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

The Extension of Traumatic Subdural Hematoma into the Interhemispheric Fissure Is Associated with Coagulation Disorders: A Retrospective Study

BACKGROUND

 This study investigates the correlation of the radiologic sign of interhemispheric subdural hematoma (iSDH) in different injury patterns with clinical coagulation disorders. It is hypothesized that the presence of iSDHs is correlated with clinical coagulation disorders in patients with traumatic brain injuries and subdural hematoma (SDH).

METHODS

 Between January 1, 2020 and June 30, 2022, 154 patients with SDH were identified. Coagulation disorders were assessed using chart review and patients were divided into four groups: SDH without iSDH without further injuries (SDH), SDH with iSDH without further injuries (SDH + iSDH), SDH without iSDH with further brain injuries (Combi), SDH with iSDH with further injuries (Combi + iSDH). These four groups were formed under the assumption that isolated SDHs result from a highly specific trauma mechanism (rupture of bridging veins) in predisposed elderly patients, while combined brain injuries with SDH result from a severe global traumatic brain injury combining different pathophysiologic mechanisms often in younger patients. The groups were analyzed for patient demographics, clinical presentation, and association with coagulation disorders. The significance level was set at p < 0.005.

RESULTS

 The presence of an iSDH was associated with a higher likelihood of concomitant coagulation disorder or anticoagulants in cases of isolated subdural hemorrhage (56.8% of the population in SDH vs. 94.7% in SDH + iSDH, p < 0.005). This effect was not significant in the cases with combined traumatic brain injuries (33.3% in Combi vs. 53.6% in Combi + iSDH, p > 0.005).

CONCLUSION

 Our data indicate a high positive predictive value (PPV = 94.7%) for coagulation disorders in traumatic SDH patients with iSDH without any further focal and diffuse brain injuries. We consider this a relevant finding since it hints at the presence of coagulation disorders and might be used in early hemostaseologic assessment and emergency management.

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.

Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis

BACKGROUND

Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management.

OBJECTIVE

To investigate inpatient mortality after conservative management of large aSDHs.

METHODS

Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale.

RESULTS

Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110).

CONCLUSION

In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.

Clinical Characterization of Traumatic Acute Interhemispheric Subdural Hematoma

OBJECT

Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH.

METHODS

This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected.

RESULTS

Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient.

CONCLUSION

IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.

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.

Geriatric Traumatic Brain Injury: Epidemiology, Outcomes, Knowledge Gaps, and Future Directions

This review of the literature on traumatic brain injury (TBI) in older adults focuses on incident TBI sustained in older adulthood ("geriatric TBI") rather than on the separate, but related, topic of older adults with a history of earlier-life TBI. We describe the epidemiology of geriatric TBI, the impact of comorbidities and pre-injury function on TBI risk and outcomes, diagnostic testing, management issues, outcomes, and critical directions for future research. The highest incidence of TBI-related emergency department visits, hospitalizations, and deaths occur in older adults. Higher morbidity and mortality rates among older versus younger individuals with TBI may contribute to an assumption of futility about aggressive management of geriatric TBI. However, many older adults with TBI respond well to aggressive management and rehabilitation, suggesting that chronological age and TBI severity alone are inadequate prognostic markers. Yet there are few geriatric-specific TBI guidelines to assist with complex management decisions, and TBI prognostic models do not perform optimally in this population. Major barriers in management of geriatric TBI include under-representation of older adults in TBI research, lack of systematic measurement of pre-injury health that may be a better predictor of outcome and response to treatment than age and TBI severity alone, and lack of geriatric-specific TBI common data elements (CDEs). This review highlights the urgent need to develop more age-inclusive TBI research protocols, geriatric TBI CDEs, geriatric TBI prognostic models, and evidence-based geriatric TBI consensus management guidelines aimed at improving short- and long-term outcomes for the large and growing geriatric TBI population.

Does the Presence of Subdural Hemorrhage Increase the Risk of Intracranial Hemorrhage Expansion after the Initiation of Antithrombotic Medication?

Patients with traumatic intracranial hemorrhage (ICH) with a clinical indication for antithrombotic medication present a clinical dilemma, burdened by the task of weighing the risks of hemorrhage expansion against the risk of thrombosis. We sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antithrombotic medication. Medical records of 1626 trauma patients admitted with traumatic ICH between March 1, 2008, and March 31, 2013, to a Level I trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant or antiplatelet medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared with patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma, postinjury day of initiation, and mortality were analyzed. A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other ICH group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the groups. Patients with subdural hemorrhage had a significantly higher rate of ICH expansion (9.1 vs 0%, P = 0.045). There was no difference in overall hospital mortality between the two groups. Incidence of ICH expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury.

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.