Neurocritical Management of Traumatic Acute Subdural Hematomas

Comparative efficacy of craniotomy versus craniectomy in surgical management of acute subdural hematoma: A systematic review and meta-analysis

INTRODUCTION

Acute subdural hematoma (ASDH), a predominantly lethal neurosurgical emergency in the settings of traumatic brain injury, requires surgical evacuation of hematoma, via craniotomy or craniectomy. The clinical practices vary, with no consensus over the superiority of either procedure.

AIM

To evaluate whether craniotomy or craniectomy is the optimal approach for surgical evacuation of ASDH.

METHODS

After a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) up to January 2024, to identify relevant studies, a meta-analysis was performed using a random-effects model, and risk ratios were calculated with 95% confidence intervals (CIs). For quality assessment, the Cochrane risk of bias tool and Newcastle-Ottawa Scale were applied.

RESULTS

Out of 2143 potentially relevant studies, 1875 were deemed suitable for screening. Eighteen studies were included in the systematic review. Thirteen studies, in which 1589 patients underwent craniotomy and 1452 patients underwent craniectomy, allowed meta-analysis. Pooled estimates showed that there was no significant correlation of mortality at 6 months (RR 1.14;95 % CI; 0.94-1.38 P = 0.18) and 12 months (RR 1.17; 95 % CI; 0.84-1.63 P = 0.36) with the two surgical modalities. A positive association was observed between improved functional outcomes at 6-months and craniotomy (RR 0.76; 95 % CI; 0.62-0.93 P = 0.008), however, no significant difference was observed between the two treatment groups at 12 months follow-up (RR 0.89; 95 % CI; 0.72-1.09 P = 0.26). Craniotomy reported a significantly higher proportion of patients discharged to home (RR 0.63; 95 % CI; 0.49-0.83 P = 0.0007), whereas incidence of residual subdural hematoma was significantly lower in the craniectomy group (RR 0.70; 95 % CI; 0.52-0.94 P = 0.02).

CONCLUSION

Craniectomy is associated with poor clinical outcomes. However, with long-term follow-up, no difference in mortality and functional outcomes is observed in either of the patient populations. On account of equivocal evidence regarding the efficacy of craniectomy over craniotomy in the realm of long-term outcomes, utmost preference shall be directed toward craniotomy as it is less invasive and associated with fewer complications.

Correlating Age and Hematoma Volume with Extent of Midline Shift in Acute Subdural Hematoma Patients: Validation of an Artificial Intelligence Tool for Volumetric Analysis

OBJECTIVE

Decision for intervention in acute subdural hematoma patients is based on a combination of clinical and radiographic factors. Age has been suggested as a factor to be strongly considered when interpreting midline shift (MLS) and hematoma volume data for assessing critical clinical severity during operative intervention decisions for acute subdural hematoma patients. The objective of this study was to demonstrate the use of an automated volumetric analysis tool to measure hematoma volume and MLS and quantify their relationship with age.

METHODS

A total of 1789 acute subdural hematoma patients were analyzed using qER-Quant software (Qure.ai, Mumbai, India) for MLS and hematoma volume measurements. Univariable and multivariable regressions analyzed association between MLS, hematoma volume, age, and MLS:hematoma volume ratio.

RESULTS

In comparison to young patients (≤ 70 years), old patients (>70 years) had significantly higher average hematoma volume (old: 62.2 mL vs. young 46.8 mL, P < 0.0001), lower average MLS (old: 6.6 mm vs. young: 7.4 mm, P = 0.025), and lower average MLS:hematoma volume ratio (old: 0.11 mm/mL vs. young 0.15 mm/mL, P < 0.0001). Young patients had an average of 1.5 mm greater MLS for a given hematoma volume in comparison to old patients. With increasing age, the ratio between MLS and hematoma volume significantly decreases (P = 0.0002).

CONCLUSIONS

Commercially available, automated, artificial intelligence (AI)-based tools may be used for obtaining quantitative radiographic measurement data in patients with acute subdural hematoma. Our quantitative results are consistent with the qualitative relationship previously established between age, hematoma volume, and MLS, which supports the validity of using AI-based tools for acute subdural hematoma volume estimation.

The Use of Histoacryl Injections to Treat Subgaleal Cerebrospinal Fluid Collection After Cranioplasty

BACKGROUND AND OBJECTIVES

Cranioplasty is an important and basic operation in the neurosurgical field. An emergency craniectomy is performed to control malignant cerebral edema. If the patient survives, cranioplasty is performed to restore the skull defect; however, subgaleal cerebrospinal fluid collection (SCSFC) may occur. The authors aimed to identify risk factors for postoperative SCSFC and effective solutions with the subgaleal Histoacryl injection.

METHODS

From January 2020 to December 2022, 154 craniectomies were performed at our hospital to relieve significant cerebral edema after traumatic brain injury; of these, 67 patients survived and underwent cranioplasty. Ten cases of postcranioplasty SCSFC were identified, among which 6 received subgaleal Histoacryl injection.

RESULTS

Among the 10 SCSFC cases, 3 resolved with compression after cerebrospinal fluid aspiration, and 1 resolved after revision surgery and dural closure. Histoacryl injection was attempted for the other 6 patients. A single injection was sufficient for SCSFC resolution in 3 patients. One patient required 2 injections, and another required 3 injections. The remaining patient underwent epiduroperitoneal shunt surgery because of SCSFC persistence after 3 Histoacryl injections. Five of 6 patients (83.3%) showed an improvement of more than 80% after Histoacryl injection.

CONCLUSION

Subgaleal Histoacryl injection is not considered a fundamental treatment for postoperative SCSFC but can be a successful alternative treatment.

Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review

Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.

Traumatic brain injury: Association between the Glasgow Coma Scale score and intensive care unit mortality

Background

Traumatic brain injury (TBI) prevalence in Botswana is high and this, coupled with a small population, may reduce productivity. There is no previous study in Botswana on the association between mortality from TBI and the Glasgow Coma Scale (GCS) score although global literature supports its existence.

Objectives

Our primary aim was to determine the association between the initial GCS score and the time to mortality of adults admitted with TBI at the Princess Marina Hospital, Gaborone, Botswana, between 2014 and 2019. Secondary aims were to assess the risk factors associated with time to mortality and to estimate the mortality rate from TBI.

Methods

This was a retrospective cohort design, medical record census conducted from 1 January 2014 to 31 December 2019.

Results

In total, 137 participants fulfilled the inclusion criteria, and the majority, 114 (83.2%), were male with a mean age of 34.5 years. The initial GCS score and time to mortality were associated (adjusted hazard ratio (aHR) 0.69; 95% confidence interval (CI) 0.508 - 0.947). Other factors associated with time to mortality included constricted pupil (aHR 0.12; 95% CI 0.044 - 0.344), temperature (aHR 0.82; 95% CI 0.727 - 0.929), and subdural haematoma (aHR 3.41; 95% CI 1.819 - 6.517). Most cases of TBI (74 (54%)) were due to road traffic accidents. The number of deaths was 48 (35% (95% CI 27.1% - 43.6%)), entirely due to severe TBI.

Conclusion

The study confirmed significant association between GCS and mortality. Males were mainly involved in TBI. These findings lack external validity because of the small sample size, and therefore a larger multicentre study is required for validation.

Contributions of the study

This study informs the relevant stakeholders in Botswana about sociodemographics, clinical characteristics, management and outcomes of patients admitted to the ICU with severe TBI on the backdrop of scarce ICU resources. It provides a basis for a larger study to inform its external validation.