Predictors of rapid spontaneous resolution of acute subdural hematoma

Rapid absorption of frontal lobe contusion and laceration with hematoma: A case report and review of literature

RATIONALE

It is rare for a traumatic intracranial hematoma to self-absorb rapidly after conservative treatment. To the best of our knowledge, there has been no report in the relevant literature of rapid absorption of hematoma formation following cerebral contusion and laceration.

PATIENT CONCERNS

A 54-year-old male was admitted to our hospital with head trauma at 3 hours prior to admission. He was alert and oriented, glasgow coma scale score of 15. Head computed tomography (CT) showed left frontal brain contusion with hematoma, however, a reexamination of CT about 29 hours following the trauma revealed that the hematoma had been absorbed.

DIAGNOSES

A diagnosis of contusion and laceration of left frontal lobe with hematoma formation was made based on the CT images.

INTERVENTIONS

The patient underwent conservative treatment.

OUTCOMES

After treatment, dizziness and headache subsided for the patient, and no special discomfort was reported.

LESSONS

It is likely that the reason for rapid absorption in this case is that the hematoma is prone to liquefaction because of abnormal platelet values and coagulation dysfunction. As the liquefaction hematoma breaks into the lateral ventricle, it is redistributed and absorbed in the lateral ventricle and subarachnoid space. Further evidence is required to support this hypothesis.

Surgical significance of prolonged fixed and dilated pupils in a case of non-traumatic, spontaneously regressing, acute subdural haemorrhage

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.

Rapid Spontaneous Resolution of Large Acute Subdural Hematoma

Usually, acute subdural hematomas (ASDHs) result from head trauma and require urgent surgical treatment. However, there have been many reports of rapid spontaneous resolution of ASDHs since 1986. Recently, we experienced a case of a massive ASDH that resolved spontaneously within 1.5 days. A 76-year-old man was admitted to a local hospital after a head injury. According to his clinical records, his initial neurologic status was good (Glasgow Coma Scale score of 14). However, his head computer tomography (CT) scan demonstrated a massive ASDH to the right, with a significant midline shift. Based on his neurological status and general condition, surgery was not considered, and the patient was closely monitored in the intensive care unit. The next day, the patient was transferred to our hospital as requested by his family, after which his neurological state stabilized, and the customary follow-up brain CT was performed. It was about 32 hours after the patient's head injury, and it revealed an unexpected finding, near-total resolution of the ASDH. Herein, we review previously reported similar cases and relevant mechanisms of rapid resolution of the ASDH. We believe that neurosurgeons should comprehensively assess the patient's condition and CT findings and provide appropriate treatment, especially when surgical intervention is unnecessary.

Factors associated with the progression of conservatively managed acute traumatic subdural hemorrhage

PURPOSE

Traumatic subdural hemorrhage (SDH) is associated with high mortality, yet many patients are not managed surgically. We sought to understand what factors might be associated with SDH enlargement to contribute to the triage of these conservatively managed patients.

MATERIALS AND METHODS

A consecutive series of 117 patients admitted to our institution's level 1 trauma center for SDH between January 1, 2010 and December 31, 2010 were evaluated. Volumetric measurement of SDHs was performed on initial and follow-up head computed tomography (CT) scans with recording of initial midline shift and classification by location. Multimodel analysis quantified associations with change in SDH volume.

RESULTS

Systolic blood pressure, presence of subarachnoid hemorrhage, and initial SDH volume demonstrated positive associations with change in SDH volume, while initial midline shift and transfusion of platelets demonstrated negative associations. Initial convexity SDH volume demonstrated positive association with change in convexity SDH volume, while initial midline shift and transfusion of platelets demonstrated negative associations. Anticoagulant/antiplatelet use demonstrated positive association with change in tentorial SDH volume, while time between CT scans demonstrated negative association.

CONCLUSIONS

Platelet transfusion, anticoagulation, and hypertension have significant associations with expansion in non-surgical cases of SDH. Monitoring these factors may assist triaging these patients.

Risk of Recurrent Chronic Subdural Hematoma Associated with Early Warfarin Resumption: A Matched Cohort Study

OBJECTIVE

Studies on resuming anticoagulation after burr-hole drainage for chronic subdural hematoma (CSDH) are limited. To evaluate the safety for early warfarin resumption after burr-hole drainage, we conducted a retrospective matched cohort study.

METHODS

Between January 2008 and April 2015, 36 patients with warfarin-related unilateral CSDH and 151 patients with ordinary unilateral CSDH were enrolled in this study. Patients taking warfarin were managed homogeneously according to the study protocol, and the usual dosage of warfarin was resumed within 2 or 3 days of burr-hole drainage to reach a target international normalized ratio (INR) of 2.1. The primary outcome, defined as recurrent CSDH requiring repeated burr-hole drainage within 3 months of the initial surgery, was compared between the two groups.

RESULTS

The primary outcome was observed in 4 (11%) of the 36 patients taking warfarin and in 18 (12%) of the 151 ordinary patients. After propensity score matching, the primary outcome was observed in 3 of 33 patients (9%) in the matched warfarin cohort and 11 of 74 patients (15%) in the matched ordinary cohort. When the results were analyzed using the generalized estimating equation, no significant difference was observed in the rate of recurrent CSDH between the 2 groups (P = 0.411). In addition, we found that recurrent CSDH was not related to postoperative international normalized ratio levels (P = 0.332).

CONCLUSIONS

There was no definitive association between postoperative early warfarin resumption and the recurrence rate of CSDH. Patients with warfarin-related CSDH and a strong indication for anticoagulation can be managed by resuming warfarin within 3 days of burr-hole drainage.

Shedding new light on rapidly resolving traumatic acute subdural hematomas

BACKGROUND

Rapidly resolving acute subdural hematomas (RRASDHs) have been described in case reports and case series but are still poorly understood. We hypothesized that a cohort analysis would confirm previously reported predictors of RRASDH including coagulopathy, additional intracranial hemorrhage, and low-density band on imaging. We also hypothesized that rapid resolution would be associated with improved trauma outcomes.

METHODS

We reviewed all nonoperative acute subdural hematomas (ASDHs) treated at our center from 2011 to 2015. Inclusion criteria were ASDH on computed tomography (CT), admission Glasgow coma score >7, and repeat CT to evaluate ASDH change. RRASDH was defined as reduced hematoma thickness by 50% within 72 h. Clinical data, CT findings, and trauma end points were analyzed for the RRASDH and nonresolving groups.

RESULTS

There were 154 ASDH patients included, with 29 cases of RRASDH. The RRASDH group had a lower rate of comorbidities than the nonresolving group (58.6% versus 78.4%, P = 0.03) and a lower rate of prehospital anticoagulation (7.7% versus 37.1%, P = 0.004). Previously reported predictors of RRASDH did not differ between the groups, nor did any clinical outcome measures. When compared with patients who experienced rapid growth (>50% increased width in 72 h), the RRASDH group had lower mortality (3.4% versus 23.5%, P = 0.04).

CONCLUSIONS

To our knowledge, this is the largest review of RRASDHs. We identified two previously unrecognized factors that may predict resolution; however, previously reported predictors were not associated with resolution. We also found no relationship between RRASDHs and improved standard trauma outcomes, calling into question the clinical significance of RRASDH.

Risk Factors of Delayed Surgical Intervention after Conservatively Treated Acute Traumatic Subdural Hematoma

Objective

Acute subdural hematoma (ASDH) is generally considered a condition that should be managed surgically. However, some patients initially receive conservative treatment, a subset of whom require surgical intervention later. This study aimed to evaluate the predictors of delayed surgical intervention in ASDH patients who are initially managed conservatively.

Methods

From January 2007 to December 2015, 842 patients diagnosed with ASDH were treated at our institution. Among them, 158 patients with convexity ASDH were initially treated conservatively. Patients were divided into a delayed surgery group and a conservative group. Demographic characteristics, past medication and medical histories, and radiological and laboratory data were collected by retrospective chart review. Independent risk factors were identified with univariate and multivariate analyses.

Results

Twenty-eight patients (17.7%) underwent delayed surgical intervention. Their mean age was 69.0 years, and 82.1% were male. Hypertension, diabetes mellitus, and heart disease prevalence and use of anti-platelet agents did not significantly differ from the conservative group. However, age (p=0.024), previous cerebral infarction history (p=0.026), increased maximal hematoma thickness (p<0.001), midline shifting (p=0.001) and accompanying subarachnoid hemorrhage (p=0.022) on initial brain computed tomography (CT) scan, low hemoglobin level (p<0.001), high leukocyte count (p=0.004), and low glucose level (p=0.002) were significantly associated with delayed surgical intervention. In multivariate analysis, increased maximal hematoma thickness (odds ratio [OR]=1.279, 95% confidence interval [CI] 1.075–1.521; p=0.006), low hemoglobin level (OR=0.673, 95% CI 0.467–0.970; p=0.034), and high leukocyte count (OR=1.142, 95% CI 1.024–1.272; p=0.017) were independent risk factors for delayed surgical intervention.

Conclusion

Due to the high likelihood of delayed surgical intervention among minimal ASDH patients with a thicker hematoma on initial brain CT, lower hemoglobin level, and higher leukocyte count, these patients should receive more careful observation.

Do Age and Anticoagulants Affect the Natural History of Acute Subdural Hematomas?

Acute subdural hematoma is a serious complication following traumatic brain injury. Large volume hematomas or those with underlying brain injury can cause mass effect, midline shift, and eventually herniation of the brain. Acute subdural hematomas in the young are associated with high-energy trauma and often have underlying contusions, while acute subdural hematomas in the elderly are associated with minor trauma and an absence of underlying contusions, even though the elderly are more likely to be on anticoagulants or anti-platelet therapy. In the young patients with high impact injuries the hematomas tend to be small and the underlying brain injury and swelling is responsible for the increased intracranial pressure and midline shift. In the elderly, the injuries are low impact (e.g fall from standing), the underlying brain is intact, and the volume of the hematoma itself produces symptoms. In addition the use of anticoagulants and antiplatelet agents in the elderly population has been thought to be a poor prognostic indicator and is considered to be responsible for larger hematomas and poor outcome. When managed conservatively, acute subdural hematomas can sometimes progress to chronic subdural hematoma formation, further enlargement, seizures, and progressive midline shift. Another potential difference in the young and the elderly is brain atrophy, which increases the potential space to accommodate a larger hematoma. It is not known if these two groups differ in other ways that might have implications for treatment or prognosis. In this paper, we investigate the clinical course of 80 patients admitted to our institution with acute subdural hematomas, to identify differences in patients above or below the age of 65 years. The natural progression/resolution of acute subdural hematomas was mapped by measuring volume expansion/regression over time. In this retrospective chart review, we investigated clinical baseline metrics and subsequent volumetric expansion outcomes between patients < 65 years old (N=44) and those > 65 years old (N=36). Volume was estimated by the ABC/2 method. We observed a statistically significant difference between groups in use of anticoagulants χ² =40.305 with p < 0.001, corrective platelet administration χ² =19.380 with p < 0.001, gender χ² =14.573 with p < 0.001, and Glasgow Coma Scale with χ² =23.125 (p=0.026). Overall outcomes were similar in the two groups. Younger patients on average had worse presenting GCS scores, but recovered comparable to older patients. No significant difference in rate of volume expansion, resolution time, or need for surgical treatment was seen between these two groups. We conclude that the initial volume, size, and severity of subdural hematoma determined by the Glasgow Coma Scale score is more likely to predict surgery or future expansion than age of the patient. Patients on oral anti-coagulants that are given appropriate medical reversal agents early do quite well and no impact on the eventual outcome could be demonstrated. Further work is needed to establish better predictors of future volume expansion, and progression to chronic subdural hematoma based on improved severity scales.

Effect of ATorvastatin On Chronic subdural Hematoma (ATOCH): a study protocol for a randomized controlled trial

Background

Chronic subdural hematoma (CSDH) is a common disease that is more prevalent in older people. Surgical intervention is a safe treatment of choice. However, the recurrence rate is relatively high and the outcome is not always satisfactory among surgically treated patients. It is believed that aberrant angiogenesis and intracapsular inflammation contribute to the development of CSDH. Atorvastatin is reported to promote angiogenesis and suppress inflammation. We have recently shown that atorvastatin is effective to non-surgically reduce and eliminate CSDH with minimal side effects. Here, we report a clinical research trial protocol that is designed to evaluate the therapeutic effects of atorvastatin on CSDH.

Methods/Design

We have designed a multi-center, randomized, placebo-controlled, double blind clinical trial for evaluating the efficacy of oral atorvastatin in reducing CSDH. We have so far recruited 96 patients with CT-confirmed or MRI-confirmed CSDHs from 16 medical centers in China. These patients were originally recruited for the Oriental Neurosurgical Evidence-based Study Team (ONET) study. After informed consent is provided, patients are randomized to receive either atorvastatin (oral 20 mg/night for 8 weeks) or placebo (dextrin for 8 weeks); and followed for 16 weeks after the treatment. The primary outcome is the change in hematoma volume at the end of 8-week treatment. Secondary outcomes include: changes in 1) the hematoma volume at the 4^th, 12^th, and 24^th weeks; 2) Markwalder’s Grading Scale and Glasgow Coma Scale (MGS-GCS); 3) Glasgow Outcome Score (GOS) and 4) Activities of Daily Life – the Barthel Index scale (ADL-BI). Safety will be assessed during the study by monitoring adverse events, laboratory tests, electrocardiography (ECG), measurements of vital signs (temperature, pulse, and blood pressure) and body weight.

Discussion

Results of this trial will provide critical information regarding whether atorvastatin is an effective and safe alternative to surgical treatment of CSDH.

Trial registration

ClinicalTrials.gov Identifier – NCT02024373

The date of trial registration: 7 August 2013

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1045-y) contains supplementary material, which is available to authorized users.

The clinical and CT features of rapid spontaneous resolution of traumatic acute subdural hematoma: A retrospective study of 14 cases

OBJECTIVE

Resolution of a traumatic acute subdural haematoma (ASDH) requires weeks or months. However, cases of rapid spontaneous resolution of ASDH within 72 hours after trauma have been reported. The purpose of this study was to obtain a better understanding of the clinical and CT features of cases of rapid resolution following traumatic ASDH.

METHOD

Between 2011-2014, the authors retrospectively collected data from 14 patients with rapid resolution of traumatic ASDH. The clinical data and CT findings of these cases were collected and analysed.

RESULTS

In 13 of the 14 patients, there was a rapid spontaneous resolution of the ASDH within 48 hours. The mean haematoma width of the second CT was significantly smaller than the width of the initial CT. A significantly marked resolution of the midline shift was observed in the second CT in all patients. The outcome was good in the majority of patients.

CONCLUSIONS

The acute fluctuation of ICP may drive the spontaneous rapid resolution and redistribution of ASDH. Patients with abnormal coagulant function may be more likely to experience rapid resolution of ASDH. A band of low density in the initial CT image may be a useful sign for rapid resolution of ASDH.