Outcomes of Subdural Hematoma in the Elderly with a History of Minor or No Previous Trauma

Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals

BACKGROUND

Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients.

METHODS

We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury.

RESULTS

Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted).

CONCLUSIONS

Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.

Mortality of Surgically Treated Neurotrauma in Elderly Patients and the Development of a Prediction Score: Geriatric Neurotrauma Mortality Score

BACKGROUND

As the population worldwide is aging, the need for surgery in elderly patients with neurotrauma is increasing. The aim of this study was to compare the outcome of elderly patients undergoing surgery for neurotrauma with younger patients and to identify the risk factors for mortality.

METHODS

We retrospectively analyzed consecutive patients undergoing craniotomy or craniectomy for neurotrauma at our institution from 2012 to 2019. Patients were divided into two groups (≥70 years or <70 years) and compared. The primary outcome was the 30-day mortality rate. Potential risk factors for 30-day mortality were assessed in a uni- and multivariate regression model for both age groups, forming the basis of a 30-day mortality prediction score.

RESULTS

We included 163 consecutive patients (average age 57.98 ± 19.87 years); 54 patients were ≥70 years. Patients ≥70 years showed a significantly better median preoperative Glasgow Coma Scale (GCS) score compared with young patients (P < 0.001), and fewer pupil asymmetry (P = 0.001), despite having a higher Marshall score (P = 0.07) at admission. Multivariate regression analysis identified low pre- and postoperative GCS scores and the lack of prompt postoperative prophylactic low-molecular-weight heparin treatment as risk factors for 30-day mortality. Our score showed moderate accuracy in predicting 30-day mortality with an area under the curve of 0.76.

CONCLUSIONS

Elderly patients after neurotrauma present with a better GCS at admission despite having more severe radiographic injuries. Mortality and favorable outcome rates are comparable between the age groups.

Non-traumatic Chronic Subdural Hematoma With Myelodysplastic Syndrome: A Case Report

Spontaneous chronic subdural hematoma is a rare condition that appears in association with myelodysplastic syndrome. A 25-year-old male with a known case of myelodysplastic syndrome presented to the emergency department with a headache and loss of consciousness. Considering ongoing chemotherapy, burr hole trephination of the chronic subdural hematoma was performed, and he was discharged following a successful procedure. To the best of our knowledge, this is the first report of myelodysplastic syndrome with spontaneous chronic subdural hematoma.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma

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.

Predictors of Mortality, Withdrawal of Life-Sustaining Measures, and Discharge Disposition in Octogenarians with Subdural Hematomas

OBJECTIVE

Risk factors for mortality in patients with subdural hematoma (SDH) include poor Glasgow Coma Scale (GCS) score, pupil nonreactivity, and hemodynamic instability on presentation. Little is published regarding prognosticators of SDH in the elderly. This study aims to examine risk factors for hospital mortality and withdrawal of life-sustaining measures in an octogenarian population presenting with SDH.

METHODS

A prospectively collected multicenter database of 3279 traumatic brain injury admissions to 45 different U.S. trauma centers between 2017 and 2019 was queried to identify patients aged >79 years old presenting with SDH. Factors collected included baseline demographic data, past medical history, antiplatelet/anticoagulant use, and clinical presentation (GCS, pupil reactivity, injury severity scale [ISS]). Primary outcome data included hospital mortality/discharge to hospice care and withdrawal of life-sustaining measures. Multivariate logistic regression analyses were used to identify factors independently associated with primary outcome variables.

RESULTS

A total of 695 patients were isolated for analysis. Of the total cohort, the rate of hospital mortality or discharge to hospice care was 22% (n = 150) and the rate of withdrawal of life-sustaining measures was 10% (n = 66). A multivariate logistic regression model identified GCS <13, pupil nonreactivity, increasing ISS, intraventricular hemorrhage, and neurosurgical intervention as factors independently associated with hospital mortality/hospice. Congestive heart failure (CHF), hypotension, GCS <13, and neurosurgical intervention were independently associated with withdrawal of life-sustaining measures.

CONCLUSIONS

Poor GCS, pupil nonreactivity, ISS, and intraventricular hemorrhage are independently associated with hospital mortality or discharge to hospice care in patients >80 years with SDH. Pre-existing CHF may further predict withdrawal of life-sustaining measures.

Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation

BACKGROUND

The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients >65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery.

METHODS

We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P < 0.05.

RESULTS

Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score = 0, 4.3% of SHE score = 1, 14.5% of SHE score = 2, 39.3% of SHE score = 3, and 37.5% of SHE score = 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P < 0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P = 0.4).

CONCLUSIONS

The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.

Relevance of comorbidities and antithrombotic medication as risk factors for reoperation in patients with chronic subdural hematoma

In an aging Western society, the incidence of chronic subdural hematomas (cSDH) is continuously increasing. In this study, we reviewed our clinical management of cSDH patients and identified predictive factors for the need of reoperation due to residual or recurrent hematomas with a focus on the use of antithrombotic drugs. In total, 623 patients who were treated for cSDH with surgical evacuation between 2006 and 2016 at our department were retrospectively analyzed. Clinical and radiological characteristics and laboratory parameters were investigated as possible predictors of reoperation with univariate and multivariate analyses. Additionally, clinical outcome measures were compared between patients on anticoagulants, on antiplatelets, and without antithrombotic medication. In univariate analyses, patients on anticoagulants and antiplatelets presented significantly more often with comorbidities, were significantly older, and their risk for perioperative complications was significantly increased. Nevertheless, their clinical outcome was comparable to that of patients without antithrombotics. In multivariate analysis, only the presence of comorbidities, but not antithrombotics, was an independent predictor for the need for reoperations. Patients on antithrombotics do not seem to necessarily have a significantly increased risk for residual hematomas or rebleeding requiring reoperation after cSDH evacuation. More precisely, the presence of predisposing comorbidities might be a key independent risk factor for reoperation. Importantly, the clinical outcomes after surgical evacuation of cSDH are comparable between patients on anticoagulants, antiplatelets, and without antithrombotics.

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score

The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.

Mild Head Trauma: Is Antiplatelet Therapy a Risk Factor for Hemorrhagic Complications?

Background and objectives: In patients who receive antiplatelet therapy (APT), the bleeding risk profile after mild head trauma (MHT) still needs clarification. Some studies have demonstrated an association with bleeding risk, whereas others have not. We studied the population of our level II emergency department (ED) trauma center to determine the risk of bleeding in patients receiving APT and whether bleeding results not from antiplatelet agents but rather from age. We assessed the bleeding risk, the incidence of intracranial hemorrhage (ICH) that necessitated hospitalization for observation, the need for cranial neurosurgery, the severity of the patient's condition at discharge, and the frequency of ED revisits for head trauma in patients receiving APT. Materials and Methods: This retrospective single-center study included 483 patients receiving APT who were in the ED for MHT in 2019. The control group consisted of 1443 patients in the ED with MHT over the same period who were not receiving APT or anticoagulant therapy. Our ED diagnostic therapeutic protocol mandates both triage and the medical examination to identify patients with MHT who are taking any anticoagulant or APT. Results: APT was not significantly associated with bleeding risk (p > 0.05); as a risk factor, age was significantly associated with the risk of bleeding, even after adjustment for therapy. Patients receiving APT had a greater need of surgery (1.2% vs. 0.4%; p < 0.0001) and a higher rate of hospitalization (52.9% vs. 37.4%; p < 0.0001), and their clinical condition was more severe (evaluated according to the exit code value on a one-dimensional quantitative five-point numerical scale) at the time of discharge (p = 0.013). The frequency of ED revisits due to head trauma did not differ between the two groups. Conclusions: The risk of bleeding in patients receiving APT who had MHT was no higher than that in the control group. However, the clinical condition of patients receiving APT, including hospital admission for ICH monitoring and cranial neurosurgical interventions, was more severe.

Antithrombotic regimens and need for critical care interventions among patients with subdural hematomas

BACKGROUND

Antithrombotic-associated subdural hematomas (SDHs) are increasingly common, and the possibility of clinical deterioration in otherwise stable antithrombotic-associated SDH patients may prompt unnecessary admissions to intensive care units. It is unknown whether all antithrombotic regimens are equally associated with the need for critical care interventions. We sought to compare the frequency of critical care interventions and poor functional outcomes among three cohorts of noncomatose SDH patients: patients on no antithrombotics, patients on anticoagulants, and patients on antiplatelets alone.

METHODS

We performed a retrospective cohort study on all noncomatose SDH patients (Glasgow Coma Scale > 12) presenting to an academic health system in 2018. The three groups of patients were compared in terms of clinical course and functional outcome. Multivariable logistic regression was used to determine predictors of need for critical care interventions and poor functional outcome at hospital discharge.

RESULTS

There were 281 eligible patients presenting with SDHs in 2018, with 126 (45%) patients on no antithrombotics, 106 (38%) patients on antiplatelet medications alone, and 49 (17%) patients on anticoagulants. Significant predictors of critical care interventions were coagulopathy (OR 5.1, P < 0.001), presence of contusions (OR 3, P = 0.007), midline shift (OR 3.4, P = 0.002), and maximum SDH thickness (OR 2.4, P = 0.002). Significant predictors of poor functional outcome were age (OR 1.8, P < 0.001), admission Glasgow Coma Scale score (OR 0.3, P < 0.001), dementia history (OR 4.2, P = 0.001), and coagulopathy (OR 3.5, P = 0.02). Isolated antiplatelet use was not associated with either critical care interventions or functional outcome.

CONCLUSION

Isolated antiplatelet use is not a significant predictor of need for critical care interventions or poor functional outcome among SDH patients and should not be used as a criterion for triage to the intensive care unit.

Mortality and Outcome in Patients Older Than 80 Years of Age Undergoing Burr-Hole Drainage of Chronic Subdural Hematoma

OBJECTIVE

Chronic subdural hematoma is frequently seen within the elderly population and neurosurgeons are confronted with patients older than 80 years presenting with symptomatic chronic subdural hematoma. However, data on surgical outcome are scarce. The aim of this study is to analyze the mortality and outcome after burr-hole drainage in patients older than 80 years.

METHODS

This is a single-center retrospective study including patients who underwent burr-hole drainage of chronic subdural hematoma between the years 2016 and 2019. The cohort was divided into 3 age groups (80-84 years; 85-89 years; >90 years). Primary outcome was 30-day and overall mortality, whereas secondary outcome measures were recurrence rates, postoperative bleeding rates, and outcome measured by the modified ranking scale. Uni- and multivariate analysis was conducted to assess for potential risk factors for mortality, recurrence and postoperative bleeding rates.

RESULTS

In total, 107 patients with a mean age of 85.5 ± 3.9 years were included. Mortality rate was less than 10% in each group, showing no significant difference between them (P = 0.455). No significant difference in recurrence and postoperative bleeding rates was seen (P = 0.491 and P = 0.532). Modified Ranking scale score differed significantly at release, whereas at follow-up no difference was seen. After uni- and multivariate analysis, age was not correlated with higher recurrence, postoperative bleeding, or mortality rates. Preoperative midline shift was found to be an independent risk factor for recurrence.

CONCLUSIONS

In patients older than 80 years undergoing burr-hole drainage for chronic subdural hematoma, age was not directly correlated with higher recurrence, postoperative bleeding, or mortality rates.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively

Acute subdural hematomas (ASDHs) are highly morbid and increasingly common. Hematoma expansion is a potentially fatal complication, and few studies have examined whether factors associated with hematoma expansion vary over time. To answer this, we performed a case-control study in a cohort of initially conservatively managed patients with ASDH. Two time periods were considered, early (<72 h from injury) and delayed (>72 h from injury). Cases were defined as patients who developed ASDH expansion in the appropriate period; controls were patients who had stable imaging. Associated factors were determined with logistic regression. We identified 68 cases and 237 controls in the early follow-up cohort. Early ASDH expansion was associated with coagulopathy (adjusted odds ratio [aOR] 2.3, 95 % CI: 1.2-4.5; p = 0.02), thicker ASDHs (aOR 1.1, 95% CI: 1.03-1.2; p = 0.006), additional intracranial lesions (aOR 3, 95% CI: 1.6-6.2; p = 0.002), no/minimal trauma history (aOR 0.4, 95% CI: 0.2-0.9; p = 0.03), and duration between injury and initial scan (aOR 0.9, 95% CI: 0.8-0.97; p = 0.04). In the delayed follow-up cohort, there were 41 cases and 126 controls. Delayed ASDH expansion was associated with older age (aOR 1.3 per 10 years, 95% CI: 1.1-1.6; p = 0.01), systolic blood pressure (SBP) >160 on hospital presentation (aOR 4.5, 95% CI: 1.8-11.3; p = 0.001), midline shift (aOR 1.5 per 1 mm, 95% CI: 1.3-1.9; p < 0.001), and convexity location (aOR 14.1, 95% CI: 2.6-265; p = 0.013). We conclude that early and delayed ASDH expansion are different processes with different associated factors, and that elevated SBP may be a modifiable risk factor of delayed expansion.

Predictors of re-operation in the setting of non-acute subdural hematomas: A 12-year single center retrospective study

Non-acute subdural hematomas (naSDH) may recur after surgical treatment. A second operation affects the quality of life and functional outcome of the patients, and lengthens hospital stay. We aim to identify the predictors of reoperation as the healthcare system in the US is moving towards patient-centered care. This retrospective study included patients treated surgically with burr-holes or mini-craniotomy for non-acute subdural hematoma between February 2006-June 2018. Univariate and multiple logistic regression models were performed. 23 (12.0%) patients had reoperation. Controlling for all the factors, postoperative acute blood in the operative bed was the strongest predictor of recurrence of naSDH (OR = 37.93, 95% CI: 5.35-268.87, p < 0.001). Those undergoing a mini-craniotomy were over six times as likely to experience a recurrent SDH compared to those operated on via burr holes (OR = 6.34, 95% CI: 1.21-33.08, p = 0.029). Finally, patients with a past medical history of thrombocytopenia were nearly six times as likely to experience a recurrence of SDH (OR = 5.80, 95% CI: 1.20-28.10, p = 0.029). Postoperative hematoma thickness showed a trend toward significance such that thicker hematomas were associated with an increased likelihood of experiencing a recurrent SDH. In conclusion, we found that operative technique, thrombocytopenia and the presence of postoperative hemorrhage are significant predictors for reoperation. Given the current interest in endovascular embolization for SDH, understanding these risk factors may aid in determining indications for such adjunctive treatment.

Identification of Prognostic Factors in Surgically Treated Patients with Acute Epidural Hematoma

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.

Drain type after burr-hole drainage of chronic subdural hematoma in geriatric patients: a subanalysis of the cSDH-Drain randomized controlled trial

OBJECTIVE

Chronic subdural hematoma (cSDH) occurs more frequently in elderly patients, while older patient age is associated with worse postoperative outcome following burr-hole drainage (BHD) of cSDH. The cSDH-Drain trial showed comparable recurrence rates after BHD and placement of either a subperiosteal drain (SPD) or subdural drain (SDD). Additionally, an SPD showed a significantly lower rate of infections as well as iatrogenic parenchymal injuries through drain misplacement. This post hoc analysis aims to compare recurrence rates and clinical outcomes following BHD of cSDH and the placement of SPDs or SDDs in elderly patients.

METHODS

The study included 104 patients (47.3%) 80 years of age and older from the 220 patients recruited in the preceding cSDH-Drain trial. SPDs and SDDs were compared with regard to recurrence rate, morbidity, mortality, and clinical outcome. A post hoc analysis using logistic regression, comparing the outcome measurements for patients < 80 and ≥ 80 years old in a univariate analysis and stratified for drain type, was further completed.

RESULTS

Patients ≥ 80 years of age treated with an SDD showed higher recurrence rates (12.8%) compared with those treated with an SPD (8.2%), without a significant difference (p = 0.46). Significantly higher drain misplacement rates were observed for patients older than 80 years and treated with an SDD compared with an SPD (0% vs 20%, p = 0.01). Comparing patients older than 80 years to younger patients, significantly higher overall mortality (15.4% vs 5.2%, p = 0.012), 30-day mortality (3.8% vs 0%, p = 0.033), and surgical mortality (2.9% vs 1.7%, p = 0.034) rates were observed. Clinical outcome at the 12-month follow-up was significantly worse for patients ≥ 80 years old, and logistic regression showed a significant association of age with outcome, while drain type had no association with outcome.

CONCLUSIONS

The initial findings of the cSDH-Drain trial and the findings of this subanalysis suggest that SPD may be warranted in elderly patients. As opposed to drain type, patient age (> 80 years) was significantly associated with worse outcome, as well as higher morbidity and mortality rates.

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

Background

Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty’s ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH.

Methods

Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints.

Results

Of the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis.

Conclusion

While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.

The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis

BACKGROUND

Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH.

METHODS

Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home.

RESULTS

Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis.

CONCLUSIONS

iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.

Development of the Subdural Hematoma in the Elderly (SHE) score to predict mortality

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.