASDH were included. RESULTS A total of 15 articles with 4853 patients [2531 (52.2%) receiving CO and 2322 (47.8%) receiving DC] were included in this meta-analysis. DC was associated with higher mortality [31.5 vs. 40.6%, odds ratio (OR)=0.58, 95% CI: 0.43-0.77] and rate of patients with poorer neurological outcomes (54.3 vs. 72.7%; OR=0.43, 95% CI: 0.28-0.67) compared to CO. The meta-regression model identified the comparability of preoperative severity as the only potential source of heterogeneity. When the preoperative severity was comparable between the two procedures, the mortality (CO 35.5 vs. DC 38.1%, OR=0.80, 95% CI: 0.62-1.02) and the proportion of patients with poorer neurological outcomes (CO 64.8 vs. DC 66.0%; OR=0.82, 95% CI: 0.57-1.16) were both similar. Reoperation rates were similar between the two procedures (CO 16.1 vs. DC 16.0%; OR=0.95, 95% CI: 0.61-1.48). CONCLUSION Our meta-analysis reveals that DC is associated with higher mortality and poorer neurological outcomes in ASDH compared to CO. Notably, this difference in outcomes might be driven by baseline patient severity, as the significance of surgical choice diminishes after adjusting for this factor. Our findings challenge previous opinions regarding the superiority of CO over DC and underscore the importance of considering patient-specific characteristics when making surgical decisions. This insight offers guidance for surgeons in making decisions tailored to the specific conditions of their patients.
Collapse
Affiliation(s)
- Hua Li
- Department of Orthopedics, Beijing Jishuitan Hospital
| | - Yuqiang Yao
- Department of Neurosurgery, Beijing Jishuitan Hospital, Beijing
| | - Yuwen Jiang
- Department of Traumatology, Zhuhai People's Hospital, Zhuhai, Guangdong
| | - Yibing Su
- Department of Neurosurgery, Beijing Jishuitan Hospital, Beijing
| | - Hanbin Wang
- Department of Neurosurgery, Beijing Jishuitan Hospital, Beijing
| | - Can Zhu
- Second Department of Clinical Medicine, Anhui Medical University, Hefei, Anhui, People's Republic of China
| | - Wenyi Gan
- Department of Traumatology, Zhuhai People's Hospital, Zhuhai, Guangdong
| |
Collapse
|
2
|
Sam JE, Komatsu F, Yamada Y, Tanaka R, Sasaki K, Tamura T, Kato Y. Endoscopic Evacuation of Acute Subdural Hematomas: A New Selection Criterion. Asian J Neurosurg 2024; 19:153-159. [PMID: 38974426 PMCID: PMC11226281 DOI: 10.1055/s-0044-1787101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Introduction Acute subdural hematomas (ASDHs) have a high mortality rate and unfavorable outcomes especially in the elderly population even after surgery is performed. The conventional recommended surgeries by the Brain Trauma Foundation in 2006 were craniotomies or craniectomies for ASDH. As the world population ages, and endoscopic techniques improve, endoscopic surgery should be utilized to improve the outcomes in elderly patients with ASDH. Materials and Methods This was a single-center retrospective report on our series of six patients that underwent endoscopic ASDH evacuation (EASE). Demographic data, the contralateral global cortical atrophy (GCA) score, evacuation rates, and outcomes were analyzed. Results All patients' symptoms and Glasgow Coma Scale improved or were similar after EASE with no complications. Good outcome was seen in 4 (66.7%) patients. Patients with poor outcome had initial low Glasgow Coma Scale scores on admission. The higher the contralateral GCA score, the higher the evacuation rate ( r = 0.825, p ≤ 0.043). All the patients had a GCA score of ≥7. Conclusion EASE is at least not inferior to craniotomy for the elderly population in terms of functional outcome for now. Using the contralateral GCA score may help identify suitable patients for this technique instead of just using a cut-off age as a criteria.
Collapse
Affiliation(s)
- Jo Ee Sam
- Department of Neurosurgery, Hospital Pulau Pinang, Penang, Malaysia
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Fuminari Komatsu
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Kento Sasaki
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Takamitsu Tamura
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| |
Collapse
|
3
|
El-Abtah ME, Roach MJ, Kelly ML. Outcomes After the Surgical Evacuation of Traumatic Acute Subdural Hematomas: The tASDH Risk Score. World Neurosurg 2023; 180:e274-e280. [PMID: 37741337 DOI: 10.1016/j.wneu.2023.09.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/08/2023] [Accepted: 09/09/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Acute subdural hematoma (ASDH) is a common pathology following traumatic brain injury (TBI). There is sparse data on the prediction of clinical outcomes following traumatic ASDH (tASDH) evacuation. We investigated prognosticators of outcome following evacuation of tASDHs, with subset analysis in a cohort of octogenarians. We developed a scoring system for stratifying the risk of in-hospital mortality for patients undergoing tASDH evacuation. METHODS A retrospective chart review was performed to identify all patients who underwent tASDH evacuation. Baseline clinical and demographic data including age, traumatic brain injury mechanism, admission Glasgow Coma Scale (GCS), and Rotterdam computed tomography Scale (RCS) were collected. In-hospital outcomes such as mortality and discharge disposition were collected. A scoring system (tASDH Score) which incorporates RCS (1-2 points), admissions GCS (0-1 points), and age (0-1 point) was created to predict the risk of in-hospital mortality following tASDH evacuation. RESULTS Being an octogenarian (OR = 6.91 [2.20-21.71], P = 0.0009), having a GCS of 9-12 (OR = 1.58 [1.32-4.12], P = 0.027) or 3-8 (OR = 2.07 [1.41-10.38], P = 0.018), and having an RCS of 4-6 (OR = 3.49 [1.45-8.44], P = 0.0055) were independently predictive of in-hospital mortality. The in-hospital mortality rate was lower for those with a tASDH score of 1 (10%), compared to those with a score of 2 (12%), 3 (42%), and 4 (100%). CONCLUSIONS Octogenarians with an RCS of 4-6 and an admission GCS <13 have a high risk of mortality following tASDH evacuation. Knowledge of which patients are unlikely to survive ASDH evacuation may help guide neurosurgeons in prognostication and goals of care discussions.
Collapse
Affiliation(s)
- Mohamed E El-Abtah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mary J Roach
- Department of Physical Medicine and Rehabilitation, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael L Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine MetroHealth Medical Center, Cleveland, Ohio, USA.
| |
Collapse
|
4
|
Azab MA, Iqbal S. Spontaneous acute subdural hematoma as a complication of preeclampsia. A case report and literature review. Surg Neurol Int 2023; 14:81. [PMID: 37025547 PMCID: PMC10070340 DOI: 10.25259/sni_22_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 02/18/2023] [Indexed: 03/06/2023] Open
Abstract
Background:
Acute subdural hematoma (ASDH) is a common form of intracranial bleeding that may be fatal. Trauma is a major cause, while a subset of cases may occur spontaneously. The authors of this article present a case of spontaneous ASDH in the context of preeclampsia and review similar cases in the literature to identify the prognosis.
Case Description:
A healthy 27-year-old woman presented in her first pregnancy which was complicated with pregnancy-induced hypertension and was sent to a provincial local maternity hospital at 37 weeks of gestation. On day 4 postpartum, the patient complained of severe headache, vomiting and blurred vision. Fundus examination showed papilledema and magnetic resonance imaging showed right acute frontoparietal subdural hematoma. The hematoma was surgically evacuated with decompressive craniotomy. Postoperatively, the patient’s symptoms improved.
Conclusion:
Spontaneous ASDH is a rare event in the context of preeclampsia; however, it should be considered as one of its possible complications. Research should be directed to emphasize on the possibility of spontaneous ASDH as a cause of neurological deterioration in those cases. A proper diagnosis and early intervention for these cases are crucial for both the mother and the fetus.
Collapse
Affiliation(s)
- Mohammed A. Azab
- Department of Neurosurgery, Cairo University Hospital, Cairo, Egypt,
| | - Sajid Iqbal
- Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore General Hospital, Lahore, Pakistan
| |
Collapse
|
5
|
Li Z, Feng Y, Wang P, Han S, Zhang K, Zhang C, Lu S, Lv C, Zhu F, Bie L. Evaluation of the prognosis of acute subdural hematoma according to the density differences between gray and white matter. Front Neurol 2023; 13:1024018. [PMID: 36686517 PMCID: PMC9853902 DOI: 10.3389/fneur.2022.1024018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Acute subdural hematoma (ASDH) is a common neurological emergency, and its appearance on head-computed tomographic (CT) imaging helps guide clinical treatment. To provide a basis for clinical decision-making, we analyzed that the density difference between the gray and white matter of the CT image is associated with the prognosis of patients with ASDH. Methods We analyzed the data of 194 patients who had ASDH as a result of closed traumatic brain injury (TBI) between 2018 and 2021. The patients were subdivided into surgical and non-surgical groups, and the non-surgical group was further subdivided into "diffused [hematoma]" and "non-diffused" groups. The control group's CT scans were normal. The 3D Slicer software was used to quantitatively analyze the density of gray and white matter depicted in the CT images. Results Imaging evaluation showed that the median difference in density between the gray and white matter on the injured side was 4.12 HU (IQR, 3.91-4.22 HU; p < 0.001) and on the non-injured side was 4.07 HU (IQR, 3.90-4.19 HU; p < 0.001), and the hematoma needs to be surgically removed. The median density difference value of the gray and white matter on the injured side was 3.74 HU (IQR, 3.53-4.01 HU; p < 0.001) and on the non-injured side was 3.71 HU (IQR, 3.69-3.73 HU; p < 0.001), and the hematoma could diffuse in a short time. Conclusion Quantitative analysis of the density differences in the gray and white matter of the CT images can be used to evaluate the clinical prognosis of patients with ASDH.
Collapse
Affiliation(s)
- Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Yan Feng
- Department of Radiology of the First Clinical Hospital, Jilin University, Changchun, China
| | - Pengju Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Kang Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shouyong Lu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Chuanxiang Lv
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China,*Correspondence: Li Bie
| |
Collapse
|
6
|
van Essen TA, Res L, Schoones J, de Ruiter G, Dekkers O, Maas A, Peul W, van der Gaag NA. Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute? J Neurotrauma 2023; 40:22-32. [PMID: 35699084 DOI: 10.1089/neu.2022.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.
Collapse
Affiliation(s)
- Thomas Arjan van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk Res
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Jan Schoones
- Directorate of Research Policy (Walaeus Library), and Leiden University Medical Center, Leiden, The Netherlands
| | - Godard de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Olaf Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Niels Anthony van der Gaag
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
7
|
Colasurdo M, Leibushor N, Robledo A, Vasandani V, Luna ZA, Rao AS, Garcia R, Srinivasan VM, Sheth SA, Avni N, Madziva M, Berejick M, Sirota G, Efrati A, Meisel A, Shaltoni H, Kan P. Automated detection and analysis of subdural hematomas using a machine learning algorithm. J Neurosurg 2022; 138:1077-1084. [PMID: 36461839 DOI: 10.3171/2022.8.jns22888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Machine learning algorithms have shown groundbreaking results in neuroimaging. Herein, the authors evaluate the performance of a newly developed convolutional neural network (CNN) to detect and quantify the thickness, volume, and midline shift (MLS) of subdural hematoma (SDH) from noncontrast head CT (NCHCT).
METHODS
NCHCT studies performed for the evaluation of head trauma in consecutive patients between July 2018 and April 2021 at a single institution were retrospectively identified. Ground truth determination of SDH, thickness, and MLS was established by the neuroradiology report. The primary outcome was performance of the CNN in detecting SDH in an external validation set, as measured using area under the receiver operating characteristic curve analysis. Secondary outcomes included accuracy for thickness, volume, and MLS.
RESULTS
Among 263 cases with valid NCHCT according to the study criteria, 135 patients (51%) were male, the mean (± standard deviation) age was 61 ± 23 years, and 70 patients were diagnosed with SDH on neuroradiologist evaluation. The median SDH thickness was 11 mm (IQR 6 mm), and 16 patients had a median MLS of 5 mm (IQR 2.25 mm). In the independent data set, the CNN performed well, with sensitivity of 91.4% (95% CI 82.3%–96.8%), specificity of 96.4% (95% CI 92.7%–98.5%), and accuracy of 95.1% (95% CI 91.7%–97.3%); sensitivity for the subgroup with an SDH thickness above 10 mm was 100%. The maximum thickness mean absolute error was 2.75 mm (95% CI 2.14–3.37 mm), whereas the MLS mean absolute error was 0.93 mm (95% CI 0.55–1.31 mm). The Pearson correlation coefficient computed to determine agreement between automated and manual segmentation measurements was 0.97 (95% CI 0.96–0.98).
CONCLUSIONS
The described Viz.ai SDH CNN performed exceptionally well at identifying and quantifying key features of SDHs in an independent validation imaging data set.
Collapse
Affiliation(s)
- Marco Colasurdo
- Department of Radiology, Division of Neuroradiology, The University of Texas Medical Branch, Galveston, Texas
| | | | | | | | | | | | | | - Visish M. Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
| | - Sunil A. Sheth
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, Texas
| | | | | | | | | | | | | | - Hashem Shaltoni
- Neurology, The University of Texas Medical Branch, Galveston, Texas
| | | |
Collapse
|
8
|
Chihi M, Darkwah Oppong M, Quesada CM, Dinger TF, Gembruch O, Pierscianek D, Ahmadipour Y, Uerschels AK, Wrede KH, Sure U, Jabbarli R. Role of Brain Natriuretic Peptide in the Prediction of Early Postoperative Seizures Following Surgery for Traumatic Acute Subdural Hematoma: A Prospective Study. Neurol Ther 2021; 10:847-863. [PMID: 34342872 PMCID: PMC8571437 DOI: 10.1007/s40120-021-00269-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/21/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Brain natriuretic peptide (BNP) is a reliable biomarker in the acute phase of traumatic brain injury. However, the relationship between BNP and traumatic acute subdural hematoma (aSDH) has not yet been addressed. This study aimed to analyze BNP levels on admission in surgically treated patients and assess their relationship with early postoperative seizures (EPS) and functional outcomes. METHODS Patients with unilateral traumatic aSDH who were surgically treated in our department between July 2017 and May 2020 were included in the study. BNP was preoperatively measured. Patients' neurologic condition, radiographic variables on initial cranial computed tomography, sodium serum levels on admission, and occurrence of EPS were prospectively assessed. Functional outcome was assessed using the modified Rankin Scale (mRS) at discharge and follow-up (at 2-3 months). A poor outcome was defined by a mRS score > 3. RESULTS EPS occurred in 20 (19.6%) of 102 surgically treated patients in the final cohort on the median day 3. A significant association between EPS and a poor Glasgow Coma Scale score at the 7th postoperative day was found, which in turn independently predicted a poor functional outcome at discharge and follow-up. Nonetheless, EPS were not associated with poor functional outcomes. The multivariate analysis revealed BNP > 95.4 pg/ml (aOR = 5.7, p = 0.003), sodium < 137.5 mmol/l (aOR = 4.6, p = 0.009), and left-sided aSDH (aOR = 4.4, p = 0.020) as independent predictors of EPS. CONCLUSION In the early postoperative phase of traumatic aSDH, EPS were associated with worse neurologic conditions, which in turn independently predicted poor outcomes at discharge and follow-up. Although several EPS risk factors have already been elucidated, this study presents BNP as a novel reliable predictor of EPS. Further larger studies are needed to determine whether a more precise estimate of EPS risk using BNP levels can be reached.
Collapse
Affiliation(s)
- Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Carlos M Quesada
- Department of Neurology, Center of Epileptology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thiemo Florin Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Oliver Gembruch
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Daniela Pierscianek
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Yahya Ahmadipour
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Anne-Kathrin Uerschels
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Hufelandstrasse 55, 45147, Essen, Germany
| |
Collapse
|
9
|
Superiority of craniotomy over supportive care for octogenarians and nonagenarians in operable acute traumatic subdural hematoma. Clin Neurol Neurosurg 2021; 212:107069. [PMID: 34844161 DOI: 10.1016/j.clineuro.2021.107069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Neurosurgical evacuation in elderly trauma patients is controversial. We analyzed impact of craniotomy for acute subdural hematoma on survival in octogenarians and nonagenarians. Methods The study population included all patients aged ≥ 80 years who presented with acute traumatic SDHs 09/01/15 - 01/01/20, with radiography indicating operative eligibility (i.e. MLS >5 mm and/or overall thickness >10 mm). Of 1054 TBIs aged ≥ 80 years, 104 (9.87%) were surgically indicated. Of these, 35 received craniotomy and 69 received supportive measures due to family/patient wishes or surgeon's professional decision. We analyzed these data using a Poisson regression adjusted for influence of covariates. RESULTS Of 35 craniotomies, 21 (60.00%) were deceased at 2 years of follow-up, compared to 48 (69.57%) deceased of 69 non-surgical patients. No significant demographic differences existed between these groups, other than age (craniotomy patients were younger; median age 84 vs 86; p < 0.001). In outcomes, the craniotomy cohort survived longer and in higher proportions (p = 0.028; Gehan-Breslow-Wilcoxon). When adjusting for covariates, this effect became more pronounced: craniotomy patients died at 41.1% the rate of non-surgical ones. Of all the covariates, only initial GCS significantly impacted the protective effect of craniotomy. In a logarithmic relationship, each point on initial GCS was associated with less benefit from surgery. We also found that patients with GCS< 3 were overall less likely to benefit from surgery. Our conclusions are limited by the impact of patient/surgeon choice on whether or not to operate. It is possible healthier subjects elected for craniotomies. We have attempted to correct for this by including comorbidities as covariates in our regression analyses. CONCLUSIONS Our results indicate a surgical benefit for this elderly cohort, consistent with prior findings of benefit in the setting of severe traumatic aSDH. Patients with worse neurologic impairment, i.e. low GCS, had the greatest survival benefit from surgical intervention.
Collapse
|
10
|
Rault F, Terrier L, Leclerc A, Gilard V, Emery E, Derrey S, Briant AR, Gakuba C, Gaberel T. Decreased number of deaths related to severe traumatic brain injury in intensive care unit during the first lockdown in Normandy: at least one positive side effect of the COVID-19 pandemic. Acta Neurochir (Wien) 2021; 163:1829-1836. [PMID: 33813617 PMCID: PMC8019477 DOI: 10.1007/s00701-021-04831-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 03/23/2021] [Indexed: 12/11/2022]
Abstract
Background The COVID-19 pandemic has led to severe containment measures to protect the population in France. The first lockdown modified daily living and could have led to a decrease in the frequency of severe traumatic brain injury (TBI). In the present study, we compared the frequency and severity of severe TBI before and during the first containment in Normandy. Methods We included all patients admitted in the intensive care unit (ICU) for severe TBI in the two tertiary neurosurgical trauma centres of Normandy during the first lockdown. The year before the containment served as control. The primary outcome was the number of patients admitted per week in ICU. We compared the demographic characteristics, TBI mechanisms, CT scan, surgical procedure, and mortality rate. Results The incidence of admissions for severe TBI in Normandy decreased by 33% during the containment. The aetiology of TBI significantly changed during the containment: there were less traffic road accidents and more TBI related to alcohol consumption. Patients with severe TBI during the containment had a better prognosis according to the impact score (p=0.04). We observed a significant decrease in the rate of short-term mortality related to severe TBI during the period of lockdown (p=0.02). Conclusions Containment related to the COVID-19 pandemic has resulted in a modification of the mechanisms of severe TBI in Normandy, which was associated with a decline in the rate of short-term death in intensive unit care.
Collapse
Affiliation(s)
- Frederick Rault
- Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14000, Caen, France.
| | - Laura Terrier
- Department of Neurosurgery, Rouen University Hospital, F-76000, Rouen, France
| | - Arthur Leclerc
- Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14000, Caen, France
| | - Vianney Gilard
- Department of Neurosurgery, Rouen University Hospital, F-76000, Rouen, France
- Laboratory of Microvascular Endothelium and Neonate Brain Lesions, Normandie Univ, UNIROUEN, INSERM U1245, F-76000, Rouen, France
| | - Evelyne Emery
- Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14000, Caen, France
- PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, INSERM, U1237, Cyceron, 14000, Caen, France
- Medical School, Université Caen Normandie, F-14000, Caen, France
| | - Stéphane Derrey
- Department of Neurosurgery, Rouen University Hospital, F-76000, Rouen, France
| | - Anaïs R Briant
- Unité de Biostatistique et Recherche Clinique (UBRC), Caen, France
| | - Clément Gakuba
- PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, INSERM, U1237, Cyceron, 14000, Caen, France
- Medical School, Université Caen Normandie, F-14000, Caen, France
- Department of Anesthesiology and Critical Care Medicine, CHU de Caen, F-14000, Caen, France
| | - Thomas Gaberel
- Department of Neurosurgery, Caen University Hospital, Avenue de la Côte de Nacre, 14000, Caen, France
- PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Normandie Univ, UNICAEN, INSERM, U1237, Cyceron, 14000, Caen, France
- Medical School, Université Caen Normandie, F-14000, Caen, France
| |
Collapse
|
11
|
Won SY, Freiman TM, Reif PS, Dubinski D, Hattingen E, Herrmann E, Seifert V, Rosenow F, Strzelczyk A, Konczalla J. DIagnostic Subdural EEG electrodes And Subdural hEmatoma (DISEASE): a study protocol for a prospective nonrandomized controlled trial. Neurol Res Pract 2020; 2:50. [PMID: 33344885 PMCID: PMC7737265 DOI: 10.1186/s42466-020-00096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 11/16/2022] Open
Abstract
Background Epileptic seizures are common clinical features in patients with acute subdural hematoma (aSDH); however, diagnostic feasibility and therapeutic monitoring remain limited. Surface electroencephalography (EEG) is the major diagnostic tool for the detection of seizures but it might be not sensitive enough to detect all subclinical or nonconvulsive seizures or status epilepticus. Therefore, we have planned a clinical trial to evaluate a novel treatment modality by perioperatively implanting subdural EEG electrodes to diagnose seizures; we will then treat the seizures under therapeutic monitoring and analyze the clinical benefit. Methods In a prospective nonrandomized trial, we aim to include 110 patients with aSDH. Only patients undergoing surgical removal of aSDH will be included; one arm will be treated according to the guidelines of the Brain Trauma Foundation, while the other arm will additionally receive a subdural grid electrode. The study’s primary outcome is the comparison of incidence of seizures and time-to-seizure between the interventional and control arms. Invasive therapeutic monitoring will guide treatment with antiseizure drugs (ASDs). The secondary outcome will be the functional outcome for both groups as assessed via the Glasgow Outcome Scale and modified Rankin Scale both at discharge and during 6 months of follow-up. The tertiary outcome will be the evaluation of chronic epilepsy within 2–4 years of follow-up. Discussion The implantation of a subdural EEG grid electrode in patients with aSDH is expected to be effective in diagnosing seizures in a timely manner, facilitating treatment with ASDs and monitoring of treatment success. Moreover, the occurrence of epileptiform discharges prior to the manifestation of seizure patterns could be evaluated in order to identify high-risk patients who might benefit from prophylactic treatment with ASDs. Trial registration ClinicalTrials.gov identifier no. NCT04211233.
Collapse
Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Philipp S Reif
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Elke Hattingen
- Institutes of Neuroradiology, Goethe University, Frankfurt, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University Frankfurt, Frankfurt am Main, Germany.,LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe-University Frankfurt, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University Frankfurt, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany
| |
Collapse
|
12
|
Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review. Curr Neurol Neurosci Rep 2020; 20:63. [PMID: 33136200 DOI: 10.1007/s11910-020-01080-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers. RECENT FINDINGS To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.
Collapse
|
13
|
Low Risk of Traumatic Intracranial Hematoma Expansion with Factor Xa Inhibitors without Andexanet Reversal. World Neurosurg 2020; 142:e95-e100. [DOI: 10.1016/j.wneu.2020.06.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 11/22/2022]
|
14
|
Choudhary A, Kaushik K, Bhaskar SN, Gupta LN, Sharma R, Varshney R. Correlation of Initial Computed Tomography Findings with Outcomes of Patients with Acute Subdural Hematoma: A Prospective Study. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Introduction In modern emergency service systems, patients are often treated with sedation, intubation, and ventilation at the accident site. But neurosurgical assessment before all these emergency services is important. Thus, this study was designed to investigate the relationships between various parameters of initial CT scan findings and the outcomes of the patients.
Methodology A total of 56 adult patients of traumatic acute subdural hematoma (SDH) whose computed tomography (CT) scan was performed within 8 hours of injury were recruited. The patients with prolonged hypotension, open head injury or depressed skull fracture, bilateral side acute SDH, or contusions/hematoma/extradural hematoma on the contralateral side were excluded. Six separate CT findings were analyzed and recorded, including hematoma, midline shift, subarachnoid hemorrhage (SAH), presence of basal cistern obliteration (BCO), intraparenchymal hematoma/contusion in the same hemisphere, and presence of effacement of the sulcal spaces, and were followed up for three months for outcome analysis.
Results The overall mortality and functional recovery rate were 27 and 50%, respectively. The patients with obliterated basal cisterns and the presence of underlying SAH in patients with acute SDH had statistically significant poorer outcomes as compared with others. However, the extent of midline shift, SDH thickness, and the presence of underlying contusions and sulcal effacement on initial CT scan showed no statistically significant correlation with patients’ outcomes.
Conclusions BCO and presence of subarchnoid hemorrhage underlying acute SDH on the earliest scan in head injury patients signify the severity of brain parenchymal injury. Along with the initial Glasgow Coma Scale score after resuscitation, these two factors should be considered as the most significant ones for predicting the outcomes in traumatic acute SDH patients.
Collapse
Affiliation(s)
- Ajay Choudhary
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Kaviraj Kaushik
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Surya Narayanan Bhaskar
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Laxmi Narayan Gupta
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Rajesh Sharma
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Rahul Varshney
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| |
Collapse
|
15
|
Sharma R, Rocha E, Pasi M, Lee H, Patel A, Singhal AB. Subdural Hematoma: Predictors of Outcome and a Score to Guide Surgical Decision-Making. J Stroke Cerebrovasc Dis 2020; 29:105180. [PMID: 33066943 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105180] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/16/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE There is little evidence to guide patient selection for subdural hemorrhage (SDH) evacuation. This study was designed to assess the benefit of surgical evacuation of SDH, identify predictors of functional outcome, and create a bedside score to guide the clinical management of SDH. METHODS A cohort of 331 patients presenting to a single center from 2010 to 2014 with a principal diagnosis of subdural hemorrhage was identified. Clinical and radiographic information were extracted from the medical record. Outcomes of interest were (1) the occurrence of surgical evacuation of SDH, and (2) an unfavorable 90-day functional status represented by a modified Rankin score (mRS) ≥ 3. Propensity score matching and adjustment techniques were employed to assess the benefit of surgery accounting for confounding by indication. Multivariable logistic regression models predicting follow-up functional outcome were generated and bootstrapped separately among those with acute SDH and those with either subacute or chronic SDH. Clinical scores were created using model coefficients. RESULTS In this cohort [65% male, mean age 67 years], 47% underwent surgery. Age, focal neurologic deficit, SDH thickness > 10 mm, midline shift > 5mm, and SDH acuity predicted undergoing surgery. Propensity score matching analysis demonstrated that operated patients overall were less likely to have unfavorable 90-day mRS outcome (OR 0.35, 95% C.I. 0.15-0.82). Among patients with acute SDH, age, female sex, pre-admission mRS, focal neurologic deficit, and neuropsychiatric symptoms predicted 90-day functional outcome (c-statistic 0.89, optimism-corrected c-statistic 0.87) and were incorporated into an acute SDH score (range 1-10). Patients with SDH score > 4 were significantly more likely to have an unfavorable outcome if treated medically versus surgically; there was no difference in 90-day functional status by treatment strategy among patients with SDH score ≤ 4. No difference in outcome was seen by surgical status across the spectrum of chronic SDH scores. CONCLUSIONS Surgical evacuation of subdural hematomas overall is associated with favorable outcome. Patient selection for evacuation is enhanced by the application of the acute SDH score. Future studies are necessary to validate the SDH score in an external cohort.
Collapse
Affiliation(s)
- Richa Sharma
- Department of Neurology, Yale School of Medicine, CT, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Eva Rocha
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marco Pasi
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Hang Lee
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Aman Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| |
Collapse
|
16
|
Wasfie T, Maxwell J, Parsons A, Hille J, Yapchai R, Hella J, Cwalina N, Barber KR, Shapiro B. Traumatic Brain Injury in the Elderly: Can We Reduce Readmissions? : A Community Hospital Experience. Am Surg 2020; 86:1647-1650. [PMID: 32683939 DOI: 10.1177/0003134820933560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a leading cause of mortality and long-term morbidity in trauma patients, with a growing incidence among the elderly. Injury-related disability has many costs, and rehospitalization is a significant part of that. The current study was carried out in an elderly population with TBI to identify risk factors and measures associated with rehospitalization. METHODS We performed a retrospective analysis of 299 patients with a primary diagnosis of TBI admitted between 2016 and 2018. Variables selected for analysis encompassed the following: patient age, sex, comorbidities, diagnosis, length of stay, use of anticoagulants, 6-month readmission rate, and diagnosis for readmission. Chi-square analysis was used to identify potential risk factors, and multiple regression analysis was conducted to model the relationship. RESULTS 209 patients met inclusion criteria, with a mean age of 69 years (SD ± 18.6 years), with (51.5%) males and (48.5%) females. 188 (62.9%) patients were on anticoagulant therapy. 120 patients were discharged to home (40.1%). 79 patients (26.4%) were readmitted within 6 months of discharge, the majority of whom (48 patients, 60.8%) presented with a subdural hematoma (SDH). 38 readmitted patients (49%) came from home, and 57 patients (80%) were on anticoagulant therapy. CONCLUSION In elderly patients with TBI, discharge to a home setting correlates with a higher risk of readmission within 6 months, a majority with a diagnosis of recurrent SDH. Anticoagulant therapy and frequent past readmissions also correlated with a higher risk of subsequent readmission.
Collapse
Affiliation(s)
- Tarik Wasfie
- 2974 Medical Education Surgery Program, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Jordan Maxwell
- 2974 Genesys Trauma Services, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Andrea Parsons
- 2974 Genesys Trauma Services, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Jennifer Hille
- 2974 Genesys Trauma Services, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Raquel Yapchai
- 2974 Genesys Trauma Services, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Jennifer Hella
- 2974 Clinical & Academic Research Dept., Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - N Cwalina
- 2974 Genesys Trauma Services, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Kimberly R Barber
- 2974 Clinical & Academic Research Dept., Ascension Genesys Medical Center, Grand Blanc, MI, USA
| | - Brian Shapiro
- 2974 Genesys Trauma Services, Ascension Genesys Medical Center, Grand Blanc, MI, USA
| |
Collapse
|
17
|
Koo AB, Elsamadicy AA, David WB, Zogg CK, Santarosa C, Sujijantarat N, Robert SM, Kundishora AJ, Cord BJ, Hebert R, Bahrassa F, Malhotra A, Matouk CC. Thirty- and 90-Day Readmissions After Treatment of Traumatic Subdural Hematoma: National Trend Analysis. World Neurosurg 2020; 139:e212-e219. [PMID: 32272271 PMCID: PMC7380544 DOI: 10.1016/j.wneu.2020.03.168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Subdural hematoma (SDH), a form of traumatic brain injury, is a common disease that requires extensive patient management and resource utilization; however, there remains a paucity of national studies examining the likelihood of readmission in this patient population. The aim of this study is to investigate differences in 30- and 90-day readmissions for treatment of traumatic SDH using a nationwide readmission database. METHODS The Nationwide Readmission Database years 2013-2015 were queried. Patients with a diagnosis of traumatic SDH and a primary procedure code for incision of cerebral meninges for drainage were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS We identified a total of 14,355 patients, with 3106 (21.6%) patients encountering a readmission (30-R: n = 2193 [15.3%]; 90-R: n = 913 [6.3%]; Non-R: n = 11,249). The most prevalent 30- and 90-day diagnoses seen among the readmitted cohorts were postoperative infection (30-R: 10.5%, 90-R: 13.0%) and epilepsy (30-R: 3.7%, 90-R: 1.1%). On multivariate logistic regression analysis, Medicare, Medicaid, hypertension, diabetes, renal failure, congestive heart failure, and coagulopathy were independently associated with 30-day readmission; Medicare and rheumatoid arthritis/collagen vascular disease were independently associated with 90-day readmission. CONCLUSIONS In this study, we determine the relationship between readmission rates and complications associated with surgical intervention for traumatic subdural hematoma.
Collapse
Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cheryl K Zogg
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Corrado Santarosa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nanthiya Sujijantarat
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Stephanie M Robert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Branden J Cord
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Farhad Bahrassa
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajay Malhotra
- Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Radiology & Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA.
| |
Collapse
|
18
|
Choi MS, Jeong D, You N, Roh TH, Kim SH. Identification of clinical characteristics and factors predicting favorable treatment outcomes in elderly patients with traumatic brain injury. J Clin Neurosci 2019; 69:61-66. [PMID: 31451377 DOI: 10.1016/j.jocn.2019.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
Age is an important prognostic factor for patients with traumatic brain injury (TBI), and worse treatment outcomes have been reported in elderly patients. Therefore, proper treatment is needed for the increasing number of elderly patients with TBI. We aimed to analyze predictive factors of favorable treatment outcomes (FTO) in elderly patients. Clinical and radiological data from 493 patients with TBI who visited a single institute were retrospectively collected from January 2014 to December 2015. We compared the characteristics of the elderly group (individuals above 65 years) and younger group (16-65 years). We analyzed the characteristics and outcomes in both groups and the factors related to the Glasgow outcome scale-extended score at 6 months after injury in 170 elderly patients. The treatment outcomes were dichotomized into favorable and unfavorable groups. In the elderly group, the proportion of female patients and the incidence of subdural hemorrhage (SDH) were higher than in the younger group. Among the 170 elderly patients, 62 had pure SDH, and 21 of the 62 with pure SDH had undergone surgical treatment. Compared with other types of intracranial hemorrhage, FTO was as high as 85.5%, and mortality was as low as 11.3% in patients with pure SDH. High initial Glasgow coma scale score, low injury severity score, and normal pupillary reflex were significantly related to FTO in multivariate analysis. Therefore, active therapeutic strategies, including surgery should be considered for elderly patients with pure SDH without intra-parenchymal injury.
Collapse
Affiliation(s)
- Mi Sun Choi
- Department of Neurosurgery, Inje University Seoul Paik Hospital, 9 Mareunnae-ro, Jung-gu, Seoul 04551, Republic of Korea
| | - Donghwan Jeong
- Department of Neurosurgery, Hallym University Medical Center, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do 18450, Republic of Korea
| | - Namkyu You
- Department of Neurosurgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea
| | - Tae Hoon Roh
- Department of Neurosurgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea
| | - Se-Hyuk Kim
- Department of Neurosurgery, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, Suwon 16499, Republic of Korea.
| |
Collapse
|
19
|
Atalay T, Ak H, Gülsen I, Karacabey S. Risk factors associated with mortality and survival of acute subdural hematoma: A retrospective study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:27. [PMID: 31007697 PMCID: PMC6450130 DOI: 10.4103/jrms.jrms_14_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/09/2016] [Accepted: 05/02/2016] [Indexed: 11/28/2022]
Abstract
Background: Acute subdural hematoma (ASDH) is mostly seen after head injury and is a major cause of morbidity and mortality. We studied the risk factors for ASDH and the effects of these factors on mortality as well as on survival with 100 cases from the rural area of Anatolia region. Materials and Methods: One-hundred cases of the ASDH that had been treated surgically between 2011 and 2014, at three different health-care centers from the rural area of Anatolia region, were retrospectively reviewed. Demographic data of patients, etiology, Glasgow Coma Scale (GCS) on admission, survival, presence of comorbid disease, unilaterality or bilaterality of the hematoma, and length of stay in the Intensive Care Unit (ICU) and/or neurosurgery clinic were recorded from the patients’ files. Results: The total mortality rate was 34%. Age, etiology, GCS on admission, and laterality of the hematoma (unilateral or bilateral) affected the mortality rates (P = 0.005, P = 0.001, P = 0.001, and P = 0.001, respectively). Advanced age, low GCS on admission, and bilaterality of the hematoma were related with high mortality rates (P = 0.005, P = 0.001, and P = 0.001, respectively). The presence of comorbid disease and gender had no effect on patient survival (P = 0.299 and P = 0.861). Conclusion: The most important factors affecting the mortality rate were GCS on admission, etiology, age, and laterality of the hematoma in this study. Advanced age, low GCS on admission, and bilaterality of the hematoma were related with high mortality rates. Etiology had an important role in mortality rates, especially in the pedestrian injury group.
Collapse
Affiliation(s)
- Tugay Atalay
- Gaziantep Sevgi Hospital Neurosurgery Department, Gaziantep, Turkey
| | - Hakan Ak
- Department of Neurosurgery, School of Medicine, Bozok University, Yozgat, Turkey
| | - Ismail Gülsen
- Department of Neurosurgery, School of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Sinan Karacabey
- Department of Eemrgency Medicine, Marmara University School of Medicine, Istanbul, Turkey
| |
Collapse
|
20
|
Bartek J, Laugesen C, Mirza S, Forsse A, Petersen MA, Corell A, Dyhrfort PW, Redebrandt HN, Reen L, Zolfaghari S, Tobieson L, Carlsvärd B, Bergholt B, Bashir A, Soerensen P, Bilgin A, Johansson C, Lindvall P, Förander P, Bellander BM, Springborg JB, Jakola AS. Scandinavian Multicenter Acute Subdural Hematoma (SMASH) Study: Study Protocol for a Multinational Population-Based Consecutive Cohort. Neurosurgery 2019; 84:799-803. [PMID: 29762769 DOI: 10.1093/neuros/nyy173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/04/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved. OBJECTIVE To evaluate postoperative (30-d) mortality in younger vs elderly (≥70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables. METHODS This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (≥18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190. EXPECTED OUTCOMES We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified. DISCUSSION An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.
Collapse
Affiliation(s)
- Jiri Bartek
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Laugesen
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Sadia Mirza
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Axel Forsse
- Department of Neurosurgery, Odense University Hospital, Odense, Denmark
| | | | - Alba Corell
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Linus Reen
- Department of Neurosurgery, Lund University Hospital, Lund, Sweden
| | | | - Lovisa Tobieson
- Department of Neurosurgery, Linköping University Hospital, Linköping, Sweden
| | - Björn Carlsvärd
- Department of Neurosurgery, Linköping University Hospital, Linköping, Sweden
| | - Bo Bergholt
- Department of Neurosurgery, Århus University Hospital, Århus, Denmark
| | - Asma Bashir
- Department of Neurosurgery, Århus University Hospital, Århus, Denmark
| | - Preben Soerensen
- Department of Neurosurgery, Ålborg University Hospital, Ålborg, Denmark
| | - Arzu Bilgin
- Department of Neurosurgery, Ålborg University Hospital, Ålborg, Denmark
| | - Conny Johansson
- Department of Neurosurgery, Umeå University Hospital, Umeå, Sweden
| | - Peter Lindvall
- Department of Neurosurgery, Umeå University Hospital, Umeå, Sweden
| | - Petter Förander
- Department of Neurosurgery, Uppsala University Hospital, Uppsala Sweden
| | | | - Jacob B Springborg
- Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Asgeir S Jakola
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Institute of Neuroscience and Physiology, Sahlgrenska Academy, Gothenburg, Sweden
| |
Collapse
|
21
|
Ho T, Frisbie J, Wasfie T, Boyer JJ, Knisely T, Cwalina N, Barber K, Shapiro B. A retrospective analysis of factors influencing readmission rates of acute traumatic subdural hematoma in the elderly: A cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
22
|
Dubinski D, Won SY, Behmanesh B, Brawanski N, Geisen C, Seifert V, Senft C, Konczalla J. The clinical relevance of ABO blood type in 100 patients with acute subdural hematoma. PLoS One 2018; 13:e0204331. [PMID: 30286106 PMCID: PMC6171832 DOI: 10.1371/journal.pone.0204331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 09/06/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The correlation of depleted blood through midline shift in acute subdural hematoma remains the most reliable clinical predictor to date. On the other hand, patient's ABO blood type has a profound impact on coagulation and hemostasis. We conducted this study to evaluate the role of patient's blood type in terms of incidence, clinical course and outcome after acute subdural hematoma bleeding. METHODS 100 patients with acute subdural hematoma treated between 2010 and 2015 at the author's institution were included. Baseline characteristics and clinical findings including Glasgow coma scale, Glasgow outcome scale, hematoma volume, rebleeding, midline shift, postoperative seizures and the presence of anticoagulation were analyzed for their association with ABO blood type. RESULTS Patient's with blood type O were found to have a lower midline shift (p<0.01) and significantly less seizures (OR: 0.43; p<0.05) compared to non-O patients. Furthermore, patients with blood type A had the a significantly higher midline shift (p<0.05) and a significantly increased risk for postoperative seizures (OR: 4.01; p<0.001). There was no difference in ABO blood type distribution between acute subdural hematoma patients and the average population. CONCLUSION The ABO blood type has significant influence on acute subdural hematoma sequelae. Patient's with blood type O benefit in their clinical course after acute subdural hematoma whereas blood type A patients are at highest risk for increased midline shift and postoperative seizures. Further studies elucidating the biological mechanisms of blood type depended hemostaseology and its role in acute subdural hematoma are required for the development of an appropriate intervention.
Collapse
Affiliation(s)
- Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Nina Brawanski
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Christof Geisen
- Institute for Transfusion Medicine and Immunohematology, Goethe University, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Christian Senft
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| |
Collapse
|
23
|
Lavrador JP, Teixeira JC, Oliveira E, Simão D, Santos MM, Simas N. Acute Subdural Hematoma Evacuation: Predictive Factors of Outcome. Asian J Neurosurg 2018; 13:565-571. [PMID: 30283506 PMCID: PMC6159091 DOI: 10.4103/ajns.ajns_51_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Acute subdural hematoma (aSDH) is a major cause of admission at Neurosurgical Emergency Department. Nevertheless, concerns regarding surgical indication in patients with multiple comorbidities, poor neurological status, antithrombotic therapy, and older age still persist. Therefore, a correct recognition of predictive outcome factors at hospital discharge is crucial to an appropriate neurosurgical treatment. METHODS Eighty-nine medical records of consecutive patients with age ≥18 years old who were submitted to aSDH evacuation between January 2008 and May 2012 were reviewed. Demographic characteristics, neurological status on admission, anticoagulant or antiplatelet therapy, and outcome on discharge were collected. Patients with insufficient data concerning these variables were excluded from the study. RESULTS Sixty-nine patients were included; 52% were male; 74% were older than 65 years; 41% were under oral antithrombotic therapy (OAT); at admission, 54% presented with Glasgow coma scale (GCS) ≤8; 23% were submitted to a craniectomy instead of a craniotomy; 26% of the patients died, 32% were dependent, and 42% were independent on discharge. Crude analysis revealed craniectomy, A/A pupils, GCS ≤8 at admission statistically significant related with the worst outcome (P < 0.05). In the adjusted evaluation only A/A pupils (P = 0.04) was associated to poor outcome (spontaneous etiology P = 0.052). Considering daily living independency at hospital discharge, either male gender (P = 0.044) and A/A pupils (P = 0.030) were related to the worst outcome. No effect of age in outcome was observed. CONCLUSIONS Male gender and A/A pupils are associated with lower probability of achieving independency living at hospital discharge. A/A pupils, low GCS at admission, spontaneous etiology, and craniectomy were associated with the worst outcome. Age and OAT were not predictive factors in this series. Caution should be taken when considering these factors in the surgical decision.
Collapse
Affiliation(s)
| | | | - Edson Oliveira
- Department of Neurosurgery, Hospital Santa Maria, Lisbon, Portugal
| | - Diogo Simão
- Department of Neurosurgery, Hospital Santa Maria, Lisbon, Portugal
| | | | - Nuno Simas
- Department of Neurosurgery, Hospital Santa Maria, Lisbon, Portugal
| |
Collapse
|
24
|
Abstract
Traumatic brain injury remains a major cause of morbidity and mortality throughout the world, affecting young and old alike. Pathologic data have been developed through observations of human autopsies and developing animal models to investigate mechanisms, although animal models do not represent the polypathology of human brain injury and there are likely to be significant differences in the anatomic basis of injury and cellular responses between species. Traumatic brain injury can be defined pathologically as either focal or diffuse, and can be considered to be either primary, directly related to the force associated with the neurotrauma, or secondary, developing as a downstream consequence of the neurotrauma. While neuropathology has traditionally focused on severe head injury, there is increasing recognition of the long-term consequences of traumatic brain injury, particularly repetitive mild traumatic brain injury, and a possible long-term association with chronic traumatic encephalopathy.
Collapse
Affiliation(s)
- Colin Smith
- Department of Neuropathology, Centre for Clinical Brain Sciences, Edinburgh, United Kingdom.
| |
Collapse
|
25
|
Won SY, Dubinski D, Brawanski N, Strzelczyk A, Seifert V, Freiman TM, Konczalla J. Significant increase in acute subdural hematoma in octo- and nonagenarians: surgical treatment, functional outcome, and predictors in this patient cohort. Neurosurg Focus 2017; 43:E10. [DOI: 10.3171/2017.7.focus17417] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAcute subdural hematoma (aSDH) is a common disease increasing in prevalence given the demographic growth of the aging population. Yet, the benefit of surgical treatment for aSDH and the subsequent functional outcome in elderly patients (age ≥ 80 years) remain unclear. Therefore, the aims of this study were to evaluate the incidence of aSDH in patients 80 years or older, determine overall functional outcome, identify predictors of an unfavorable or favorable outcome, and establish specific risk factors for seizures.METHODSThe authors retrospectively analyzed patients 80 years and older who presented with isolated aSDH in the past 10 years at their institution. The following parameters were assessed: baseline characteristics, clinical status on admission and 24 hours after surgery, and clinical course. Functional outcome was assessed at discharge and the 3-month follow-up (FU).RESULTSIn the period from January 2007 to December 2016, 165 patients with aSDH were admitted to the authors’ institution. Sixty-eight patients (41.2%) were 80 years old or older, and the mean age overall was 85 years (range 80–96 years). The incidence of aSDH in the elderly had significantly increased over past decade, with more than 50% of patients admitted to our institution for aSDH now being 80 years or older. The overall mortality rate was 28% at discharge and 48% at the FU. Independent predictors of an unfavorable outcome at discharge were a GCS score ≤ 8 at 24 hours after operation (p < 0.001) and pneumonia (p < 0.02). At the FU, a GCS score ≤ 8 at 24 hours after operation (p < 0.001) and cumulative comorbidities (≥ 5; p < 0.05) were significant independent predictors. All patients with more than 6 comorbidities had died by the FU. Surgical treatment in comatose compared to noncomatose patients had statistically significant, higher mortality rates at discharge and the FU. Still, 23% of the comatose patients and more than 50% of the noncomatose patients had a favorable outcome at the FU (p = 0.06).CONCLUSIONSThe number of octo- and nonagenarians with aSDH significantly increased over the last decade. These patients can achieve a favorable outcome, especially those with a noncomatose status and fewer than 5 comorbidities. Surgical and nonsurgical treatment of octo- and nonagenarians during and after discharge should be optimized to increase clinical improvement.
Collapse
Affiliation(s)
| | | | | | - Adam Strzelczyk
- 2Neurology, and
- 3Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | | | | | | |
Collapse
|
26
|
Alliez JR, Kaya JM, Leone M. Ematomi intracranici post-traumatici in fase acuta. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
27
|
Thelin EP, Nelson DW, Vehviläinen J, Nyström H, Kivisaari R, Siironen J, Svensson M, Skrifvars MB, Bellander BM, Raj R. Evaluation of novel computerized tomography scoring systems in human traumatic brain injury: An observational, multicenter study. PLoS Med 2017; 14:e1002368. [PMID: 28771476 PMCID: PMC5542385 DOI: 10.1371/journal.pmed.1002368] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 07/05/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major contributor to morbidity and mortality. Computerized tomography (CT) scanning of the brain is essential for diagnostic screening of intracranial injuries in need of neurosurgical intervention, but may also provide information concerning patient prognosis and enable baseline risk stratification in clinical trials. Novel CT scoring systems have been developed to improve current prognostic models, including the Stockholm and Helsinki CT scores, but so far have not been extensively validated. The primary aim of this study was to evaluate the Stockholm and Helsinki CT scores for predicting functional outcome, in comparison with the Rotterdam CT score and Marshall CT classification. The secondary aims were to assess which individual components of the CT scores best predict outcome and what additional prognostic value the CT scoring systems contribute to a clinical prognostic model. METHODS AND FINDINGS TBI patients requiring neuro-intensive care and not included in the initial creation of the Stockholm and Helsinki CT scoring systems were retrospectively included from prospectively collected data at the Karolinska University Hospital (n = 720 from 1 January 2005 to 31 December 2014) and Helsinki University Hospital (n = 395 from 1 January 2013 to 31 December 2014), totaling 1,115 patients. The Marshall CT classification and the Rotterdam, Stockholm, and Helsinki CT scores were assessed using the admission CT scans. Known outcome predictors at admission were acquired (age, pupil responsiveness, admission Glasgow Coma Scale, glucose level, and hemoglobin level) and used in univariate, and multivariable, regression models to predict long-term functional outcome (dichotomizations of the Glasgow Outcome Scale [GOS]). In total, 478 patients (43%) had an unfavorable outcome (GOS 1-3). In the combined cohort, overall prognostic performance was more accurate for the Stockholm CT score (Nagelkerke's pseudo-R2 range 0.24-0.28) and the Helsinki CT score (0.18-0.22) than for the Rotterdam CT score (0.13-0.15) and Marshall CT classification (0.03-0.05). Moreover, the Stockholm and Helsinki CT scores added the most independent prognostic value in the presence of other known clinical outcome predictors in TBI (6% and 4%, respectively). The aggregate traumatic subarachnoid hemorrhage (tSAH) component of the Stockholm CT score was the strongest predictor of unfavorable outcome. The main limitations were the retrospective nature of the study, missing patient information, and the varying follow-up time between the centers. CONCLUSIONS The Stockholm and Helsinki CT scores provide more information on the damage sustained, and give a more accurate outcome prediction, than earlier classification systems. The strong independent predictive value of tSAH may reflect an underrated component of TBI pathophysiology. A change to these newer CT scoring systems may be warranted.
Collapse
Affiliation(s)
- Eric Peter Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - David W. Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Juho Vehviläinen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harriet Nyström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mikael Svensson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Markus B. Skrifvars
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
28
|
Wasfie T, Frisbie J, Ho T, Boyer JJ, Knisely T, Barber KR, Shapiro B. Acute Traumatic Subdural Hematoma among the Elderly: Reducing Readmission. Am Surg 2017. [DOI: 10.1177/000313481708300707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tarik Wasfie
- Surgery Department Trauma Section Genesys Regional Medical Center Grand Blanc, Michigan
| | - Jacob Frisbie
- Surgery Department Trauma Section Genesys Regional Medical Center Grand Blanc, Michigan
| | - Tran Ho
- Surgery Department Trauma Section Genesys Regional Medical Center Grand Blanc, Michigan
| | - Jennifer J. Boyer
- Surgery Department Trauma Section Genesys Regional Medical Center Grand Blanc, Michigan
| | - Tara Knisely
- Research Office Genesys Regional Medical Center Grand Blanc, Michigan
| | | | - Brian Shapiro
- Surgery Department Trauma Section Genesys Regional Medical Center Grand Blanc, Michigan
| |
Collapse
|
29
|
Abstract
PURPOSE Subdural hematomas (SDH) are associated with seizures and epileptiform discharges, but little is known about the prevalence and impact of seizures, status epilepticus (SE), and epileptiform discharges on outcomes in patients with isolated acute SDH (aSDH). METHODS Continuous EEG reports from 76 adult patients admitted to Rush University Medical Center with aSDH between January 2009 and March 2012 were reviewed. Clinical and radiographic findings, comorbidities, treatment, and outcome parameters, such as mortality, discharge destination, need for tracheostomy/percutaneous endoscopic gastrostomy placement, and length of stay (LOS), were assessed. Univariate and multivariate analyses were performed to assess the impact of clinical seizures, SE, and epileptiform EEG on outcomes. RESULTS Of 76 patients with aSDH who underwent EEG monitoring, 74 (97.4%) received antiseizure prophylaxis. Thirty-two (41.1%) patients had seizures, most of which were clinical seizures. Twenty-four (32%) patients had epileptiform EEG findings. Clinical or nonconvulsive SE was diagnosed in 12 (16%) patients. Clinical seizures were not associated with outcome parameters. Epileptiform EEG findings were independently associated with longer hospital LOS (13 vs. 8 days, P = 0.04) and intensive care unit LOS (10 vs. 4 days, P = 0.002). The SE also predicted longer intensive care unit LOS (10 vs. 4 days, P = 0.002). Neither epileptiform EEG nor SE was significantly related to mortality, discharge destination, or need for tracheostomy/percutaneous endoscopic gastrostomy placement. CONCLUSIONS Seizures and epileptiform EEG findings are very common in patients with aSDH despite antiseizure prophylaxis. While clinical seizures did not affect outcomes, the presence of epileptiform EEG findings and SE was independently associated with longer intensive care unit LOS and hospital LOS.
Collapse
|
30
|
Won SY, Dubinski D, Herrmann E, Cuca C, Strzelczyk A, Seifert V, Konczalla J, Freiman TM. Epileptic Seizures in Patients Following Surgical Treatment of Acute Subdural Hematoma-Incidence, Risk Factors, Patient Outcome, and Development of New Scoring System for Prophylactic Antiepileptic Treatment (GATE-24 score). World Neurosurg 2017; 101:416-424. [PMID: 28213197 DOI: 10.1016/j.wneu.2017.02.024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/18/2022]
Abstract
OBJECT Clinically evident or subclinical seizures are common manifestations in acute subdural hematoma (aSDH); however, there is a paucity of research investigating the relationship between seizures and aSDH. The purpose of this study is 2-fold: determine incidence and predictors of seizures and then establish a guideline in patients with aSDH to standardize the decision for prophylactic antiepileptic treatment. METHOD The author analyzed 139 patients with aSDH treated from 2007 until 2015. Baseline characteristics and clinical findings including Glasgow Coma Scale (GCS) at admission, 24 hours after operation, timing of operation, anticoagulation, and Glasgow Outcome Scale at hospital discharge and after 3 months were analyzed. Multivariate logistic regression analysis was performed to detect independent predictors of seizures, and a scoring system was developed. RESULTS Of 139 patients, overall incidence of seizures was 38%, preoperatively 16% and postoperatively 24%. Ninety percent of patients with preoperative seizures were seizure free after operation for 3 months. Independent predictors of seizures were GCS <9 (odds ratio [OR] 3.3), operation after 24 hours (OR 2.0), and anticoagulation (OR 2.2). Patients with seizures had a significantly higher rate of unfavorable outcome at hospital discharge (P = 0.001) and in 3-month follow-up (P = 0.002). Furthermore, a score system (GATE-24) was developed. In patients with GCS <14, anticoagulation, or surgical treatment 24 hours after onset, a prophylactic antiepileptic treatment is recommended. CONCLUSION Occurrence of seizures affected severity and outcomes after surgical treatment of aSDH. Therefore seizure prophylaxis should be considered in high-risk patients on the basis of the GATE-24 score to promote better clinical outcome.
Collapse
Affiliation(s)
- Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany.
| | - Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Colleen Cuca
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurology and Epilepsy Center Frankfurt Rhine-Main, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| | - Thomas M Freiman
- Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany
| |
Collapse
|
31
|
Woischneck D, Kapapa T. The prognostic reliability of intracranial pressure monitoring and MRI data in severe traumatic brain injury. Magn Reson Imaging 2017; 36:210-215. [DOI: 10.1016/j.mri.2016.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/30/2016] [Accepted: 10/30/2016] [Indexed: 11/27/2022]
|
32
|
Won SY, Konczalla J, Dubinski D, Cattani A, Cuca C, Seifert V, Rosenow F, Strzelczyk A, Freiman TM. A systematic review of epileptic seizures in adults with subdural haematomas. Seizure 2017; 45:28-35. [DOI: 10.1016/j.seizure.2016.11.017] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/10/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022] Open
|
33
|
Huang KT, Bi WL, Abd-El-Barr M, Yan SC, Tafel IJ, Dunn IF, Gormley WB. The Neurocritical and Neurosurgical Care of Subdural Hematomas. Neurocrit Care 2017; 24:294-307. [PMID: 26399248 DOI: 10.1007/s12028-015-0194-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Subdural hematomas (SDHs), though frequently grouped together, can result from a variety of different etiologies, and therefore many different subtypes exist. Moreover, the high incidence of these lesions in the neurocritical care settings behooves practitioners to have a firm grasp on their diagnosis and management. We present here a review of SDHs, with an emphasis on how different subtypes of SDHs differ from one another and with discussion of their medical and surgical management in the neurocritical care setting. In this paper, we discuss considerations for acute, subacute, and chronic SDHs and how presentation and management may change in both the elderly and pediatric populations. We discuss SDHs that arise in the setting of anticoagulation, those that arise in the setting of active cerebrospinal fluid diversion, and those that are recurrent and recalcitrant to initial surgical evacuation. Management steps reviewed include detailed discussion of initial assessment, anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring. Direct surgical management options are reviewed, including open craniotomy, twist-drill, and burr-hole drainage and the usage of subdural drainage systems. SDHs are a common finding in the neurocritical care setting and have a diverse set of presentations. With a better understanding of the fundamental differences between subtypes of SDHs, critical care practitioners can better tailor their management of both the patient's intracranial and multi-systemic pathologies.
Collapse
Affiliation(s)
- Kevin T Huang
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Wenya Linda Bi
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Muhammad Abd-El-Barr
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Sandra C Yan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Ian J Tafel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - Ian F Dunn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 15 Francis Street, PBB-3, Boston, MA, 02115, USA.
| |
Collapse
|
34
|
Li LF, Lui WM, Wong HHT, Yuen WK, Leung GKK. Outcome after operative intervention for traumatic brain injuries in the elderly. Asian J Neurosurg 2017; 12:37-43. [PMID: 28413530 PMCID: PMC5379801 DOI: 10.4103/1793-5482.148787] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The management of traumatic brain injuries in the elderly (age ≥ 65 years) is a constant dilemma. The aim of this study is to investigate for factors that may predict outcome of operative treatment in this group of patients. MATERIALS AND METHODS A retrospective analysis was conducted on 68 elderly patients who had been operated in a designated center from 2006 to 2010. Patients' age, Glasgow Coma score (GCS), pupillary responses, imaging findings, medical conditions, and the use of anticoagulant/antiplatelet agents on patient outcomes were studied. RESULTS The overall mortality rate was 55.9%. Older age, abnormal pupillary response, low GCS, the presence of midline shift and cistern obliteration on computerized tomography were associated with poor survival. Patient aged 75-84 with normal bilateral pupillary response still had an overall survival rate of 52.6% and good outcomes (Glasgow outcome score: 4 or 5) in 36.8% of patients. Abnormal pupillary response in at least one eye and preoperative GCS ≤ 12 were associated with very poor prognosis. CONCLUSIONS More advanced age was found to be associated with progressively worse outcome. A subgroup patients aged below 85 would survive and could achieve good clinical outcome. The prognosis of those aged over 85 with moderate or severe head injuries was extremely poor.
Collapse
Affiliation(s)
- Lai-Fung Li
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Man Lui
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Heidi Hay-Tai Wong
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Wai-Kei Yuen
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Gilberto Ka-Kit Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| |
Collapse
|
35
|
Kwon YS, Yang KH, Lee YH. Craniotomy or Decompressive Craniectomy for Acute Subdural Hematomas: Surgical Selection and Clinical Outcome. Korean J Neurotrauma 2016; 12:22-7. [PMID: 27182498 PMCID: PMC4866560 DOI: 10.13004/kjnt.2016.12.1.22] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 02/11/2016] [Accepted: 02/14/2016] [Indexed: 11/15/2022] Open
Abstract
Objective Craniotomy (CO) and decompressive craniectomy (DC) are two main surgical options for acute subdural hematomas (ASDH). However, optimal selection of surgical modality is unclear and decision may vary with surgeon's experience. To clarify this point, we analyzed preoperative findings and surgical outcome of patients with ASDH treated with CO or DC. Methods From January 2010 to December 2014, data for 46 patients with ASDH who underwent CO or DC were retrospectively reviewed. The demographic, clinical, imaging and clinical outcomes were analyzed and statistically compared. Results Twenty (43%) patients underwent CO and 26 (57%) patients received DC. In DC group, preoperative Glascow Coma Scale was lower (p=0.034), and more patient had non-reactive pupil (p=0.004). Computed tomography findings of DC group showed more frequent subarachnoid hemorrhage (p=0.003). Six month modified Rankin Scale showed favorable outcome in 60% of CO group and 23% of DC group (p=0.004). DC was done in patient with more unfavorable preoperative features (p=0.017). Patients with few unfavorable preoperative features (<6) had good outcome with CO (p<0.001). Conclusion In selective cases of few unfavorable clinical findings, CO may also be an effective surgical option for ASDH. Although DC remains to be standard of surgical modality for patients with poor clinical status, CO can be an alternative considering the possible complications of DC.
Collapse
Affiliation(s)
- Young Sub Kwon
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
- Department of Neurosurgery, School of Medicine, Kangwon National University, Chuncheon, Korea
| | - Kook Hee Yang
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Yun Ho Lee
- Department of Neurosurgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| |
Collapse
|
36
|
Won SY, Bruder MG, Mersmann J, Seifert V, Senft C. Dislocated Pacemaker Electrode Simulating Focal Epileptic State in a Patient with Subdural Hematoma—Case Report and Review of the Literature. World Neurosurg 2016; 88:696.e1-696.e4. [DOI: 10.1016/j.wneu.2015.12.099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/31/2015] [Indexed: 10/22/2022]
|
37
|
Atraumatic Subdural Hematoma in a Third-Trimester Gravid Patient. Case Rep Emerg Med 2016; 2016:8252746. [PMID: 26989526 PMCID: PMC4773536 DOI: 10.1155/2016/8252746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/28/2016] [Indexed: 11/18/2022] Open
Abstract
Acute atraumatic subdural hematoma is a rare occurrence and there exist few case studies which describe suspected cases and causes for this condition. We present a case of a 36-year-old female at 32-week gestation who initially presented to the emergency department for evaluation of lower extremity cellulitis but had acute neurologic change while being in the ED. Computed tomography revealed a right subdural hematoma with midline shift and mass effect. The primary cause for the patient’s subdural hematoma is unknown; however, this patient had several risk factors for developing an atraumatic subdural hematoma.
Collapse
|
38
|
Herou E, Romner B, Tomasevic G. Acute Traumatic Brain Injury: Mortality in the Elderly. World Neurosurg 2015; 83:996-1001. [DOI: 10.1016/j.wneu.2015.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 02/07/2015] [Accepted: 02/11/2015] [Indexed: 11/29/2022]
|
39
|
Walcott BP, Khanna A, Kwon CS, Phillips HW, Nahed BV, Coumans JV. Time interval to surgery and outcomes following the surgical treatment of acute traumatic subdural hematoma. J Clin Neurosci 2014; 21:2107-11. [PMID: 25065950 DOI: 10.1016/j.jocn.2014.05.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 05/17/2014] [Indexed: 01/22/2023]
Abstract
Although the pre-surgical management of patients with acute traumatic subdural hematoma prioritizes rapid transport to the operating room, there is conflicting evidence regarding the importance of time interval from injury to surgery with regards to outcomes. We sought to determine the association of surgical timing with outcomes for subdural hematoma. A retrospective review was performed of 522 consecutive patients admitted to a single center from 2006-2012 who underwent emergent craniectomy for acute subdural hematoma. After excluding patients with unknown time of injury, penetrating trauma, concurrent cerebrovascular injury, epidural hematoma, or intraparenchymal hemorrhage greater than 30 mL, there remained 45 patients identified for analysis. Using a multiple regression model, we examined the effect of surgical timing, in addition to other variables on in-hospital mortality (primary outcome), as well as the need for tracheostomy or gastrostomy (secondary outcome). We found that increasing injury severity score (odds ratio [OR] 1.146; 95% confidence interval [CI] 1.035-1.270; p=0.009) and age (OR1.066; 95%CI 1.006-1.129; p=0.031) were associated with in-hospital mortality in multivariate analysis. In this model, increasing time to surgery was not associated with mortality, and in fact had a significant effect in decreasing mortality (OR 0.984; 95%CI 0.971-0.997; p=0.018). Premorbid aspirin use was associated with a paradoxical decrease in mortality (OR 0.019; 95%CI 0.001-0.392; p=0.010). In this patient sample, shorter time interval from injury to surgery was not associated with better outcomes. While there are potential confounding factors, these findings support the evaluation of rigorous preoperative resuscitation as a priority in future study.
Collapse
Affiliation(s)
- Brian P Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA.
| | - Arjun Khanna
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - Churl-Su Kwon
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - H Westley Phillips
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - Brian V Nahed
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| | - Jean-Valery Coumans
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White Building Room 502, Boston, MA 02114, USA
| |
Collapse
|
40
|
The influence of coagulopathy on outcome after traumatic subdural hematoma. Blood Coagul Fibrinolysis 2014; 25:353-9. [DOI: 10.1097/mbc.0000000000000042] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
41
|
Cohen JE, Rajz G, Itshayek E, Umansky F. Bilateral acute epidural hematoma after evacuation of acute subdural hematoma: brain shift and the dynamics of extraaxial collections. Neurol Res 2013; 26:763-6. [PMID: 15494119 DOI: 10.1179/016164104225015930] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Acute epidural hematoma following supratentorial decompressive craniectomy is a very seldom described but serious complication. The occurrence of intraoperative brain swelling may suggest the development of a contralateral hematoma. A unique case of bilateral acute epidural following decompressive craniectomy and evacuation of acute subdural hematoma is presented. Awareness of unexplained elevation of intracranial pressure is of paramount importance when routine immediate postoperative computed tomography is not performed. This case provides insight into the well-known but poorly understood dynamic process of brain shift and extraaxial collections.
Collapse
MESH Headings
- Aged
- Decompression, Surgical/adverse effects
- Female
- Hematoma, Epidural, Cranial/diagnostic imaging
- Hematoma, Epidural, Cranial/etiology
- Hematoma, Subdural, Acute/diagnostic imaging
- Hematoma, Subdural, Acute/surgery
- Humans
- Intraoperative Complications
- Outcome Assessment, Health Care
- Tomography, X-Ray Computed
Collapse
Affiliation(s)
- José E Cohen
- Department of Neurosurgery, Endovascular Neurosurgery and Interventional Neuroradiology, Hadassah University Hospital, Jerusalem, Israel.
| | | | | | | |
Collapse
|
42
|
Abstract
OBJECT Subdural hematoma (SDH) is a common diagnosis in neurosurgical and neurocritical practice. Comprehensive outcome data are lacking for nontraumatic SDH. The authors determined which factors are associated with in-hospital mortality in a large sample of patients with nontraumatic SDH. METHODS Using the Nationwide Inpatient Sample, the authors selected adults who had been hospitalized in the US between 2007 and 2009 and in whom a primary diagnosis of nontraumatic SDH (ICD-9-CM code 432.1) had been made. Demographics, comorbidities, surgical treatment, and discharge outcomes were identified. Univariate and multivariate analyses were performed to identify predictors of in-hospital mortality. RESULTS Among 14,093 patients with acute nontraumatic SDH, the mean age was 71.4 ± 14.8 (mean ± standard deviation). In addition, 22.2% of the patients were admitted during the weekend. Surgical evacuation was performed in 51.4% of the patients, and 11.8% of all patients died during hospitalization. In multivariate analyses, patient age (adjusted OR 1.02, 95% CI 1.012-1.022), congestive heart failure (adjusted OR 1.42, 95% CI 1.19-1.71), warfarin use (adjusted OR 1.41, 95% CI 1.17-1.70), coagulopathy (adjusted OR 2.14, 95% CI 1.75-2.61), mechanical ventilation (adjusted OR 16.85, 95% CI 14.29-19.86), and weekend admission (adjusted OR 1.19, 95% CI 1.02-1.38) were independent predictors of in-hospital mortality. Race (Hispanic: adjusted OR 0.65, 95% CI 0.51-0.83; black: adjusted OR 0.78, 95% CI 0.63-0.96), urban hospital location (adjusted OR 0.69, 95% CI 0.54-0.89), and surgical SDH evacuation (adjusted OR 0.52, 95% CI 0.45-0.60) were strong independent predictors for decreased mortality. CONCLUSIONS One in 9 patients with nontraumatic SDH dies during hospitalization. Among the several predictors of in-hospital mortality, the weekend effect and treatment with surgical evacuation are potentially modifiable factors. Further investigation may lead to improvements in management and outcomes.
Collapse
Affiliation(s)
- Katharina M Busl
- Department of Neurological Sciences, Section of Neurocritical Care, Rush University Medical Center; and
| | | |
Collapse
|
43
|
Honeybul S, Ho KM. The current role of decompressive craniectomy in the management of neurological emergencies. Brain Inj 2013; 27:979-91. [DOI: 10.3109/02699052.2013.794974] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
44
|
Gürer B, Kertmen H, Yilmaz ER, Sekerci Z. The surgical outcome of traumatic extra-axial hematomas causing brain herniation in children. Pediatr Neurosurg 2013; 49:215-22. [PMID: 25073982 DOI: 10.1159/000363193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/20/2014] [Indexed: 11/19/2022]
Abstract
AIM The aim of this study was to assess the surgical outcome and prognostic importance of clinical and radiological data from children operated on under emergency conditions due to an extra-axial hematoma causing brain herniation. METHODS This retrospective study included 25 children operated on due to herniated traumatic extra-axial hematomas from January 2000 to December 2010. RESULTS Of those 25 children, 17 (68%) were diagnosed with subdural hematoma (SDH), 7 (28%) with epidural hematoma (EDH) and only 1 patient (4%) suffered from both SDH and EDH. Overall mortality from a herniated extra-axial hematoma was 44%. The mortality rate for herniated SDH patients was 52.9%, and only 1 patient died from a herniated EDH (14.2%). Low Glasgow coma scale scores at admission, high postoperative intracranial pressure (ICP) values, longer intervals from trauma to surgery, longer durations of brain herniation, the presence of intraoperative brain swelling, larger and thicker hematomas and more displacement of the midline structures and obliteration of the basal cisterns were all correlated with mortality and an unfavorable outcome. CONCLUSIONS Brain herniation is a serious consequence of traumatic extra-axial hematomas in children, and approximately one third of these patients have the potential for a favorable outcome. We recommend postoperative ICP monitoring to predict outcome and early decompressive surgery when possible for promising results.
Collapse
Affiliation(s)
- Bora Gürer
- Neurosurgery Clinic, Fatih Sultan Mehmet Education and Research Hospital, Ministry of Health, Istanbul, Turkey
| | | | | | | |
Collapse
|
45
|
Dynamics of brain tissue changes induced by traumatic brain injury assessed with the Marshall, Morris-Marshall, and the Rotterdam classifications and its impact on outcome in a prostacyclin placebo-controlled study. Acta Neurochir (Wien) 2012; 154:1069-79. [PMID: 22538327 DOI: 10.1007/s00701-012-1345-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 03/27/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The present study evaluates the types and dynamics of intracranial pathological changes in patients with severe traumatic brain injury (sTBI) who participated in a prospective, randomized, double-blinded study of add-on treatment with prostacyclin. Further, the changes of brain CT scan and their correlation to Glasgow Coma Scale score (GCS), maximal intracranial pressure (ICP(max)), minimal cerebral perfusion pressure (CPP(min)), and Glasgow Outcome Score (GOS) at 3, 6, and 12 months were studied. METHODS Forty-eight subjects with severe traumatic brain injury were treated according to an ICP-targeted therapy protocol based on the Lund concept with the addition of prostacyclin or placebo. The first available CT scans (CT(i)) and follow-up scans nearest to 24 h (CT(24)) were evaluated using the Marshall, Rotterdam, and Morris-Marshall classifications. RESULTS There was a significant correlation of the initial Marshall, Rotterdam, Morris-Marshall classifications and GOS at 3 and 12 months. The CT(24) Marshall classification did not significantly correlate to GOS while the Rotterdam and the Morris-Marshall classification did. The CT(i) Rotterdam classification predicted outcome evaluated as GOS at 3 and 12 months. Prostacyclin treatment did not influence the dynamic of tissue changes. CONCLUSIONS The Rotterdam classification seems to be appropriate for describing the evolution of the injuries on the CT scans and contributes in predicting of outcome in patients treated with an ICP-targeted therapy. The Morris-Marshall classification can also be used for prognostication of outcome but it describes only the impact of traumatic subarachnoid hemorrhage (tSAH).
Collapse
|
46
|
Schulz C, Mauer UM. [Postoperative course after acute traumatic subdural hematoma in the elderly. Does the extent of craniotomy influence outcome?]. Z Gerontol Geriatr 2012; 44:177-80. [PMID: 21505941 DOI: 10.1007/s00391-011-0168-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIM The goal of the study was to analyze the short-term outcome after surgical treatment of acute subdural hematomas in two treatment groups in a patient population >65 years. Whether there are disadvantages from invasive treatment or whether advantages can be achieved with the less invasive treatment has not been previously examined in a prospective study. METHODS A prospective, nonrandomized study of 50 patients >65 years with acute traumatic subdural hematoma was performed, comparing the short-term outcome after two different primary surgical procedures: limited craniotomy (group A, n=25) and large decompressive craniectomy (group B, n=25). RESULTS There were no differences of hematoma volume, degree of midline structure shift, and time from trauma to operation between the two groups. Initial Glasgow coma scale and short-term outcome after 4 weeks measured by the Glasgow outcome score in both groups showed no significant differences. CONCLUSION No significant differences between short-term outcome after limited craniotomy versus large decompressive craniectomy were found for patients >65 years, and the results indicate that decompressive craniectomy can be accepted as a surgical treatment option for acute traumatic subdural hematoma even in elderly patients.
Collapse
Affiliation(s)
- C Schulz
- Neurochirurgische Klinik, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, Ulm, Germany.
| | | |
Collapse
|
47
|
Kalanithi P, Schubert RD, Lad SP, Harris OA, Boakye M. Hospital costs, incidence, and inhospital mortality rates of traumatic subdural hematoma in the United States. J Neurosurg 2011; 115:1013-8. [DOI: 10.3171/2011.6.jns101989] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
This study provides the first US national data regarding frequency, cost, and mortality rate of traumatic subdural hematoma (SDH), and identifies demographic factors affecting morbidity and death in patients with traumatic SDH undergoing surgical drainage.
Methods
A retrospective analysis was conducted by querying the Nationwide Inpatient Sample, the largest all-payer database of nonfederal community hospitals. All cases of traumatic SDH were identified using ICD-9 codes. The study consisted of 2 parts: 1) trends data, which were abstracted from the years 1993–2006, and 2) univariate analysis and multivariate logistic regression of demographic variables on inhospital complications and deaths for the years 1993–2002.
Results
Admissions for traumatic SDH increased 154% from 17,328 in 1993 to 43,996 in 2006. Inhospital deaths decreased from 16.4% to 11.6% for traumatic SDH. Average costs increased 67% to $47,315 per admission. For the multivariate regression analysis, between 1993 and 2002, 67,864 patients with traumatic SDH underwent operative treatment. The inhospital mortality rate was 14.9% for traumatic SDH drainage, with an 18% inhospital complication rate. Factors affecting inhospital deaths included presence of coma (OR = 2.45) and more than 2 comorbidities (OR = 1.60). Increased age did not worsen the inhospital mortality rate.
Conclusions
Nationally, frequency and cost of traumatic SDH cases are increasing rapidly.
Collapse
Affiliation(s)
- Paul Kalanithi
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| | | | - Shivanand P. Lad
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| | - Odette A. Harris
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| | - Maxwell Boakye
- 1Department of Neurosurgery, Stanford University Hospitals and Clinics, and Outcomes Research Center, VA Palo Alto Health Care System, Palo Alto; and
| |
Collapse
|
48
|
Risk Factors Related to Prognosis in Patients with Isolated Traumatic Subdural Hematoma. ACTA ACUST UNITED AC 2011. [DOI: 10.13004/jknts.2011.7.1.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
49
|
Rabinstein AA, Chung SY, Rudzinski LA, Lanzino G. Seizures after evacuation of subdural hematomas: incidence, risk factors, and functional impact. J Neurosurg 2010; 112:455-60. [DOI: 10.3171/2009.7.jns09392] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The purpose of this study was to evaluate the incidence of seizures or epileptiform abnormalities on electroencephalography (EEG) studies in patients undergoing surgical treatment for acute subdural hematoma (SDH).
Methods
This was a retrospective study of 134 consecutive patients with acute or acute-on-chronic SDH who underwent surgical treatment at the authors' institution between January 2004 and July 2008. Detailed information was collected regarding baseline clinical data (including preexistent functional impairment); Glasgow Coma Scale (GCS) sum scores before and 24 hours after surgery; presence of clinical seizures; EEG findings; and functional outcome on discharge and up to the 6-month follow-up. All brain CT scans were reviewed to calculate SDH volume and midline shift. The Glasgow Outcome Scale (GOS) score was used for functional assessment, and GOS scores of 1–3 were considered indicative of poor outcome. Univariate and multivariate logistic regression analyses were performed to identify statistical associations.
Results
Clinical seizures or epileptiform changes on EEG were observed during the acute postoperative period in 33 patients (25%). Preexistent functional impairment and seizures/epileptiform EEG findings after surgery were independently associated with poor functional outcome upon hospital discharge (p < 0.001 for both). Preexistent functional impairment (p < 0.001), lower GCS score before surgery (p = 0.04), and lower GCS score 24 hours after surgery (p = 0.007), but not seizures/epileptiform EEG findings, were independently associated with poor functional recovery at 1- to 6-month follow-up evaluations. Seizures/epileptiform EEG findings had a strong association with lower GCS scores after surgery (p = 0.01), and they were more common in patients who underwent evacuation by craniotomy (p = 0.02).
Conclusions
Epileptic complications are common after acute SDH evacuation, and should be suspected in patients with an unanticipated depressed level of consciousness after surgery. Seizures worsen early functional outcome, but delayed favorable recovery is possible. Therefore, one should be cautious when discussing prognosis in the early postoperative period of patients with epileptic complications.
Collapse
Affiliation(s)
| | - Seung Young Chung
- 2Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | | | | |
Collapse
|
50
|
Rickels E. Neurotraumatologie. NeuroRehabilitation 2010. [DOI: 10.1007/978-3-642-12915-5_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|