Cognitive performance in late adolescence and the subsequent risk of subdural hematoma: an observational study of a prospective nationwide cohort

Nontraumatic subdural hematoma in patients on hemodialysis with end-stage kidney disease: a systematic review and pooled analysis

Background

The original treatment may aggravate when hemodialysis (HD) patients have nontraumatic subdural hematoma (NSDH). End-stage kidney disease patients are at increased risk for NSDH, but its risk factors and outcomes are not sufficiently explored at present.

Methods

Electronic databases, including PubMed, EMBASE, and Web of Science were searched by using various combinations of the keywords "Hemodialysis," "Renal Insufficiency," "Extracorporeal Dialysis," "Subdural Hematoma," "Subdural Hemorrhage," "Subdural Hematomas," and "Subdural Hemorrhages" in accordance with the PRISMA guidelines. Sixteen papers were selected. Relevant patient data were extracted, aggregated, and analyzed.

Results

A total of 74 patients were analyzed, including 37 male, 26 female, and 11 with no gender data, with a mean age of 56 years (range, 16-81 years). There were 43 patients with hypertension, 36 patients with diabetes, 16 patients who used oral anticoagulants before dialysis, and 10 patients with atrial fibrillation. The diagnosis of subdural hematoma (SDH) was made by computed tomography (CT) (n = 51), carotid arteriography (n = 7), surgical exploration (n = 3), and autopsy (n = 2). Forty cases underwent surgical treatment, including craniotomy and burr hole (or twist drill) drainage. The 1 year mortality rate of NSDH was 45.9%. The mortality rate after conservative treatment (61.8%) was higher than that after surgical intervention (32.5%). The mortality rate of NSDH in dialysis patients with atrial fibrillation and in those who used oral anticoagulants before hemodialysis (HD) was 90 and 81%, respectively.

Conclusion

NSDH is rare in HD, and mortality is high if NSDH occurs in dialysis patients. Surgical intervention reduces the mortality from NSDH in patients on HD (p < 0.02). Patients with atrial fibrillation and those who were taking oral anticoagulants before dialysis have a higher NSDH mortality (p < 0.01).

Risk of Dementia After Hospitalization Due to Traumatic Brain Injury: A Longitudinal Population-Based Study

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is considered a potential modifiable dementia risk factor. We aimed to determine whether TBI actually increases the risk of dementia when adjusting for other relevant dementia risk factors.

METHODS

This was a national prospective longitudinal cohort study that included random and representative population samples from different parts of Finland of patients 25 through 64 years of age from 1992 to 2012. Major TBI was defined as a diagnosis of traumatic intracranial hemorrhage and hospital length of stay (LOS) ≥3 days and minor TBI was defined as a diagnosis of concussion and hospital LOS ≤1 day. Dementia was defined as any first hospital contact with a diagnosis of dementia, first use of an antidementia drug, or dementia as an underlying or contributing cause of death. Follow-up was until death or end of 2017.

RESULTS

Of 31,909 participants, 288 were hospitalized due to a major TBI and 406 were hospitalized due to a minor TBI. There was a total of 976 incident dementia cases during a median follow-up of 15.8 years. After adjusting for age and sex, hospitalization due to major TBI (hazard ratio [HR] 1.51, 95% CI 1.03-2.22), but not minor TBI, increased the risk of dementia. After additional adjustment for educational status, smoking status, alcohol consumption, physical activity, and hypertension, the association between major TBI and dementia weakened (HR 1.30, 95% CI 0.86-1.97). The risk factors most strongly attenuating the association between major TBI and dementia were alcohol consumption and physical activity.

DISCUSSION

There was an association between hospitalized major TBI and incident dementia. The association was diluted after adjusting for confounders, especially alcohol consumption and physical activity. Hospitalization due to minor TBI was not associated with an increased risk of dementia.

CLASSIFICATION OF EVIDENCE

This study provides Class I evidence that major TBI is associated with incident dementia.

Increased risk of subdural hematoma in patients with liver cirrhosis

BACKGROUND

Subdural hematoma (SDH) is associated with a high mortality rate. The risk of SDH in cirrhotic patients has not been well studied.

AIM

The aim of the study was to examine the risk of SDH in cirrhotic patients.

DESIGN

A retrospective study from a universal insurance claims database of Taiwan.

METHODS

A cohort of 9455 liver cirrhotic patients from 2000 to 2011 and an age-and sex-matched control cohort of 35992 subjects without cirrhosis were identified. The severity of liver cirrhosis was classified into uncomplicated and complicated according to presence of complications or not. The incidence and hazard ratio of SDH were measured by the end of 2011.

RESULTS

The mean follow-up years were 4.34 ± 3.45 years in the cirrhosis cohort and 6.36 ± 3.28 years in the non-cirrhosis cohort. The incidence of SDH was 2.73-fold higher in the cirrhosis cohort than in the control cohort (29.3 vs. 10.9 per 10 000 person-years), with an adjusted hazard ratio of 2.73 (95% CI = 2.19-3.42), 2.42 (95% CI = 1.89-3.08), and 5.07 (95% CI = 3.38-7.60) in the all liver cirrhosis, the uncomplicated liver cirrhosis, and the complicated liver cirrhosis patients compared to the control cohort. The adjusted hazard ratios were 2.65 (95% CI = 2.06-3.41) for traumatic SDH and 3.09 (95% CI 1.91-5.02) for non-traumatic SDH in liver cirrhosis patients, compared to the controls.

CONCLUSIONS

This study demonstrates that patients with cirrhosis are at higher risk of both traumatic and non-traumatic SDH than individuals without cirrhosis. The risk increases further in patients with complicated liver cirrhosis.

A rat model of chronic subdural hematoma: Insight into mechanisms of revascularization and inflammation

Chronic subdural hematoma (CSDH) is a common neurological occurrence in the elderly population with significant impact on the quality of life and work. Studies have attempted to determine the risk factors and pathophysiological mechanisms of CSDH using models in numerous mammalian species. To date, these animal models have only been able to reproduce limited durations of hematoma which does not accurately reflect the chronic state of CSDH. To address some of these challenges we modified a rat model of CSDH using two consecutive injections of autologous blood resulting in a hematoma of more than three weeks. We observed inflammatory and angiogenic changes related to the development and recovery of CSDH. In this study the technique for producing a CSDH in a small animal model had a success rate of 78.13%. The hematoma was sustainable up to 24 days. Hematoma resolution was associated with a gradual decrease in local pro-inflammatory factors and gradual increase in anti-inflammatory factors as well as proliferation and subsequent maturation of newly formed vessels. These events were also associated with improved behavioral outcome. Expression of anti-inflammatory cytokines also paralleled reabsorption of the hematoma. Reduction in hematoma size was also associated with neurological recovery. These data suggest that vessel maturation and anti-inflammatory pathways may contribute to the resolution of CSDH and neurological recovery. The regulation of the two mechanisms is a potential target for the treatment of CSDH. The modified model of rat CSDH demonstrated a high level of reproducibility in our hands and may be useful in future CSDH studies.

Comparison of Subdural Hematoma Risk between Hemodialysis and Peritoneal Dialysis Patients with ESRD

BACKGROUND AND OBJECTIVES

This study compared the risk of subdural hematoma (SDH) and subsequent mortality in hemodialysis (HD) and peritoneal dialysis (PD) patients with ESRD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Claims data were obtained from the National Health Insurance Administration Research Database in Taiwan. This retrospective cohort study comprised 10,136 PD patients and 10,136 HD patients with newly diagnosed ESRD from 1998 to 2010. Patients were matched by propensity score and year of dialysis initiation. Incidence rates and hazard ratios of SDH as well as odds ratios of subsequent 30-day deaths from SDH were evaluated from the date of the first dialysis session to the date when SDH was diagnosed, or the date of renal transplantation, death, withdraw from insurance, or the end of the follow-up period (December 31, 2011).

RESULTS

Median (25th percentile, 75th percentile) follow-up times for SDH events were 3.61 years (1.91, 6.33) and 3.33 years (1.83, 5.66) in the HD and PD cohorts, respectively. The overall SDH incidence rate (95% confidence interval [95% CI]) was 61.4% higher in the HD cohort than in the PD cohort (34.7 [95% CI, 31.4 to 35.4] versus 21.5 [95% CI, 20.2 to 22.9] per 10,000 person-years, with an adjusted hazard ratio of 1.62 [95% CI, 1.17 to 2.33]). Approximately 152 of 253 (60%) of SDH events were associated with trauma. Subsequent 30-day SDH-related mortality was not statistically higher in HD patients than in PD patients (29.1% versus 25.3%; adjusted odds ratio, 1.30; 95% CI, 0.70 to 2.41).

CONCLUSIONS

HD patients have a higher risk of developing SDH than PD patients. Both patient groups have a high risk of mortality. Routine education on fall prevention is needed for dialysis patients.

Subdural hematoma in diabetic patients

BACKGROUND AND PURPOSE

Subdural hematoma (SDH) is associated with a high mortality rate. However, the risk of SDH in diabetic patients has not been well studied. The aim of the study was to examine the risk of SDH in incident diabetic patients.

METHODS

From a universal insurance claims database of Taiwan, a cohort of 28,045 incident diabetic patients from 2000 to 2005 and a control cohort of 56,090 subjects without diabetes were identified. The incidence and hazard ratio of SDH were measured by the end of 2010.

RESULTS

The mean follow-up years were 7.24 years in the diabetes cohort and 7.44 years in the non-diabetes cohort. The incidence of SDH was 1.57-fold higher in the diabetes cohort than in the non-diabetes cohort (2.04 vs. 1.30 per 1000 person-years), with an adjusted hazard ratio of 1.63 [95% confidence interval (CI) 1.43-1.85]. The stratified data showed that adjusted hazard ratios were 1.51 (95% CI 1.28-1.77) for traumatic SDH and 1.89 (95% CI 1.52-2.36) for non-traumatic SDH. The 30-day mortality rate for those who developed SDH in the diabetes cohort was 8.94%.

CONCLUSIONS

This study demonstrates that incident diabetic patients are at higher risk of SDH than individuals without diabetes. Proper intervention for diabetic patients is necessary for preventing the devastating disorder.

Risk factors in chronic subdural hematoma: comparison of irrigation with artificial cerebrospinal fluid and normal saline in a cohort analysis

Background

Chronic subdural hematoma (CSDH) is known to have a substantial recurrence rate. Artificial cerebrospinal fluid (ACF) is an effective irrigation solution in general open craniotomy and endoneurosurgery, but no evidence of its use in burr-hole surgery exists.

Objective

To identify the potential of ACF irrigation to prevent CSDH recurrence. More specifically, to investigate the perioperative and intraoperative prognostic factors, and to identify controllable ones.

Methods

To examine various prognostic factors, 120 consecutive patients with unilateral CSDH treated with burr-hole drainage between September 2007 and March 2013 were analyzed. Intraoperative irrigation was performed with one of two irrigation solutions: normal saline (NS; n = 60) or ACF (n = 60). All patients were followed-up for at least 6 months postoperatively. We also examined the morphological alternations of the hematoma outer membranes after incubation with different solutions.

Results

Eleven patients (9.2%) had recurrence. Nine patients (15%) required additional surgery in the NS group, whereas only 2 patients (3.3%) in the ACF group required additional surgery. Among preoperative and intraoperative data, age (<80 years old, P = .044), thrombocyte (>22.0, P = .037), laterality (right, P = .03), and irrigation solution (ACF, P = .027) were related to smaller recurrence rates by log-rank tests. Only the type of irrigation solution used significantly correlated with recurrence in favor of ACF in both Cox proportional hazards (relative hazard: 0.20, 95% confidence interval (CI): 0.04–0.99; P = .049) and logistic regression models (odds ratio, 0.17, 95% CI: 0.03–0.92; P = .04) using these factors. Histological examinations of the hematoma membranes showed that the membranes incubated with NS were loose and infiltrated by inflammatory cells compared with those incubated with ACF.

Conclusion

Irrigation with ACF decreased the rate of CSDH recurrence.

Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players

BACKGROUND

Little is known about the short-term and long-term sequelae of concussion, and about when athletes who have sustained such injuries can safely return to play.

PURPOSE

To examine whether sports-related concussion increases the risk of subsequent injury in elite male football players.

STUDY DESIGN

Prospective cohort study.

METHODS

Injuries were registered for 46 male elite football teams in 10 European countries in the 2001/2002-2011/2102 seasons. Two survival models were used to analyse whether concussion increased the subsequent risk of an injury in the first year.

RESULTS

During the follow-up period, 66 players sustained concussions and 1599 players sustained other injuries. Compared with the risk following other injuries, concussion was associated with a progressively increased risk of a subsequent injury in the first year (0 to <3 months, HR=1.56, 95% CI 1.09 to 2.23; 3 to <6 months, HR=2.78, 95% CI 1.58 to 4.89; 6-12 months, HR=4.07, 95% CI 2.14 to 7.76). In the second model, after adjustment for the number of injuries in the year preceding the concussion, this injury remained significantly associated with the risk of subsequent injury in the first year (HR=1.47, 95% CI 1.05 to 2.05).

CONCLUSIONS

Concussion was a risk factor for sustaining subsequent injury within the following year. In-depth medical evaluation, which includes neurological and cognitive assessment, is warranted within the concussion management and return-to- play process.

Traumatic brain injury and young onset dementia: a nationwide cohort study

OBJECTIVE

To investigate the association between traumatic brain injuries (TBIs) and the risk of young onset dementia (YOD), that is, dementia before 65 years of age.

METHODS

The study cohort comprised 811,622 Swedish men (mean age 5 18 years) conscripted for military service between 1969 and 1986. TBIs, dementia, and covariates were extracted from national registers. Time-dependent exposures using Cox proportional hazard regression models were evaluated.

RESULTS

During a median follow-up period of 33 years, there were 45,249 men with at least 1 TBI in the cohort. After adjustment for covariates, 1 mild TBI (hazard ratio [HR] 5 1.0, 95% confidence interval [CI] 5 0.5–2.0), at least 2 mild TBIs (HR 5 2.5, 95% CI 5 0.8–8.1), or 1 severe TBI (HR 5 0.7, 95% CI 5 0.1–5.2) were not associated with Alzheimer dementia (AD). Other types of dementia were strongly associated with the risk of 1 mild TBI (HR 5 3.8, 95% CI 5 2.8–5.2), at least 2 mild TBIs (HR 5 10.4, 95% CI 5 6.3–17.2), and 1 severe TBI (HR 5 11.4, 95% CI 5 7.4–17.5) in age-adjusted analysis. However, these associations were largely attenuated after adjustment for covariates (1 mild TBI: HR 5 1.7; at least 2 mild TBIs: HR 5 1.7; 1 severe TBI: HR 5 2.6; p < 0.05 for all).

INTERPRETATION

In the present study, we found strong associations between YOD of non-AD forms and TBIs of different severity. These associations were, however, markedly attenuated after multivariate adjustment.