Falcine and Tentorial Subdural Hematomas May Not Routinely Require Transfer to a Tertiary Care Center

Dual-energy computed tomography material decomposition improves prediction accuracy of hematoma expansion in traumatic intracranial hemorrhage

OBJECTIVE

The angiographic spot sign (AS) on CT angiography (CTA) is known to be useful for predicting expansion in intracranial hemorrhage, but its use is limited due to its relatively low sensitivity. Recently, dual-energy computed tomography (DECT) has been shown to be superior in distinguishing between hemorrhage and iodine. This study aimed to evaluate the diagnostic performance of hematoma expansion (HE) using DECT AS in traumatic intracranial hemorrhage.

METHODS

We recruited participants with intracranial hemorrhage confirmed via CTA for suspected traumatic cerebrovascular injuries. We evaluated AS on both conventional-like and fusion images of DECT. AS is grouped into three categories: intralesional enhancement without change, delayed enhancement (DE), and growing contrast leakage (GL). HE was evaluated by measuring hematoma size on DECT and follow-up CT. Logistic regression analysis was used to evaluate whether AS on fusion images was a significant risk factor for HE. Diagnostic accuracy was calculated, and the results from conventional-like and fusion images were compared.

RESULTS

Thirty-nine hematomas in 24 patients were included in this study. Of these, 18 hematomas in 13 patients showed expansion on follow-up CT. Among the expanders, AS and GL on fusion images were noted in 13 and 5 hematomas, respectively. In non-expanders, 10 and 1 hematoma showed AS and GL, respectively. In the logistic regression model, GL on the fusion image was a significant independent risk factor for predicting HE. However, when AS was used on conventional-like images, no factors significantly predicted HE. In the receiver operating characteristic curve analysis, the area under the curve of AS on the fusion images was 0.71, with a sensitivity and specificity of 66.7% and 76.2%, respectively.

CONCLUSIONS

GL on fusion images of DECT in traumatic intracranial hemorrhage is a significant independent radiologic risk factor for predicting HE. The AS of DECT fusion images has improved sensitivity compared to that of conventional-like images.

Risk factors, management, and outcomes in isolated parafalcine or tentorial subdural hematomas

INTRODUCTION

Indications for hospitalization in patients with parafalcine or tentorial subdural hematomas (SDH) remain unclear. This study derived and validated a clinical decision rule to identify patients at low risk for complications such that hospitalization can be avoided.

METHODS

A multicenter retrospective medical record review of adult patients with parafalcine or tentorial SDHs was completed. The primary outcome was significant injury, defined as injury that led to neurosurgery, discharge to another facility, or death. A multivariable logistic regression was performed to identify variables independently associated with the outcome in the derivation cohort. These variables were then validated on a separate cohort from a different institution abstracted without knowledge of the identified variables.

RESULTS

In the derivation cohort, 134 patients with parafalcine/tentorial SDHs were identified. The mean age was 63 ± 19 years with 82 (61%) male. Seventy-one (53%) had significant injuries. Variables independently associated with significant injury included: age over 60, adjusted odds ratio (aOR) 3.46 (95% CI 1.24, 9.62), initial Glasgow Coma Scale score below 15, aOR =7.92 (95% CI 2.78, 22.5), and additional traumatic brain injuries (TBIs) on computerized tomography (CT), aOR =5.97 (95% CI 2.48, 14.4). These three variables had a sensitivity of 71/71 (100%, 95% CI 96, 100%) and specificity of 12/63 (19%, 95% CI 10, 31%). The validation cohort (n = 83) had a mean age of 62 ± 22 years with 50 (60%) male. The three variables had a sensitivity of 36/36 (100%, 95% CI 92, 100%) and specificity of 7/47 (15%, 95% CI 6.2, 28%). All 39 (100%, 95% CI 93, 100%) patients from both cohorts who underwent neurosurgery had additional TBI findings on their CT scan.

CONCLUSIONS

Patients with parafalcine/tentorial SDHs who are under 60 years with initial GCS scores of 15 and no addition TBIs on CT are at low risk and may not need hospitalization. Furthermore, patients with isolated parafalcine/tentorial SDHs are unlikely to undergo neurosurgery. Prospective, external validation with a larger sample size is now recommended.

STUDY TYPE

Retrospective Cohort Study.

Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding

BACKGROUND

Guidelines for management of intracranial hemorrhage do not account for bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to convexity SDH, is a distinct clinical entity and these patients do not benefit from critical care monitoring or repeat imaging.

METHODS

We identified patients presenting to a single level I trauma center with isolated head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH.

RESULTS

Demographics, comorbidities, and use of antiplatelet and anticoagulant agents were similar between the groups. As compared to patients with convexity SDH, patients with parafalcine SDH had a significantly lower incidence of radiographic progression, and had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all P < 0.005). Compared to patients admitted to the intensive care unit, patients with parafalcine SDH admitted to the floor had a shorter length of stay (2.0 ± 1.6 versus 3.8 ± 2.9 d, P < 0.005) with no difference in outcomes.

CONCLUSIONS

Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission.

Enlarging acute tentorial subdural hematoma evacuated by surgery

Acute intracranial subdural hematomas (SDHs) of tentorial type generally pose no serious clinical threats, and unlike other variants of SDH, rarely require surgical intervention. Herein, we present an exceedingly rare case of tentorial SDH, marked by gradual enlargement and eventually calling for surgical evacuation. A 55-year-old man presented to the emergency department after sustaining head trauma. Initially, he was alert, fully oriented, and neurologically stable. Although computed tomography (CT) of the brain revealed an acute SDH scantily distributed along right tentorium, brain swelling or midline shift was negligible. On the following day, he became confused, but pupil size and light reflex remained normal. A follow-up CT scan showed considerable enlargement of the acute SDH, with midline shift. In a matter of hours, he deteriorated to a stuporous state, as the SDH enlarged even more. We performed a craniotomy and completely evacuated the SDH on an emergency basis. As a result, the midline shift improved, and he again became alert, soon recovering without any new neurologic deficit. This illustrative case demonstrates that even a tentorial SDH may ultimately deteriorate, forcing surgical evacuation. We, therefore, feel that close observation is mandatory for such events, even if the initial volume is small.

Utility of Repeat Head CT in Patients with Blunt Traumatic Brain Injury Presenting with Small Isolated Falcine or Tentorial Subdural Hematomas

BACKGROUND AND PURPOSE

In blunt traumatic brain injury with isolated falcotentorial subdural hematoma not amenable to neurosurgical intervention, the routinely performed, nonvalidated practice of serial head CT scans frequently necessitates increased hospital resources and exposure to ionizing radiation. The study goal was to evaluate clinical and imaging features of isolated falcotentorial subdural hematoma at presentation and short-term follow-up.

MATERIALS AND METHODS

We performed a retrospective analysis of patients presenting to a level 1 trauma center from January 2013 to March 2015 undergoing initial and short-term follow-up CT with initial findings positive for isolated subdural hematoma along the falx and/or tentorium. Patients with penetrating trauma, other sites of intracranial hemorrhage, or depressed skull fractures were excluded. Patient sex, age, Glasgow Coma Scale score, and anticoagulation history were obtained through review of the electronic medical records.

RESULTS

Eighty patients met the inclusion criteria (53 males; 27 females; median age, 61 years). Of subdural hematomas, 57.1% were falcine, 33.8% were tentorial, and 9.1% were mixed. The mean initial Glasgow Coma Scale score was 14.2 (range, 6-15). Isolated falcotentorial subdural hematomas were small (mean, 2.8 mm; range, 1-8 mm) without mass effect and significant change on follow-up CT (mean, 2.7 mm; range, 0-8 mm; P = .06), with an average follow-up time of 10.3 hours (range, 3.9-192 hours). All repeat CTs demonstrated no change or decreased size of the initial subdural hematoma. No new intracranial hemorrhages were seen on follow-up CT.

CONCLUSIONS

Isolated falcotentorial subdural hematomas in blunt traumatic brain injury average 2.8 mm in thickness and do not increase in size on short-term follow-up CT. Present data suggest that repeat CT in patients with mild traumatic brain injury with isolated falcotentorial subdural hematoma may not be necessary.

Management and Outcomes of Isolated Tentorial and Parafalcine "Smear" Subdural Hematomas at a Level-1 Trauma Center: Necessity of High Acuity Care

Data suggest that patients who present to trauma centers with mild traumatic brain injury (TBI) are admitted to an excessively high level of care and undergo myriad, unnecessary repeat radiographic and laboratory tests that do not affect outcome. Surprisingly, a paucity of data exists regarding the management of isolated, traumatic, parafalcine, or tentorial acute subdural hematoma (aSDH). Therefore, a retrospective, cohort study was completed to analyze factors associated with outcomes in patients who present to a high-volume, urban, level 1 trauma center with isolated parafalcine or tentorial aSDH after closed head injury. Out of 3097 patients admitted with TBI over the study period, 65 met inclusion criteria. More than 90% of patients were admitted to the intensive care unit (ICU), irrespective of Glasgow Coma Scale (GCS) score at presentation or the presence of systemic injury. Factors determined to be statistically associated with increased ICU and total length of stay were GCS ≤ 12 on presentation and presence of systemic injury. Depressed GCS, systemic injury, and being elderly were associated with poor discharge disposition; whereas being systemically injured, female, or elderly were associated with poor functional status at discharge. Although 94% of admitted patients underwent at least one repeat head computed tomography (CT) scan while hospitalized, not a single aSDH enlarged, including four patients on antiplatelet agents, anticoagulants, or both. Based on these data, young patients who present with GCS 13-15 without systemic injury following blunt trauma with an associated isolated parafalcine and tentorial aSDH may be safely admitted to a standard medical/surgical floor for observation.