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Basilio AV, Zeng D, Pichay LA, Ateshian GA, Xu P, Maas SA, Morrison B. Simulating Cerebral Edema and Ischemia After Traumatic Acute Subdural Hematoma Using Triphasic Swelling Biomechanics. Ann Biomed Eng 2024:10.1007/s10439-024-03496-y. [PMID: 38532172 DOI: 10.1007/s10439-024-03496-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
Poor outcome following traumatic acute subdural hematoma (ASDH) is associated with the severity of the primary injury and secondary injury including cerebral edema and ischemia. However, the underlying secondary injury mechanism contributing to elevated intracranial pressure (ICP) and high mortality rate remains unclear. Cerebral edema occurs in response to the exposure of the intracellular fixed charge density (FCD) after cell death, causing ICP to increase. The increased ICP from swollen tissue compresses blood vessels in adjacent tissue, restricting blood flow and leading to ischemic damage. We hypothesize that the mass occupying effect of ASDH exacerbates the ischemic injury, leading to ICP elevation, which is an indicator of high mortality rate in the clinic. Using FEBio (febio.org) and triphasic swelling biomechanics, this study modeled clinically relevant ASDHs and simulated post-traumatic brain swelling and ischemia to predict ICP. Results showed that common convexity ASDH significantly increased ICP by exacerbating ischemic injury, and surgical removal of the convexity ASDH may control ICP by preventing ischemia progression. However, in cases where the primary injury is very severe, surgical intervention alone may not effectively decrease ICP, as the contribution of the hematoma to the elevated ICP is insignificant. In addition, interhemispheric ASDH, located between the cerebral hemispheres, does not significantly exacerbate ischemia, supporting the conservative surgical management generally recommended for interhemispheric ASDH. The joint effect of the mass occupying effect of the blood clot and resulting ischemia contributes to elevated ICP which may increase mortality. Our novel approach may improve the fidelity of predicting patient outcome after motor vehicle crashes and traumatic brain injuries due to other causes.
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Affiliation(s)
- Andrew V Basilio
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Delin Zeng
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Leanne A Pichay
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Gerard A Ateshian
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
- Department of Mechanical Engineering, Columbia University, 220 S. W. Mudd Building, 500 West 120th Street, New York, NY, 10027, USA
| | - Peng Xu
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA
| | - Steve A Maas
- Department of Bioengineering, University of Utah, 36 S. Wasatch Drive, SMBB 3100, Salt Lake City, UT, 84112, USA
| | - Barclay Morrison
- Department of Biomedical Engineering, Columbia University, 351 Engineering Terrace MC 8904, 1210 Amsterdam Avenue, New York, NY, 10027, USA.
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Heino I, Sajanti A, Lyne SB, Frantzén J, Girard R, Cao Y, Ritala JF, Katila AJ, Takala RS, Posti JP, Saarinen AJ, Hellström S, Laukka D, Saarenpää I, Rahi M, Tenovuo O, Rinne J, Koskimäki J. Outcome and survival of surgically treated acute subdural hematomas and postcraniotomy hematomas - A retrospective cohort study. BRAIN & SPINE 2023; 3:102714. [PMID: 38105801 PMCID: PMC10724206 DOI: 10.1016/j.bas.2023.102714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023]
Abstract
Background The morbidity and mortality of acute subdural hematoma (aSDH) remains high. Several factors have been reported to affect the outcome and survival of these patients. In this study, we explored factors potentially associated with the outcome and survival of surgically treated acute subdural hematoma (aSDH), including postcraniotomy hematomas (PCHs). Methods This retrospective cohort study was conducted in a single tertiary university hospital between 2008 and 2012 and all aSDH patients that underwent surgical intervention were included. A total of 132 cases were identified for collection of demographics, clinical, laboratory, and imaging data. Univariate and multivariable analyses were performed to assess factors associated with three-month Glasgow Outcome Scale (GOS) and survival at one- and five-year. Results In this study, PCH (n = 14, 10.6%) was not associated with a worse outcome according to the 3- month GOS (p = 0.37) or one (p = 0.34) and five-year (p = 0.37) survival. The multivariable analysis showed that the volume of initial hematoma (p = 0.009) and Abbreviated Injury Scale score (p = 0.016) were independent predictors of the three-month GOS. Glasgow Coma Scale (GCS) score (p < 0.001 and p = 0.037) and age (p = 0.048 and p = 0.003) were predictors for one and five-year survival, while use of antiplatelet drug (p = 0.030), neuroworsening (p = 0.005) and smoking (p = 0.026) were significant factors impacting one year survival. In addition, blood alcohol level on admission was a predictor for five-year survival (p = 0.025). Conclusions These elucidations underscore that, although PCHs are pertinent, a comprehensive appreciation of multifarious variables is indispensable in aSDH prognosis. These findings are observational, not causal. Expanded research endeavors are advocated to corroborate these insights.
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Affiliation(s)
- Iiro Heino
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Antti Sajanti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Seán B. Lyne
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janek Frantzén
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, (5841 S. Maryland), Chicago, IL, 60637, USA
| | - Ying Cao
- Department of Radiation Oncology, Kansas University Medical Center, Kansas City, KS, 66160, USA
| | - Joel F. Ritala
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Ari J. Katila
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Riikka S.K. Takala
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Jussi P. Posti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Neurocenter, Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520, Turku, Finland
| | - Antti J. Saarinen
- Department of Paediatric Orthopaedic Surgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Santtu Hellström
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Dan Laukka
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Ilkka Saarenpää
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Melissa Rahi
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Olli Tenovuo
- Neurocenter, Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520, Turku, Finland
| | - Jaakko Rinne
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Janne Koskimäki
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
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Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma. Neuroradiology 2023; 65:489-501. [PMID: 36434311 DOI: 10.1007/s00234-022-03087-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/12/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course. METHODS We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed. RESULTS The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome. CONCLUSION rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.
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Kaewborisutsakul A, Tunthanathip T. Development and internal validation of a nomogram for predicting outcomes in children with traumatic subdural hematoma. Acute Crit Care 2022; 37:429-437. [PMID: 35791657 PMCID: PMC9475159 DOI: 10.4266/acc.2021.01795] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/07/2022] [Indexed: 12/23/2022] Open
Abstract
Background A subdural hematoma (SDH) following a traumatic brain injury (TBI) in children can lead to unexpected death or disability. The nomogram is a clinical prediction tool used by physicians to provide prognosis advice to parents for making decisions regarding treatment. In the present study, a nomogram for predicting outcomes was developed and validated. In addition, the predictors associated with outcomes in children with traumatic SDH were determined. Methods In this retrospective study, 103 children with SDH after TBI were evaluated. According to the King’s Outcome Scale for Childhood Head Injury classification, the functional outcomes were assessed at hospital discharge and categorized into favorable and unfavorable. The predictors associated with the unfavorable outcomes were analyzed using binary logistic regression. Subsequently, a two-dimensional nomogram was developed for presentation of the predictive model. Results The predictive model with the lowest level of Akaike information criterion consisted of hypotension (odds ratio [OR], 9.4; 95% confidence interval [CI], 2.0–42.9), Glasgow coma scale scores of 3–8 (OR, 8.2; 95% CI, 1.7–38.9), fixed pupil in one eye (OR, 4.8; 95% CI, 2.6–8.8), and fixed pupils in both eyes (OR, 3.5; 95% CI, 1.6–7.1). A midline shift ≥5 mm (OR, 1.1; 95% CI, 0.62–10.73) and co-existing intraventricular hemorrhage (OR, 6.5; 95% CI, 0.003–26.1) were also included. Conclusions SDH in pediatric TBI can lead to mortality and disability. The predictability level of the nomogram in the present study was excellent, and external validation should be conducted to confirm the performance of the clinical prediction tool.
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Affiliation(s)
- Anukoon Kaewborisutsakul
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Thara Tunthanathip
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Vychopen M, Schneider M, Borger V, Schuss P, Behning C, Vatter H, Güresir E. Complete hemispheric exposure vs. superior sagittal sinus sparing craniectomy: incidence of shear-bleeding and shunt-dependency. Eur J Trauma Emerg Surg 2022; 48:2449-2457. [PMID: 34605961 PMCID: PMC9192399 DOI: 10.1007/s00068-021-01789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Decompressive hemicraniectomy (DC) has been established as a standard therapeutical procedure for raised intracranial pressure. However, the size of the DC remains unspecified. The aim of this study was to analyze size related complications following DC. METHODS Between 2013 and 2019, 306 patients underwent DC for elevated intracranial pressure at author´s institution. Anteroposterior and craniocaudal DC size was measured according to the postoperative CT scans. Patients were divided into two groups with (1) exposed superior sagittal sinus (SE) and (2) without superior sagittal sinus exposure (SC). DC related complications e.g. shear-bleeding at the margins of craniectomy and secondary hydrocephalus were evaluated and compared. RESULTS Craniectomy size according to anteroposterior diameter and surface was larger in the SE group; 14.1 ± 1 cm vs. 13.7 ± 1.2 cm, p = 0.003, resp. 222.5 ± 40 cm2 vs. 182.7 ± 36.9 cm2, p < 0.0001. The SE group had significantly lower rates of shear-bleeding: 20/176 patients; (11%), compared to patients of the SC group; 36/130 patients (27%), p = 0.0003, OR 2.9, 95% CI 1.6-5.5. There was no significant difference in the incidence of shunt-dependent hydrocephalus; 19/130 patients (14.6%) vs. 24/176 patients (13.6%), p = 0.9. CONCLUSIONS Complete hemispheric exposure in terms of DC with SE was associated with significantly lower levels of iatrogenic shear-bleedings compared to a SC-surgical regime. Although we did not find significant outcome difference, our findings suggest aggressive craniectomy regimes including SE to constitute the surgical treatment strategy of choice for malignant intracranial pressure.
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Affiliation(s)
- Martin Vychopen
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Matthias Schneider
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Charlotte Behning
- Department of Medical Biometry, Informatics and Epidemiology, Universität Bonn, Institut für Medizinische Biometrie, Informatik und Epidemiologie (IMBIE), Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, Venusberg Campus 1, 53127 Bonn, Germany
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Jain R, The CS, Murphy MM, Pandit AS. Surgical significance of prolonged fixed and dilated pupils in a case of non-traumatic, spontaneously regressing, acute subdural haemorrhage. BMJ Case Rep 2022; 15:e247388. [PMID: 35473704 PMCID: PMC9045004 DOI: 10.1136/bcr-2021-247388] [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] [Accepted: 04/06/2022] [Indexed: 11/04/2022] Open
Abstract
Bilaterally fixed and dilated pupils (BFDP) in traumatic acute subdural haematoma (ASDH) patients represent an ominous sign that portends irreversible brainstem injury and death. Whether patients with spontaneous ASDH and BFDP follow similar outcomes is unknown. We present a mid-60s man, found unconscious, with a Glasgow Coma Scale (GCS) of 4 following 8 days of headaches. Emergency CT imaging demonstrated a large right ASDH and the patient exhibited BFDP for >3 hours despite sedation and mannitol. Neurological improvement and spontaneously reduced SDH thickness were observed 10 hours postadmission, and he was later transferred for craniotomy and ASDH evacuation. His long-term outcomes were good: achieving independence in his activities of daily living and a GCS of 15. To the best of our knowledge, this is the first reported patient with a spontaneous, regressing ASDH and prolonged BFDP who clinically improved. This case raises important questions regarding factors used to determine prognosis and surgical viability for ASDH.
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Affiliation(s)
- Raunak Jain
- Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Crystallynn Skye The
- Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Mary M Murphy
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Anand S Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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Factors influencing the outcome of patients with traumatic acute subdural hematoma (ASDH) – A single centre analysis. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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de Souza MR, Fagundes CF, Solla DJF, da Silva GCL, Barreto RB, Teixeira MJ, Oliveira de Amorim RL, Kolias AG, Godoy D, Paiva WS. Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma. Trauma Surg Acute Care Open 2021; 6:e000707. [PMID: 34104799 PMCID: PMC8144027 DOI: 10.1136/tsaco-2021-000707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country. METHODS This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (<0.00, 0.01-3, and >3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated. RESULTS A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively. CONCLUSIONS The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH. LEVEL OF EVIDENCE Level III, epidemiological study.
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Affiliation(s)
| | | | - Davi Jorge Fontoura Solla
- Department of Neurology, University of São Paulo, São Paulo, Brazil
- Department of Neurology, University of Cambridge, Cambridge, UK
| | | | | | | | | | - Angelos G Kolias
- Department of Clinical Neuroscience - Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Daniel Godoy
- Intensive Care Unit, San Juan Bautista Hospital, San Fernando del Valle de Catamarca, Argentina
| | - Wellingson Silva Paiva
- Department of Neurology, University of São Paulo, São Paulo, Brazil
- Department of Neurology, University of Cambridge, Cambridge, UK
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Siddiq F, Bains NK, Herbert JP, Akhtar IN, Thomas AJ, Kan P, Cassarly C, Martin RH, Selim M, Qureshi AI. Reliability of an Automated Computerized Hematoma Volumetric Analysis Protocol in Patients with Chronic Subdural Hemorrhage. World Neurosurg 2021; 150:e372-e377. [PMID: 33722724 DOI: 10.1016/j.wneu.2021.03.017] [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: 10/14/2020] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Hematoma volume in chronic subdural hematoma (CSDH) may predict neurologic deterioration and need for surgical evacuation. Several computer software-assisted methods exist for accurate volume measurements of intracerebral hemorrhage, but no reliable method has been identified for measurement of CSDH volume. METHODS A total of 30 consecutive patients with CSDH from 2018-2019 admitted to our institution were selected. The noncontrast computed tomography head studies were reviewed by 2 residents. The region of interest method on a Horos Open Source Medical Image Viewer (version 3.3.6) was utilized for volume measurement by each resident (resident-1 and resident-2) independently. Resident-1 repeated the protocol on the same studies 1 month later. We calculated the intra- and interobserver reliability of hematoma volume measurements using the Bland-Altman method. RESULTS Mean age of the patients was 79 years (range, 50-92 years). For interobserver analysis, resident-1 mean hematoma volume was 85.46 cm3 (range, 6.40-178.63 cm3) and was 87.15 cm3 (range, 8.79-165.97 cm3) for resident-2. The Bland-Altman coefficient of variation was 13.15% (range, 0.07%-46.29%, 97% within the limits of acceptance). For intraobserver analysis, the initial average volume measured by resident-1 was 85.46 cm3 (range, 6.40-178.63 cm3) and subsequent was 95.26 cm3 (range, 10.48-182.99 cm3). The Bland-Altman coefficient of variation was 13.76% (range, 0.81%-48.34%, 97% within the limits of acceptance). CONCLUSIONS We are reporting inter- and intraobserver reliability for a novel volumetric analysis of CSDH volume using Horos Medical Image Viewer region of interest generated volume calculation. This method is accurate and efficient and could have important clinical and research implications for risk stratification.
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Affiliation(s)
- Farhan Siddiq
- Division of Neurological Surgery, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Navpreet K Bains
- Department of Neurology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA.
| | - Joseph P Herbert
- Division of Neurological Surgery, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Iqra N Akhtar
- Department of Neurology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch, Galveston, Texas, USA
| | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Renee H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri-Columbia School of Medicine, Columbia, Missouri, USA; Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA
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Liao CC, Liao HC, Lai F, Xiao F. A nomogram for estimating intracranial pressure using acute subdural hematoma thickness and midline shift. Sci Rep 2020; 10:21787. [PMID: 33311523 PMCID: PMC7733494 DOI: 10.1038/s41598-020-77667-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/02/2020] [Indexed: 11/09/2022] Open
Abstract
Although criteria for surgical treatment of acute subdural hematoma (SDH) have been proposed, interaction exists between SDH, midline shift (MLS), and intracranial pressure (ICP). Based on our half sphere finite-element model (FEM) of the supratentorial brain parenchyma, tools for ICP estimation using SDH thickness (SDHx) and MLS were developed. We performed 60 single load step, structural static analyses, simulating a left-sided SDH compressing the cerebral hemispheres. The Young's modulus was taken as 10,000 Pa. The ICP loads ranged from 10 to 80 mmHg with Poisson's ratios between 0.25 and 0.49. The SDHx and the MLS results were stored in a lookup table. An ICP estimation equation was derived from these data and then was converted into a nomogram. Numerical convergence was achieved in 49 model analyses. Their SDHx ranged from 0.79 to 28.3 mm, and the MLS ranged from 1.5 to 16.9 mm. The estimation formula was log(ICP) = 0.614-0.520 log(SDHx) + 1.584 log(MLS). Good correlations were observed between invasive ICP measurements and those estimated from preoperative SDHx and MLS data on images using our model. These tools can be used to estimate ICP noninvasively, providing additional information for selecting the treatment strategy in patients with SDH.
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Affiliation(s)
- Chun-Chih Liao
- Department of Neurosurgery, Taipei Hospital, Ministry of Health and Welfare, Taipei, Taiwan
| | - Heng-Chun Liao
- School of Medicine, National Taiwan University, Taipei, Taiwan
| | - Feipei Lai
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, Taiwan
| | - Furen Xiao
- Department of Neurosurgery, National Taiwan University Hospital, Taipei, Taiwan.
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Onodera K, Kamide T, Kimura T, Tabata S, Ikeda T, Kikkawa Y, Kurita H. Identification of Prognostic Factors in Surgically Treated Patients with Acute Epidural Hematoma. Asian J Neurosurg 2020; 15:532-536. [PMID: 33145203 PMCID: PMC7591190 DOI: 10.4103/ajns.ajns_129_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/19/2020] [Indexed: 11/06/2022] Open
Abstract
Context: Only few comprehensive studies have investigated acute epidural hematoma (AEDH), and a low incidence of the lesion has been observed in comparison with other types of traumatic brain injuries such as subdural hematoma, traumatic subarachnoid hemorrhage, and contusion. Aim: This study aims to identify the prognostic factors of surgically treated AEDH. Settings and Design: The medical records of 58 consecutive patients with surgically treated AEDH between September 2011 and 2018 were retrospectively reviewed. Subjects and Methods: All patients were diagnosed with AEDHs using 5-mm-slice computed tomography (CT). Information regarding the following demographic and clinical characteristics was collected: age, sex, antithrombotic drug use, mechanisms of injury, time from onset to operation, neurological examination, vital signs, blood examination, and CT findings. Statistical Analysis Used: We analyzed prognostic factors in patients with AEDH using univariate and multivariate regression analyses. Results: Univariate and multivariate regression analyses revealed that age (P < 0.01) and the Glasgow Coma Scale (GCS; P < 0.01) were independent predictive factors for good prognosis. In addition, receiver operating characteristics (ROC) analysis showed that an age of <55 years and a GCS score of >12 were optimal cutoff values for predicting good prognoses, with the areas under the ROC curve of 0.827 and 0.810, respectively. Conclusions: Age and GCS are useful predictors of prognosis in patients with surgically treated AEDH. These findings are appropriate prognostic indicators for urgent surgery performed to treat AEDH and intended to help clinicians make a prompt diagnosis.
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Affiliation(s)
- Koki Onodera
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Tomoya Kamide
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Tatsuki Kimura
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Shinya Tabata
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Toshiki Ikeda
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Yuichiro Kikkawa
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
| | - Hiroki Kurita
- Department of Neurosurgery, International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan
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Harris L, Hill CS. Craniectomy size for subdural haematomas and the impact on brain shift and outcomes. Acta Neurochir (Wien) 2020; 162:2019-2027. [PMID: 32556813 DOI: 10.1007/s00701-020-04448-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Midline shift in trauma relates to the severity of head injury. Large craniectomies are thought to help resolve brain shift but can be associated with higher rates of morbidity. This study explores the relationship between craniectomy size and subtemporal decompression for acute subdural haematomas with the resolution of brain compression and outcomes. No systematic study correlating these measures has been reported. METHOD A retrospective study of all adult cases of acute subdural haematomas that presented to a Major Trauma Centre and underwent a primary decompressive craniectomy between June 2008 and August 2013. Data collection included patient demographics and presentation, imaging findings and outcomes. All imaging metrics were measured by two independent trained assessors. Compression was measured as midline shift, brainstem shift and cisternal effacement. RESULTS Thirty-six patients with mean age of 36.1 ± 12.5 (range 16-62) were included, with a median follow-up of 23.5 months (range 2.2-109.6). The median craniectomy size was 88.7 cm2 and the median subtemporal decompression was 15.0 mm. There was significant post-operative resolution of shift as measured by midline shift, brainstem shift and cisternal effacement score (all p < .00001). There was no mortality, and the majority of patients made a good recovery with 82.8% having a Modified Rankin Score of 2 or less. There was no association between craniectomy size or subtemporal decompression and any markers of brain shift or outcome (all R2 < 0.05). CONCLUSIONS This study suggests that there is no clear relationship between craniectomy size or extent of subtemporal decompression and resolution of brain shift or outcome. Further studies are needed to assess the relative efficacy of large craniectomies and the role of subtemporal decompression.
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Affiliation(s)
- Lauren Harris
- Department of Neurosurgery, The Royal London Hospital, London, E1 1BB, UK.
| | - Ciaran Scott Hill
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, London, W1B 3GG, UK
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Alford EN, Rotman LE, Erwood MS, Oster RA, Davis MC, Pittman HBC, Zeiger HE, Fisher WS. Development of the Subdural Hematoma in the Elderly (SHE) score to predict mortality. J Neurosurg 2020; 132:1616-1622. [PMID: 30978691 DOI: 10.3171/2019.1.jns182895] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 01/14/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The purpose of this study was to describe the development of a novel prognostic score, the Subdural Hematoma in the Elderly (SHE) score. The SHE score is intended to predict 30-day mortality in elderly patients (those > 65 years of age) with an acute, chronic, or mixed-density subdural hematoma (SDH) after minor, or no, prior trauma. METHODS The authors used the Prognosis Research Strategy group methods to develop the clinical prediction model. The training data set included patients with acute, chronic, and mixed-density SDH. Based on multivariate analyses from a large data set, in addition to review of the extant literature, 3 components to the score were selected: age, admission Glasgow Coma Scale (GCS) score, and SDH volume. Patients are given 1 point if they are over 80 years old, 1 point for an admission GCS score of 5-12, 2 points for an admission GCS score of 3-4, and 1 point for SDH volume > 50 ml. The sum of points across all categories determines the SHE score. RESULTS The 30-day mortality rate steadily increased as the SHE score increased for all SDH acuities. For patients with an acute SDH, the 30-day mortality rate was 3.2% for SHE score of 0, and the rate increased to 13.1%, 32.7%, 95.7%, and 100% for SHE scores of 1, 2, 3, and 4, respectively. The model was most accurate for acute SDH (area under the curve [AUC] = 0.94), although it still performed well for chronic (AUC = 0.80) and mixed-density (AUC = 0.87) SDH. CONCLUSIONS The SHE score is a simple clinical grading scale that accurately stratifies patients' risk of mortality based on age, admission GCS score, and SDH volume. Use of the SHE score could improve counseling of patients and their families, allow for standardization of clinical treatment protocols, and facilitate clinical research studies in SDH.
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Affiliation(s)
| | | | | | - Robert A Oster
- 2Department of Medicine, Division of Preventive Medicine; and
| | | | | | - H Evan Zeiger
- 3Department of Neurology, University of Alabama at Birmingham, Alabama
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Baucher G, Troude L, Pauly V, Bernard F, Zieleskiewicz L, Roche PH. Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series. World Neurosurg 2019; 126:e944-e952. [PMID: 30876998 DOI: 10.1016/j.wneu.2019.02.194] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on. METHODS This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed. RESULTS At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5. CONCLUSIONS The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.
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Affiliation(s)
- Guillaume Baucher
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France.
| | - Lucas Troude
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France
| | - Vanessa Pauly
- CEReSS, Health Service Research and Quality of life Center, La Timone Medical Campus, Aix Marseille University, Marseille, France; Department of Public Health, La Conception Hospital, APHM, Aix Marseille University, Marseille, France
| | - Florian Bernard
- Department of Neurosurgery, CHU Angers, University of Angers, Angers, France
| | - Laurent Zieleskiewicz
- Department of Anesthesiology and Critical Care, North University Hospital, APHM, Aix Marseille University, Marseille, France
| | - Pierre-Hugues Roche
- Department of Neurosurgery, North University Hospital, APHM, Aix Marseille University, Marseille, France
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Chrastina J, Šilar Č, Zeman T, Svoboda M, Krajsa J, Musilová B, Novák Z. Reoperations after surgery for acute subdural hematoma: reasons, risk factors, and effects. Eur J Trauma Emerg Surg 2019; 46:347-355. [DOI: 10.1007/s00068-019-01077-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/18/2019] [Indexed: 11/30/2022]
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Jin XQ, Du XF, Yang MF, Zhang Q. Development and Validation of Prognostic Model for Patients with Acute Subdural Hematoma-Reliable Nomogram. World Neurosurg 2018; 124:S1878-8750(18)32904-8. [PMID: 30593962 DOI: 10.1016/j.wneu.2018.12.081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 12/07/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE By extracting clinical and computed tomography imaging data of patients with acute subdural hematoma (ASDH), factors that were significantly associated with poor prognosis were screened and a nomogram model was established and validated. METHODS All patients with ASDH who underwent subdural hematoma removal and decompressive craniectomy from January 2014 to March 2018 in Qinghai Provincial People's Hospital were continuously collected. Finally, 124 patients were included in the study. According to the Glasgow Outcome Scale at 3 months after operation, patients were divided into a good prognosis group and a poor prognosis group. RESULTS Univariate and binary logistic regression analysis were performed to screen out independent predictors that were significantly associated with poor prognosis of ASDH. On the basis of these factors, a nomogram model was established. CONCLUSIONS The nomogram model had high accuracy for predicting poor prognosis in patients with ASDH, and it was easy to promote. In the future, large sample and multicenter prospective studies are necessary to complement and identify the results.
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Affiliation(s)
- Xiao-Qing Jin
- Department of Graduate School, Qinghai University, Xining, Qinghai, China
| | - Xiao-Feng Du
- Department of Nursing, Qinghai Institute of Health Sciences, Xining, Qinghai, China
| | - Ming-Fei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China.
| | - Qiang Zhang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, China
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