1
|
Zaki PG, Bolger J, Rogowski B, Busch N, Elhamdani S, Jeong S, Li J, Leonardo J, Williamson R, Yu A, Shepard MJ. The Utility of the 5 Factor Modified Frailty Index in Outcome Prediction for Patients with Chronic Subdural Hematoma Treated with Surgical Drainage. World Neurosurg 2023; 179:e328-e341. [PMID: 37634666 DOI: 10.1016/j.wneu.2023.08.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/19/2023] [Indexed: 08/29/2023]
Abstract
OBJECTIVE Increasing frailty is a significant determinant of perioperative morbidity and mortality within neurosurgical literature. This study investigates the predictive value of the modified frailty index 5 (mFI-5) for postoperative morbidity and mortality following surgical drainage of chronic subdural hematoma (cSDH). METHODS A retrospective cohort study was performed on patients who underwent surgical evacuation of a cSDH. The mFI-5 score was calculated for each patient and used to stratify patients: prefrail (mFI-5<2), frail (mFI-5 = 2), and severely frail (mFI-5>2). Multivariate Cox proportional hazards (CPH) regression analysis were used to identify factors associated with our primary outcomes: overall survival and 30-day readmission. Secondary outcomes included nonhome discharge, length of stay, hematoma accumulation, development of new postoperative neurologic deficits, resolution of preoperative neurologic deficits, and a modified Rankin score >2 at discharge. RESULTS 118 patients with a mean age of 74.4 ± 11.9 years were analyzed. All baseline demographics were similar across the 3 groups. On multivariate analysis, severely frail patients (N = 24, 20.3%) had increased rates of 30-day readmission (hazard ratio [HR] 4.3, CPH regression P value<0.001) and postoperative mortality (HR 3.1, CPH regression P value<0.01) compared to the prefrail cohort. Severely frail patients had increased rates of nonhome disposition (HR 9.6, CPH regression P value< 0.001), development of new postoperative neurologic deficits (HR 2.75, CPH regression P value = 0.03), and hematoma reaccumulation (HR 4.07, CPH regression P value = 0.004). A novel scoring system accounting for patient age and frailty was predictive of 90-day mortality (area under the curve 0.77). CONCLUSIONS Frailty, measured by the mFI-5, and our novel scoring system hold a predictive value regarding outcomes for patients undergoing surgical drainage of a cSDH.
Collapse
Affiliation(s)
- Peter G Zaki
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - John Bolger
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - Brandon Rogowski
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - Nisha Busch
- College of Medicine, Drexel University, Philadelphia, Pennsylvania, USA
| | - Shahed Elhamdani
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA
| | - Seung Jeong
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA
| | - Jenna Li
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA
| | - Jody Leonardo
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA
| | - Alexander Yu
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA
| | - Matthew J Shepard
- Department of Neurosurgery, Allegheny Health Network, Neuroscience Institute, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
2
|
Rodriguez B, Morgan I, Young T, Vlastos J, Williams T, Hrabarchuk EI, Tepper J, Baker T, Kellner CP, Bederson J, Rapoport BI. Surgical techniques for evacuation of chronic subdural hematoma: a mini-review. Front Neurol 2023; 14:1086645. [PMID: 37456631 PMCID: PMC10338715 DOI: 10.3389/fneur.2023.1086645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/30/2023] [Indexed: 07/18/2023] Open
Abstract
Chronic subdural hematoma is one of the most common neurosurgical pathologies with over 160,000 cases in the United States and Europe each year. The current standard of care involves surgically evacuating the hematoma through a cranial opening, however, varied patient risk profiles, a significant recurrence rate, and increasing financial burden have sparked innovation in the field. This mini-review provides a brief overview of currently used evacuation techniques, including emerging adjuncts such as endoscopic assistance and middle meningeal artery embolization. This review synthesizes the body of available evidence on efficacy and risk profiles for each critical aspect of surgical technique in cSDH evacuation and provides insight into trends in the field and promising new technologies.
Collapse
Affiliation(s)
- Benjamin Rodriguez
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Isabella Morgan
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Tirone Young
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joseph Vlastos
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Tyree Williams
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Rensselaer Polytechnic Institute, Troy, NY, United States
| | - Eugene I. Hrabarchuk
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Jaden Tepper
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Turner Baker
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
| | - Christopher P. Kellner
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Joshua Bederson
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| | - Benjamin I. Rapoport
- Mount Sinai BioDesign, Mount Sinai Medical System, New York, NY, United States
- Department of Neurosurgery, Mount Sinai Medical System, New York, NY, United States
- Icahn School of Medicine, New York, NY, United States
| |
Collapse
|
3
|
Saway BF, Roth W, Salvador CD, Essibayi MA, Porto GBF, Dowlati E, Felbaum DR, Rock M, Withington C, Desai SK, Hassan AE, Tekle WG, Spiotta A. Subdural evacuation port system and middle meningeal artery embolization for chronic subdural hematoma: a multicenter experience. J Neurosurg 2022:1-8. [PMID: 36681990 DOI: 10.3171/2022.10.jns221476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/07/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Middle meningeal artery (MMA) embolization and the Subdural Evacuation Port System (SEPS) are minimally invasive treatment paradigms for chronic subdural hematoma (cSDH). Although SEPS offers acute decompression of local mass effect from a cSDH, MMA embolization has been shown to reduce the rate of cSDH recurrence. In combination, these procedures present a potentially safer strategy to a challenging pathology. The authors present a multi-institutional retrospective case series that assessed the safety, efficacy, and complications of SEPS and MMA embolization for cSDH. METHODS A retrospective review was performed of patients who underwent SEPS placement and MMA embolization for cSDH between 2018 and 2021 at three institutions. RESULTS One hundred patients with 136 cSDHs and a median age of 73 years underwent both SEPS placement and MMA embolization. Initial Glasgow Coma Scale scores were between 14 and 15 in 81% of patients and between 9 and 13 in 14%. The median initial midline shift (MLS) was 7 mm, with subdural hematoma (SDH) in the left hemisphere (lh) in 30% of patients, right hemisphere (rh) in 34%, and bilateral hemispheres in 36%. Follow-up was available for 86 patients: 93.4% demonstrated decreased MLS, and all patients with lhSDH and rhSDH demonstrated progressive decrease in SDH size. The overall complication rate was 4%, including 1 case of facial palsy and 3 cases of iatrogenic acute SDH. Two subjects (2%) required craniotomy for hematoma evacuation. The rate of good functional outcomes, with modified Rankin Scale (mRS) score < 2, was 89% on final follow-up and the overall mortality rate was 2%. A good mRS score on admission was associated with increased odds of functional improvement at follow-up (p < 0.001). CONCLUSIONS SEPS placement with MMA embolization for cSDH can be done safely and effectively reduces cSDH size with minimal perioperative morbidity.
Collapse
Affiliation(s)
- Brian F Saway
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Warren Roth
- 2College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Craig D Salvador
- 2College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Muhammed Amir Essibayi
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Guilherme B F Porto
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Ehsan Dowlati
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Daniel R Felbaum
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Mitchell Rock
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Charles Withington
- 3Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Sohum K Desai
- 4Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and
| | - Ameer E Hassan
- 4Department of Surgery, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and
| | - Wondwossen G Tekle
- 5Department of Neuroscience, Valley Baptist Medical Center, Harlingen, Texas
| | - Alejandro Spiotta
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| |
Collapse
|
4
|
Solou M, Ydreos I, Gavra M, Papadopoulos EK, Banos S, Boviatsis EJ, Savvanis G, Stavrinou LC. Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review. Diagnostics (Basel) 2022; 12:2060. [PMID: 36140462 PMCID: PMC9498240 DOI: 10.3390/diagnostics12092060] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (cSDH) is one of the most common neurosurgical entities, especially in the elderly population. Diagnosis is usually established via a head computed tomography, while an increasing number of studies are investigating biomarkers to predict the natural history of cSDH, including progression and recurrence. Surgical evacuation remains the mainstay of treatment in the overwhelming majority of cases. Nevertheless, many controversies are associated with the nuances of surgical treatment. We performed a systematic review of the literature between 2010 and 2022, aiming to identify and address the issues in cSDH surgical management where consensus is lacking. The results show ambiguous data in regard to indication, the timing and type of surgery, the duration of drainage, concomitant membranectomy and the need for embolization of the middle meningeal artery. Other aspects of surgical treatment-such as the use of drainage and its location and number of burr holes-seem to have been adequately clarified: the drainage of hematoma is strongly recommended and the outcome is considered as independent of drainage location or the number of burr holes.
Collapse
Affiliation(s)
- Mary Solou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Ioannis Ydreos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Maria Gavra
- Department of CT and MRI Imaging, “Agia Sofia” Hospital, 11527 Athens, Greece
| | - Evangelos K. Papadopoulos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Stamatis Banos
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Efstathios J. Boviatsis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Georgios Savvanis
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| | - Lampis C. Stavrinou
- 2nd Department of Neurosurgery, “Attikon” University General Hospital, National and Kapodistrian University, Athens Medical School, 12462 Athens, Greece
| |
Collapse
|
5
|
Hang S, Hopp FP, Zalenski RJ, Dixit P, Francis T. Threading the Needle: When a Cranial Burr Hole Is Palliative Therapy. J Palliat Med 2022; 25:1317-1320. [PMID: 35133892 DOI: 10.1089/jpm.2021.0376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Subdural hematoma (SDH) impacts up to 58.1 per 100,000 individuals aged ≥65 years. Some patients or proxies elect to focus exclusively on comfort care treatments, whereas others may consider surgical procedures such as a craniotomy or cranial trephination (burr hole) to relieve intracranial pressure. The central lesson of this case report is that the burr hole is a potential palliative care treatment in terms of experiences and outcomes, even among very old adults provided they have excellent baseline function. We present a case of a 95-year-old woman presenting to the emergency department with acute on chronic SDH and aphasia. Neurosurgical consultation and cranial trephination reversed her aphasia, and she continues to live independently with good function three years postsurgery. We discuss how the burr hole is consistent with a palliative care approach as well as the value of interdisciplinary discussions of minimally invasive neurosurgical interventions with potential for enhancing quality of life.
Collapse
Affiliation(s)
- Stephanie Hang
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA
| | - Faith P Hopp
- School of Social Work, Wayne State University, Detroit, Michigan, USA
| | - Robert J Zalenski
- Palliative Care, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA.,Department of Emergency Medicine, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Priyadarshini Dixit
- Department of Internal Medicine, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA
| | - Todd Francis
- Division of Neurosurgery, St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA
| |
Collapse
|
6
|
Deng J, Wang F, Wang H, Zhao M, Chen G, Shangguan H, Yu L, Jiang C, Fang W, Yao P, Kang D, Zheng S. Efficacy of Neuroendoscopic Treatment for Septated Chronic Subdural Hematoma. Front Neurol 2022; 12:765109. [PMID: 35087465 PMCID: PMC8788945 DOI: 10.3389/fneur.2021.765109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Neuroendoscopic treatment is an alternative therapeutic strategy for the treatment of septate chronic subdural hematoma (sCSDH). However, the safety and efficacy of this strategy remain controversial. We compared the clinical outcomes of neuroendoscopic treatment with those of standard (large bone flap) craniotomy for sCSDH reported in our center. Furthermore, the safety and efficacy of the neuroendoscopic treatment procedure for sCSDH were evaluated. Methods: We retrospectively collected the clinical data of 43 patients (37 men and six women) with sCSDH who underwent either neuroendoscopic treatment or standard (large bone flap) craniotomy, such as sex, age, smoking, drinking, medical history, use of antiplatelet drugs, postoperative complications, sCSDH recurrence, length of hospital stay, and postoperative hospital stay. We recorded the surgical procedures and the neurological function recovery prior to surgery and 6 months following the surgical treatment. Results: The enrolled patients were categorized into neuroendoscopic treatment (n = 23) and standard (large bone flap) craniotomy (n = 20) groups. There were no differences in sex, age, smoking, drinking, medical history, antiplatelet drug use, postoperative complications, and sCSDH recurrence between the two groups (p > 0.05). However, the patients in neuroendoscopic treatment group had a shorter length of total hospital stay and postoperative hospital stay as compared with the standard craniotomy group (total hospital stay: 5.26 ± 1.89 vs. 8.15 ± 1.04 days, p < 0.001; postoperative hospital stay: 4.47 ± 1.95 vs. 7.96 ± 0.97 days, p < 0.001). The imaging and Modified Rankin Scale at the 6-month follow-up were satisfactory, and no sCSDH recurrence was reported in the two groups. Conclusions: The findings of this study indicate that neuroendoscopic treatment is safe and effective for sCSDH; it is minimally invasive and could be clinically utilized.
Collapse
Affiliation(s)
- Jianhong Deng
- Department of Neurosurgery, Guangze County Hospital, Nanping, China
| | - Fangyu Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Haojie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Mingpei Zhao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guorong Chen
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Huangcheng Shangguan
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lianghong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Changzhen Jiang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhua Fang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Peisen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Dezhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Shufa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| |
Collapse
|
7
|
De Jesus O, Monserrate AE. Burr Hole Surgery for Drainage of Chronic and Subacute Subdural Hematomas: Low Recurrence Rate in a Single Surgeon Cohort. Cureus 2021; 13:e19288. [PMID: 34900470 PMCID: PMC8648283 DOI: 10.7759/cureus.19288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Background: A complication after surgical intervention for chronic and subacute subdural hematoma drainage is the recurrence of hematoma, often requiring repeat surgical management. Recurrence rates varied widely across the published series, which may partially be due to different technical strategies used by the surgeons involved in the study. We decided to review our patients with chronic and subacute subdural hematomas that were surgically managed with a burr hole procedure by a single surgeon to compare recurrence rates with the evidence available. Methods: A retrospective review of the medical records was performed on the patients who underwent burr hole surgical intervention to drain a chronic or subacute subdural hematoma between April 1995 and March 2020. All patients were under the care of a single surgeon at an academic institution. Variables analyzed included age, sex, laterality of the hematoma, and recurrence. Results: During the selected timeframe, 610 cases were identified. There were 35 cases of recurrence of the hematoma. The recurrence rate after burr hole drainage was 5.73%. Conclusion: Surgical drainage of chronic and subacute subdural hematoma via burr hole using consistent stepwise management is associated with a relatively low recurrence rate in our single surgeon patient cohort.
Collapse
Affiliation(s)
- Orlando De Jesus
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| | - Andres E Monserrate
- Neurosurgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI
| |
Collapse
|
8
|
Petrella L, Muscas G, Montemurro VM, Lastrucci G, Fainardi E, Pansini G, Della Puppa A. Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation. World Neurosurg 2021; 157:e294-e300. [PMID: 34648990 DOI: 10.1016/j.wneu.2021.10.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Luca Petrella
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Giovanni Muscas
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy.
| | - Vita Maria Montemurro
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Giancarlo Lastrucci
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Gastone Pansini
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| | - Alessandro Della Puppa
- Department of Neurosurgery, Department of Neuroscience, Psychology, Drug Area and Child Health (NEUROFARBA), Florence, Italy
| |
Collapse
|
9
|
Chronic subdural hematoma under local anesthesia with manual burr hole. Acta Neurochir (Wien) 2021; 163:1837-1841. [PMID: 33786686 DOI: 10.1007/s00701-021-04818-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Burr hole evacuation (BHE) of symptomatic chronic subdural hematoma (CSH) carries significant morbidity and mortality in the elderly because they are a fragile population. As military neurosurgeons, we perform a simplified technique under local anesthesia using a manual craniotome. METHODS We present the case of an 85-year-old woman suffering from a right-sided CSH causing confusion and severe left-sided hemiparesis. CONCLUSION After the procedure, the patient presented immediate neurological improvement. Performing manual BHE of symptomatic CSH under local anesthesia is safe, and it is of great interest for very old patients or in case of strained resources, thus we think that this technique should be taught to every young neurosurgery resident.
Collapse
|
10
|
Shchatsko A, Purcell LN, Tignanelli CJ, Charles A. The Effect of Organ System Surgery on Intensive Care Unit Mortality in a Cohort of Critically Ill Surgical Patients. Am Surg 2020; 87:1230-1237. [PMID: 33342251 DOI: 10.1177/0003134820956353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The critical illness burden in the United States is growing with an aging population obtaining surgical intervention despite age-related comorbidities. The effect of organ system surgical intervention on intensive care units (ICUs) mortality is unknown. METHODS We performed an 8-year retrospective analysis of surgical ICU patients. Poisson regression analysis was performed assessing the relative risk of in-hospital mortality based on surgical intervention. RESULTS Of 468 000 ICU patients included, 97 968 (20.9%) were surgical admissions and 97 859 (99.9%) had complete outcomes data. Nonsurvivors were older (68.8 ± 15.4 vs. 62.7 ± 15.8 years, P < .001) with higher Acute Physiology, Age, Chronic Health Evaluation (APACHE) III Scores (81.4 ± 33.6 vs. 46.7 ± 20.1, P < .001. Patients with gastrointestinal (GI) (n = 1,558, 7.8%), musculoskeletal (n = 277, 5.5%), and neurological (n = 884, 4.6%) system operations had the highest mortality. Upon Poisson regression model, patients undergoing emergent operative interventions on the neurologic system (RR 1.86, 95% CI 1.67-2.07, P < .001) had increased relative risk of mortality when compared to emergent operative interventions on the cardiovascular system after controlling for pertinent covariates. Elective operative interventions on the respiratory (RR 2.39, 95% CI 2.03-2.80, P < .001), GI (RR 2.34, 95% CI 2.10-2.61, P < .001), and skin and soft tissue (RR 2.26, 95% CI 1.77-2.89, P < .001) systems had increased risk of mortality when compared to elective cardiovascular system surgery after controlling for pertinent covariates. CONCLUSION We found significant differences in the risk of mortality based on organ system of operative intervention. The prognostication of critically ill patients undergoing surgical intervention is currently not accounted for in prognostic scoring systems.
Collapse
Affiliation(s)
- Anastasiya Shchatsko
- Department of Surgery, Central Michigan University College of Medicine, Saginaw, USA
| | - Laura N Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | | | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
11
|
McIntyre MK, Rawanduzy C, Afridi A, Honig JA, Halabi M, Hehir J, Schmidt M, Cole C, Miller I, Gandhi C, Al-Mufti F, Bowers CA. The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis. Cureus 2020; 12:e10048. [PMID: 32983738 PMCID: PMC7515811 DOI: 10.7759/cureus.10048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health & Science University, Portland, USA.,Department of Neurosurgery, New York Medical College, Valhalla, USA
| | | | - Adil Afridi
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Jesse A Honig
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Mohamed Halabi
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Jake Hehir
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | | |
Collapse
|