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Vattipally VN, Ran KR, Giwa GA, Myneni S, Dardick JM, Rincon-Torroella J, Ye X, Byrne JP, Suarez JI, Lin SC, Jackson CM, Mukherjee D, Gallia GL, Huang J, Weingart JD, Azad TD, Bettegowda C. Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma. World Neurosurg 2024; 182:e431-e441. [PMID: 38030067 DOI: 10.1016/j.wneu.2023.11.117] [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: 07/31/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics. METHODS Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes. RESULTS Of 138 patients who met inclusion criteria, 13.0% (n = 18) reported taking anticoagulants, 16.7% (n = 23) reported taking antiplatelets, and 3.6% (n = 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P = 0.040) and higher rates of palliative care consultations (P = 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group. CONCLUSIONS Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.
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Affiliation(s)
- Vikas N Vattipally
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Kathleen R Ran
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ganiat A Giwa
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Saket Myneni
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joseph M Dardick
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xiaobu Ye
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James P Byrne
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jose I Suarez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Shih-Chun Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jon D Weingart
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Beucler N. Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article. Asian J Neurosurg 2023; 18:454-467. [PMID: 38152528 PMCID: PMC10749853 DOI: 10.1055/s-0043-1772763] [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] [Indexed: 12/29/2023] Open
Abstract
Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.
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Affiliation(s)
- Nathan Beucler
- Neurosurgery Department, Sainte-Anne Military Teaching Hospital, Toulon, France
- Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
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