Hospital costs, incidence, and inhospital mortality rates of traumatic subdural hematoma in the United States

The off-hour effect on mortality in traumatic brain injury according to age group

BACKGROUND

Traumatic brain injury (TBI) is a time-sensitive and life-threatening medical condition. We hypothesized that off-hours, which includes night-time, weekends, and holidays, may influence mortality in TBI. Our study aimed to evaluate if the off-hours effect influences mortality in patients with TBI and whether this effect is dependent on the age group.

METHODS

This study included patients who experienced TBI and were admitted to Chonnam National University Hospital (CNUH) between 2017 to 2020. The main exposure was arrival time at the emergency department (ED) (off-hours vs. working hours). The main outcome was mortality at hospital discharge. Multivariable logistic regression analysis was conducted to estimate the effect size of off-hours on mortality compared to that of working hours. We performed an interaction analysis between ED admission time and age group on study outcomes.

RESULTS

A total of 2086 patients with TBI with intracranial injury who were transported by EMS were enrolled in our registry. In the multivariable logistic regression analysis, there was no significant difference in mortality (AOR, 95% CI (1.05 [0.54-1.81]) in patients visiting the ED during off-hours. In the interaction analysis, the effect measure of ED admission during off-hours on mortality was significant among younger people (0-17 years: 1.16 [1.03-1.31]), compared to that in other age groups (18-64 years: 1.02 [0.48-2.39] and 65-100 years (0.99 [0.51-2.23])).

CONCLUSIONS

In patients under 18 years old, admission during off-hours was associated with higher mortality at hospital discharge compared to admission during working-hours in patients with TBI with intracranial hemorrhage. EDs should be designed such that the same quality of emergency care is provided regardless of admission time.

Acute-on-Chronic Subdural Hematoma Secondary to Falls Due to Alcoholism

The authors present a case of a 58-year-old male who is a daily drinker, experiencing bitemporal headaches starting one week prior to seeking medical attention. The patient’s physical examination and vital signs exhibited no irregularities. Imaging studies revealed an acute-on-chronic left subdural hematoma but no intracranial arterial thrombosis or significant stenosis. The patient was managed conservatively due to his intact mental status and did well. The authors discuss alcohol use as a predisposing factor for intracerebral hemorrhage due to the increased risk for head trauma.

Length of Stay, Cost, and Outcomes related to Traumatic Subdural Hematoma in inpatient setting in the United States

OBJECTIVE

In the US, the prevalence of traumatic subdural hematoma (TSDH) continues to increase. Using a nationally representative sample of discharge records of patients with TSDH, the study objectives were to estimate trend in number of TSDH cases, surgical management, inpatient cost, length of stay (LOS), mortality rate, and complication rate; and to identify the association of sociodemographic, clinical and hospital characteristics with complications and mortality.

METHOD

We identified patients with a primary diagnosis of TSDH from the National Inpatient Sample (NIS) database from 2010 to 2017. Quarterly and monthly trends were estimated using interrupted time series design. Multivariate logistic regressions measured association between various factors and inpatient death and complications.

RESULTS

Number of cases, mean LOS, rate of complication increased. Proportion of patients undergoing surgery, mean inpatient cost, inpatient mortality decreased. Mean inpatient cost was $23,182.40 and LOS was 6.41 days. Odds of inpatient death and complications increased with injury severity score and comorbid conditions requiring use of anticoagulants. Odds of inpatient death were highest among those ≥85 years old and in south and northeast region.

CONCLUSION

Given the increase in prevalence of TSDH in USA, additional resources should be allocated toward improving patient outcomes and lowering healthcare costs.

Factors Associated With Morbidity and Retreatment After Surgical Management of Nonacute Subdural Hematomas in Elderly Patients

Background

Preoperative identification of clinical, radiographic, and surgery-specific factors associated with nonacute subdural hematomas (SDHs) may enable clinicians to optimize the efficacy of the initial surgical intervention, improve outcomes, and decrease rates of surgical recurrence.

Methods

The authors identified patients aged ≥65 years who underwent surgical treatment of chronic, subacute, or mixed-density SDH at a level-1 trauma hospital over a ten-year period (2010-2019). Pre-and postoperative clinical, radiographic, and surgery-specific data were collected. Predictors of surgical recurrence as well as morbidity, mortality, and discharge disposition were analyzed.

Results

There were 268 nonacute SDHs treated surgically; 46 were chronic, 19 were subacute, and 203 were mixed density. Of these, 179 were treated with burr hole(s), 62 with miniature craniotomy, and 27 via a large craniotomy and removal of subdural membranes. Statin use was protective (OR 0.22; 95% CI 0.08, 0.60) against recurrence requiring reoperation. Preoperative use of antithrombotic agents was not significantly associated with increased recurrence requiring reoperation. Smaller preoperative hematoma thickness was associated with significantly lower mortality risk, whereas mixed-density hematomas, patient age, change in thickness after surgery, density, and presence of cisternal effacement were significantly associated with discharge disposition. Hematoma type was also associated with hospital and intensive care length of stay.

Conclusions

Our experience suggests that, in elderly patients, premorbid statin usage is associated with lower recurrence rates and preoperative antithrombotic use does not affect recurrence when appropriately reversed before surgery. Patient age, preoperative thickness, and hematoma type contribute to postoperative outcomes such as discharge disposition and length of stay.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly

INTRODUCTION

Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH.

METHODS

A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study.

RESULTS

There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05).

CONCLUSION

Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Influence of Insurance Status on Subdural Hematoma Management- An NTDB Analysis

BACKGROUND

Traumatic brain injury is a major public health concern with a rising incidence in the United States. Prior studies have looked at associations between insurance status and traumatic brain injury, but none have focused specifically on traumatic subdural hematomas (SDH). It is important to evaluate whether insurance and/or other social determinants of health play a role in treatment and outcomes of traumatic SDH.

METHODS

A retrospective analysis of the National Trauma Data Bank was conducted from 2012 to 2016 to look at associations between insurance status and management of SDH with surgery versus intracranial pressure (ICP)/EVD monitoring. Secondary outcomes of interest were emergency department (ED) length of stay (LOS), hospital LOS, ICU admission, ICU LOS, and mortality.

RESULTS

We identified 68,687 adult patients with a single diagnosis of subdural hematoma. Overall, self-pay patients with SDH were younger, predominately male, and more likely to be non-white compared to patients with public or private health insurance.  More specifically, Black/African American SDH patients made up a large percentage of the self-pay category (15.5%; P < 0.001) compared to publicly and privately insured (7.5% and 8.0%, respectively). After adjusting for age, sex, injury severity score (ISS), Glasgow Coma Scale, alcohol intoxication, and trauma center level, publicly insured patients were 1.86 (95% CI 1.36-2.55, P < 0.001) times more likely to undergo a craniotomy or craniectomy compared to self-pay patients. However, insurance status did not appear to impact whether a patient received ICP/EVD monitoring (OR 0.52; 95% CI 0.24-1.18, P = 0.118). There was no statistically significant difference in ED LOS, Hospital LOS, and ICU LOS between insurance categories.

CONCLUSIONS

Publicly insured patients have higher odds of undergoing surgical management for traumatic SDH compared to self-pay patients. Further studies evaluating this association are warranted.

Machine Learning and Improved Quality Metrics in Acute Intracranial Hemorrhage by Noncontrast Computed Tomography

OBJECTIVE

The timely reporting of critical results in radiology is paramount to improved patient outcomes. Artificial intelligence has the ability to improve quality by optimizing clinical radiology workflows. We sought to determine the impact of a United States Food and Drug Administration-approved machine learning (ML) algorithm, meant to mark computed tomography (CT) head examinations pending interpretation as higher probability for intracranial hemorrhage (ICH), on metrics across our healthcare system. We hypothesized that ML is associated with a reduction in report turnaround time (RTAT) and length of stay (LOS) in emergency department (ED) and inpatient populations.

MATERIALS AND METHODS

An ML algorithm was incorporated across CT scanners at imaging sites in January 2018. RTAT and LOS were derived for reports and patients between July 2017 and December 2017 prior to implementation of ML and compared to those between January 2018 and June 2018 after implementation of ML. A total of 25,658 and 24,996 ED and inpatient cases were evaluated across the entire healthcare system before and after ML, respectively.

RESULTS

RTAT decreased from 75 to 69 minutes (P <0.001) at all facilities in the healthcare system. At the level 1 trauma center specifically, RTAT decreased from 67 to 59 minutes (P <0.001). ED LOS decreased from 471 to 425 minutes (P <0.001) for patients without ICH, and from 527 to 491 minutes for those with ICH (P = 0.456). Inpatient LOS decreased from 18.4 to 15.8 days for those without ICH (P = 0.001) and 18.1 to 15.8 days for those with ICH (P = 0.02).

CONCLUSION

We demonstrated that utilization of ML was associated with a statistically significant decrease in RTAT. There was also a significant decrease in LOS for ED patients without ICH, but not for ED patients with ICH. Further evaluation of the impact of such tools on patient care and outcomes is needed.

Hemorrhagic presentations of COVID-19: Risk factors for mortality

OBJECTIVE

We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19.

METHODS

This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality.

RESULTS

We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43-243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69-122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31-118.89] p = 0.023) had significantly higher risk for mortality.

CONCLUSIONS

Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.

Subdural Hematoma: Predictors of Outcome and a Score to Guide Surgical Decision-Making

OBJECTIVE

There is little evidence to guide patient selection for subdural hemorrhage (SDH) evacuation. This study was designed to assess the benefit of surgical evacuation of SDH, identify predictors of functional outcome, and create a bedside score to guide the clinical management of SDH.

METHODS

A cohort of 331 patients presenting to a single center from 2010 to 2014 with a principal diagnosis of subdural hemorrhage was identified. Clinical and radiographic information were extracted from the medical record. Outcomes of interest were (1) the occurrence of surgical evacuation of SDH, and (2) an unfavorable 90-day functional status represented by a modified Rankin score (mRS) ≥ 3. Propensity score matching and adjustment techniques were employed to assess the benefit of surgery accounting for confounding by indication. Multivariable logistic regression models predicting follow-up functional outcome were generated and bootstrapped separately among those with acute SDH and those with either subacute or chronic SDH. Clinical scores were created using model coefficients.

RESULTS

In this cohort [65% male, mean age 67 years], 47% underwent surgery. Age, focal neurologic deficit, SDH thickness > 10 mm, midline shift > 5mm, and SDH acuity predicted undergoing surgery. Propensity score matching analysis demonstrated that operated patients overall were less likely to have unfavorable 90-day mRS outcome (OR 0.35, 95% C.I. 0.15-0.82). Among patients with acute SDH, age, female sex, pre-admission mRS, focal neurologic deficit, and neuropsychiatric symptoms predicted 90-day functional outcome (c-statistic 0.89, optimism-corrected c-statistic 0.87) and were incorporated into an acute SDH score (range 1-10). Patients with SDH score > 4 were significantly more likely to have an unfavorable outcome if treated medically versus surgically; there was no difference in 90-day functional status by treatment strategy among patients with SDH score ≤ 4. No difference in outcome was seen by surgical status across the spectrum of chronic SDH scores.

CONCLUSIONS

Surgical evacuation of subdural hematomas overall is associated with favorable outcome. Patient selection for evacuation is enhanced by the application of the acute SDH score. Future studies are necessary to validate the SDH score in an external cohort.

Traumatic Brain Injury in the Elderly: Can We Reduce Readmissions? : A Community Hospital Experience

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of mortality and long-term morbidity in trauma patients, with a growing incidence among the elderly. Injury-related disability has many costs, and rehospitalization is a significant part of that. The current study was carried out in an elderly population with TBI to identify risk factors and measures associated with rehospitalization.

METHODS

We performed a retrospective analysis of 299 patients with a primary diagnosis of TBI admitted between 2016 and 2018. Variables selected for analysis encompassed the following: patient age, sex, comorbidities, diagnosis, length of stay, use of anticoagulants, 6-month readmission rate, and diagnosis for readmission. Chi-square analysis was used to identify potential risk factors, and multiple regression analysis was conducted to model the relationship.

RESULTS

209 patients met inclusion criteria, with a mean age of 69 years (SD ± 18.6 years), with (51.5%) males and (48.5%) females. 188 (62.9%) patients were on anticoagulant therapy. 120 patients were discharged to home (40.1%). 79 patients (26.4%) were readmitted within 6 months of discharge, the majority of whom (48 patients, 60.8%) presented with a subdural hematoma (SDH). 38 readmitted patients (49%) came from home, and 57 patients (80%) were on anticoagulant therapy.

CONCLUSION

In elderly patients with TBI, discharge to a home setting correlates with a higher risk of readmission within 6 months, a majority with a diagnosis of recurrent SDH. Anticoagulant therapy and frequent past readmissions also correlated with a higher risk of subsequent readmission.

Regional Variation in the Management of Nontraumatic Subdural Hematomas Across the United States

BACKGOUND

Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States.

METHODS

Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management.

RESULTS

There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone.

CONCLUSIONS

There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas.

Predictors of Thirty-day Mortality and Length of Stay in Operative Subdural Hematomas

The rate of postoperative morbidity and mortality after subdural hematoma (SDH) evacuation is high. The aim of this study was to compare mortality statistics from a high-volume database to historical figures and determine the most significant preoperative predictors of mortality and length of stay (LOS). The National Surgical Quality Improvement Program registry was searched (2005-2016) for patients with operatively treated SDHs, of which 2709 were identified for univariate analysis. After exclusion for missing data, 2010 individuals were analyzed with multivariable logistic regression. Primary outcome was 30-day mortality. The average patient age was 68.8 ± 14.9 years, and 64.1% were males. Upon multivariate analysis, nine variables were found to be associated with increased mortality: platelet count < 135,000 (OR 2.04, 95% CI 1.39-2.99), INR >1.2 (OR 1.87, 95% CI 1.34-2.6), bleeding disorder (OR 1.80, 95% CI 1.32-2.46), need for dialysis within two weeks preoperatively (OR 5.69, 95% CI 3.15-10.27), ventilator dependence in the 48 hours preceding surgery (OR 3.99, 95% CI 2.82-5.63), disseminated cancer (OR 2.95, 95% CI 1.34-6.47), WBC count >10,000 (OR 1.55, 95% CI 1.15-2.08), totally dependent functional status (OR 1.84, 95% CI 1.2-2.8), and each increasing year of age (OR 1.04, 95% CI 1.031-1.05). It is not surprising that chronic conditions and functional status were associated with increased mortality. However, specific laboratory abnormalities were also associated with increased mortality at levels generally considered within normal limits. More studies are needed to determine if correcting lab abnormalities preoperatively can improve outcomes in patients with intrinsic coagulopathy.

Functional and patient-reported outcome versus in-hospital costs after traumatic acute subdural hematoma (t-ASDH): a neurosurgical paradox?

BACKGROUND

The decision whether to operate or not in patients with a traumatic acute subdural hematoma (t-ASDH) can, in many cases, be a neurosurgical dilemma. There is a general conception that operating on severe cases leads to the survival of severely disabled patients and is associated with relatively high medical costs. There is however little information on the quality of life of patients after operation for t-ASDH, let alone on the cost-effectiveness.

METHODS

This study retrospectively investigated patient outcome and in-hospital costs for 108 consecutive patients with a t-ASDH. Patient outcome was assessed using the Glasgow Outcome Score (GOS) and the Traumatic Brain Injury (TBI)-specific QOLIBRI questionnaire. The in-hospital costs were calculated using the Dutch guidelines for costs calculation.

RESULTS

Out of 108 patients, 40 were classified as having sustained a mild (Glasgow Coma Scale (GCS) 13-15), 19 a moderate (GCS 9-12), and 49 a severe (GCS 3-8) TBI. As expected, mortality rates increased with higher TBI severity (23%, 47%, and 61% respectively), whereas the chance for favorable outcome (GOS 4-5) decreased (72%, 47%, and 29%). Interestingly, the mean QOLIBRI scores for survivors were quite similar between the TBI severity groups (61, 61, and 64). Healthcare consumption and in-hospital costs increased with TBI severity. In-hospital costs were relatively high (€24,980), especially after emergency surgery (€28,670) and when additional ICP monitoring was used (€36,580).

CONCLUSIONS

Although this study confirms that outcome is often "unfavorable" after t-ASDH, it also shows that "favorable" outcome can be achieved, even in the most severely injured patients. In-hospital treatment costs were substantial and mainly related to TBI severity, with admission and surgery as main cost drivers. These results serve as a basis for necessary future research focusing on the value-based cost-effectiveness of surgical treatment of patients with a t-ASDH.

Seizure frequency in patients with isolated subdural hematoma and preserved consciousness

Background: Seizures are a complication of subdural hematoma (SDH), and there is substantial variability in the use of seizure prophylaxis for patients with SDH. However, the incidence of seizures in patients with SDH without severe neurotrauma is not clear. The objective of this study was to assess the frequency of and factors associated with seizures in patients with isolated SDH (iSDH) without severe neurotrauma. Methods: In this retrospective, observational study, we identified adults with Glasgow Coma Score (GCS) ≥13 and computed tomography (CT)-documented iSDH. The primary outcome was clinical seizure frequency. Seizure medication use was also assessed. Fisher's exact test and logistic regression were used to assess association. Results: Of 643 patients with iSDH, 14 (2.2%) had seizures during hospitalization. Of 630 patients (98%) not receiving seizure medication prior to SDH, 522 (82.9%) received levetiracetam. Of the patients who received a seizure medication, 12 (2.3%) had a seizure, while of the 121 patients who did not receive seizure medications, 2 (1.9%) had a seizure (p = .49). In multivariable regression, the only variable significantly associated with seizure was thickness of subdural hematoma (OR 1.16, p = .005). Conclusion: In patients with iSDH and preserved consciousness, in-hospital seizures were rare regardless of seizure medications use.

Estimating the global incidence of traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI)-the "silent epidemic"-contributes to worldwide death and disability more than any other traumatic insult. Yet, TBI incidence and distribution across regions and socioeconomic divides remain unknown. In an effort to promote advocacy, understanding, and targeted intervention, the authors sought to quantify the case burden of TBI across World Health Organization (WHO) regions and World Bank (WB) income groups.

METHODS

Open-source epidemiological data on road traffic injuries (RTIs) were used to model the incidence of TBI using literature-derived ratios. First, a systematic review on the proportion of RTIs resulting in TBI was conducted, and a meta-analysis of study-derived proportions was performed. Next, a separate systematic review identified primary source studies describing mechanisms of injury contributing to TBI, and an additional meta-analysis yielded a proportion of TBI that is secondary to the mechanism of RTI. Then, the incidence of RTI as published by the Global Burden of Disease Study 2015 was applied to these two ratios to generate the incidence and estimated case volume of TBI for each WHO region and WB income group.

RESULTS

Relevant articles and registries were identified via systematic review; study quality was higher in the high-income countries (HICs) than in the low- and middle-income countries (LMICs). Sixty-nine million (95% CI 64-74 million) individuals worldwide are estimated to sustain a TBI each year. The proportion of TBIs resulting from road traffic collisions was greatest in Africa and Southeast Asia (both 56%) and lowest in North America (25%). The incidence of RTI was similar in Southeast Asia (1.5% of the population per year) and Europe (1.2%). The overall incidence of TBI per 100,000 people was greatest in North America (1299 cases, 95% CI 650-1947) and Europe (1012 cases, 95% CI 911-1113) and least in Africa (801 cases, 95% CI 732-871) and the Eastern Mediterranean (897 cases, 95% CI 771-1023). The LMICs experience nearly 3 times more cases of TBI proportionally than HICs.

CONCLUSIONS

Sixty-nine million (95% CI 64-74 million) individuals are estimated to suffer TBI from all causes each year, with the Southeast Asian and Western Pacific regions experiencing the greatest overall burden of disease. Head injury following road traffic collision is more common in LMICs, and the proportion of TBIs secondary to road traffic collision is likewise greatest in these countries. Meanwhile, the estimated incidence of TBI is highest in regions with higher-quality data, specifically in North America and Europe.

Neurosurgical Considerations in Craniofacial Trauma

Spinal and traumatic brain injuries (TBIs) often accompany craniofacial trauma. Neurosurgical considerations can range from initial emergent surgery to conservative management of closed head injuries in patients with craniofacial injuries. This article discusses the most common disorders managed by neurosurgeons in the setting of craniofacial trauma, and reviews the usual timing and setting for various treatments that patients with TBI encounter throughout the course of treatment. It also highlights the consequences of TBI on the timing and planning of craniofacial repairs and the importance of multidisciplinary cooperation to provide comprehensive care to survivors of trauma.

A Decision Instrument to Identify Isolated Traumatic Subdural Hematomas at Low Risk of Neurologic Deterioration, Surgical Intervention, or Radiographic Worsening

OBJECTIVES

Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low risk for neurologic decline, neurosurgical intervention, or radiographic worsening.

METHODS

Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and computed tomography (CT)-documented isolated SDH presenting to a university-affiliated, urban, 100,000-annual-visit ED from 2009 to 2015. Demographic, historical, and physical examination variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT, and neurologic decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model.

RESULTS

A total of 644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. A total 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors-SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14, and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1%, and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5%, and negative likelihood ratio was 0.127.

CONCLUSION

Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.

Shedding new light on rapidly resolving traumatic acute subdural hematomas

BACKGROUND

Rapidly resolving acute subdural hematomas (RRASDHs) have been described in case reports and case series but are still poorly understood. We hypothesized that a cohort analysis would confirm previously reported predictors of RRASDH including coagulopathy, additional intracranial hemorrhage, and low-density band on imaging. We also hypothesized that rapid resolution would be associated with improved trauma outcomes.

METHODS

We reviewed all nonoperative acute subdural hematomas (ASDHs) treated at our center from 2011 to 2015. Inclusion criteria were ASDH on computed tomography (CT), admission Glasgow coma score >7, and repeat CT to evaluate ASDH change. RRASDH was defined as reduced hematoma thickness by 50% within 72 h. Clinical data, CT findings, and trauma end points were analyzed for the RRASDH and nonresolving groups.

RESULTS

There were 154 ASDH patients included, with 29 cases of RRASDH. The RRASDH group had a lower rate of comorbidities than the nonresolving group (58.6% versus 78.4%, P = 0.03) and a lower rate of prehospital anticoagulation (7.7% versus 37.1%, P = 0.004). Previously reported predictors of RRASDH did not differ between the groups, nor did any clinical outcome measures. When compared with patients who experienced rapid growth (>50% increased width in 72 h), the RRASDH group had lower mortality (3.4% versus 23.5%, P = 0.04).

CONCLUSIONS

To our knowledge, this is the largest review of RRASDHs. We identified two previously unrecognized factors that may predict resolution; however, previously reported predictors were not associated with resolution. We also found no relationship between RRASDHs and improved standard trauma outcomes, calling into question the clinical significance of RRASDH.

Survival Trends After Surgery for Acute Subdural Hematoma in Adults Over a 20-year Period

OBJECTIVE

We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period.

SUMMARY OF BACKGROUND DATA

ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time.

METHODS

Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data.

RESULTS

The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors.

CONCLUSIONS

A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.

Patient factors associated with 30-day morbidity, mortality, and length of stay after surgery for subdural hematoma: a study of the American College of Surgeons National Surgical Quality Improvement Program

OBJECT

Surgery for subdural hematoma (SDH) is a commonly performed neurosurgical procedure. This study identifies patient characteristics associated with adverse outcomes and prolonged length of stay (LOS) in patients who underwent surgical treatment for SDH.

METHODS

All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) who were treated via craniotomy or craniectomy for SDH between 2005 and 2012 were identified. Patient demographics, comorbidities, and 30-day outcomes were described. Multivariate regression was used to identify predictors of adverse events.

RESULTS

A total of 746 surgical procedures performed for SDH were identified and analyzed. Patients undergoing this procedure were 64% male with an average age (± SD) of 70.9 ± 14.1 years. The most common individual adverse events were death (17%) and intubation for more than 48 hours (19%). In total, 34% experienced a serious adverse event other than death, 8% of patients returned to the operating room (OR), and the average hospital LOS was 9.8 ± 9.9 days. In multivariate analysis, reduced mortality was associated with age less than 60 years (relative risk [RR] = 0.47, p = 0.017). Increased mortality was associated with gangrene (RR = 3.5, p = 0.044), ascites (RR = 3.00, p = 0.006), American Society of Anesthesiologists (ASA) Class 4 or higher (RR = 2.34, p = 0.002), coma (RR = 2.25, p < 0.001), and bleeding disorders (RR = 1.87, p = 0.003). Return to the OR was associated with pneumonia (RR = 3.86, p = 0.044), male sex (RR = 1.85, p = 0.015), and delirium (RR = 1.75, p = 0.016). Serious adverse events were associated with ventilator dependence preoperatively (RR = 1.86, p < 0.001), dialysis (RR = 1.44, p = 0.028), delirium (RR = 1.40, p = 0.005), ASA Class 4 or higher (RR = 1.36, p = 0.035), and male sex (RR = 1.29, p = 0.037). Similarly, LOS was increased in ventilator dependent patients by 1.56-fold (p = 0.002), in patients with ASA Class 4 or higher by 1.30-fold (p = 0.006), and in delirious patients by 1.29-fold (p = 0.008).

CONCLUSIONS

Adverse outcomes are common after surgery for SDH. In this study, 18% of the patients died within 30 days of surgery. Factors associated with adverse outcomes were identified. Patients and families should be counseled about the serious risks of morbidity and death associated with acute traumatic SDH requiring surgery.

Risk Factors of Chronic Subdural Hematoma Progression after Conservative Management of Cases with Initially Acute Subdural Hematoma

OBJECTIVE

Acute subdural hematoma (ASDH) patients are treated conservatively or surgically according to the guidelines for surgical treatment. Many patients with thin ASDH and mild neurologic deficit are managed conservatively, but sometimes aggravation of thin ASDH to chronic subdural hematoma (CSDH) results in exacerbated clinical symtoms and consequently requires surgery. The aim of this study is to evaluate risk factors that indicate progression of initially non-operated ASDH to CSDH.

METHODS

We divided 177 patients, presenting with ASDH (managed conservatively initially) between January 2008 to December 2013, into two groups; 'CSDH progression group' (n=16) and 'non-CSDH progression group' (n=161). Patient's data including age, sex, past medical history, medication were collected and brain computed tomography was used for radiologic analysis.

RESULTS

Our data demonstrated that no significant intergroup difference with respect to age, sex ratio, co-morbid conditions, medication history, ischemic heart disease, liver disease and end-stage renal disease was found. However, Hounsfield unit (hematoma density) and mixed density was higher in the 'ASDH progression group' (67.50±7.63) than in the 'non-CSDH progression group' (61.53±10.69) (p=0.031). Midline shifting and hematoma depth in the 'CSDH progression group' were significantly greater than the 'non-CSDH progression group' (p=0.067, p=0.005).

CONCLUSION

Based on the results of this study, the risk factors that are related to progression of initially non-operated ASDH to CSDH are higher Hounsfield unit and hematoma depth. Therefore, we suggest that ASDH patients, who have bigger hematoma depth and higher Hounsfield unit, should be monitored and managed carefully during the follow-up period.

Time interval to surgery and outcomes following the surgical treatment of acute traumatic subdural hematoma

Although the pre-surgical management of patients with acute traumatic subdural hematoma prioritizes rapid transport to the operating room, there is conflicting evidence regarding the importance of time interval from injury to surgery with regards to outcomes. We sought to determine the association of surgical timing with outcomes for subdural hematoma. A retrospective review was performed of 522 consecutive patients admitted to a single center from 2006-2012 who underwent emergent craniectomy for acute subdural hematoma. After excluding patients with unknown time of injury, penetrating trauma, concurrent cerebrovascular injury, epidural hematoma, or intraparenchymal hemorrhage greater than 30 mL, there remained 45 patients identified for analysis. Using a multiple regression model, we examined the effect of surgical timing, in addition to other variables on in-hospital mortality (primary outcome), as well as the need for tracheostomy or gastrostomy (secondary outcome). We found that increasing injury severity score (odds ratio [OR] 1.146; 95% confidence interval [CI] 1.035-1.270; p=0.009) and age (OR1.066; 95%CI 1.006-1.129; p=0.031) were associated with in-hospital mortality in multivariate analysis. In this model, increasing time to surgery was not associated with mortality, and in fact had a significant effect in decreasing mortality (OR 0.984; 95%CI 0.971-0.997; p=0.018). Premorbid aspirin use was associated with a paradoxical decrease in mortality (OR 0.019; 95%CI 0.001-0.392; p=0.010). In this patient sample, shorter time interval from injury to surgery was not associated with better outcomes. While there are potential confounding factors, these findings support the evaluation of rigorous preoperative resuscitation as a priority in future study.

Predictors of mortality in nontraumatic subdural hematoma

OBJECT

Subdural hematoma (SDH) is a common diagnosis in neurosurgical and neurocritical practice. Comprehensive outcome data are lacking for nontraumatic SDH. The authors determined which factors are associated with in-hospital mortality in a large sample of patients with nontraumatic SDH.

METHODS

Using the Nationwide Inpatient Sample, the authors selected adults who had been hospitalized in the US between 2007 and 2009 and in whom a primary diagnosis of nontraumatic SDH (ICD-9-CM code 432.1) had been made. Demographics, comorbidities, surgical treatment, and discharge outcomes were identified. Univariate and multivariate analyses were performed to identify predictors of in-hospital mortality.

RESULTS

Among 14,093 patients with acute nontraumatic SDH, the mean age was 71.4 ± 14.8 (mean ± standard deviation). In addition, 22.2% of the patients were admitted during the weekend. Surgical evacuation was performed in 51.4% of the patients, and 11.8% of all patients died during hospitalization. In multivariate analyses, patient age (adjusted OR 1.02, 95% CI 1.012-1.022), congestive heart failure (adjusted OR 1.42, 95% CI 1.19-1.71), warfarin use (adjusted OR 1.41, 95% CI 1.17-1.70), coagulopathy (adjusted OR 2.14, 95% CI 1.75-2.61), mechanical ventilation (adjusted OR 16.85, 95% CI 14.29-19.86), and weekend admission (adjusted OR 1.19, 95% CI 1.02-1.38) were independent predictors of in-hospital mortality. Race (Hispanic: adjusted OR 0.65, 95% CI 0.51-0.83; black: adjusted OR 0.78, 95% CI 0.63-0.96), urban hospital location (adjusted OR 0.69, 95% CI 0.54-0.89), and surgical SDH evacuation (adjusted OR 0.52, 95% CI 0.45-0.60) were strong independent predictors for decreased mortality.

CONCLUSIONS

One in 9 patients with nontraumatic SDH dies during hospitalization. Among the several predictors of in-hospital mortality, the weekend effect and treatment with surgical evacuation are potentially modifiable factors. Further investigation may lead to improvements in management and outcomes.

Comparative effectiveness of treatments for cerebral arteriovenous malformations: trends in nationwide outcomes from 2000 to 2009

Object

The development of multimodality approaches for the treatment of cerebral arteriovenous malformations (AVMs), including microsurgery, endovascular therapy, and radiosurgery, has shifted modern treatment paradigms in the last 10 years. This study examines these changes in detail from a nationwide perspective.

Methods

The authors examined data from 2001 to 2009 in the Nationwide Inpatient Sample (NIS) database, and they assessed the safety, quality, and cost-effectiveness, including the total number of discharges, discharge proportion, length of stay, and hospital charges. The authors also examined patient demographics (including age, sex, income level, and insurance), hemorrhage status at presentation, and trends in open surgical and endovascular treatment.

Results

A total of 33,997 inpatient admissions for patients with a primary diagnosis of intracranial AVM were identified, with a mean of 4191 patients admitted annually. The mean hospital charges increased 2-fold over the study period without significant differences in outcomes. There were substantial differences between surgical, endovascular, radiosurgical, and multimodality treatments. The proportion of AVMs treated microsurgically remained stable over this period, while the proportion treated endovascularly dramatically increased in size, and the data demonstrate important patient-level distinctions among groups. Outcomes and complication profiles were significantly different between treatment modalities and were impacted by age and hemorrhage status.

Conclusions

Charges associated with treatment of cerebral AVMs to the payer and society have increased dramatically over the first decade of the 21st century without clear improvements in quality parameters. However, analysis of the 3 primary treatment modalities has demonstrated differences and warrants further investigation to understand which patient population would benefit maximally from each. Unfortunately, with only imprecise measurements of quality in health care delivery, it remains imperative to develop national databases in which parameters, such as survival, functional outcomes, quality of life, and complication rates, can be assessed to examine the value of care delivered in a more meaningful way. Demonstrating an ever-increasing value of delivered health care will be imperative in our evolving health care system.

Neuroradiology back to the future: brain imaging

The beginning of neuroradiology can be traced to the early 1900s with the use of skull radiographs. Ventriculography and pneumoencephalography were introduced in 1918 and 1919, respectively, and carotid angiography, in 1927. Technical advances were made in these procedures during the next 40 years that lead to improved diagnosis of intracranial pathology. Yet, they remained invasive procedures that were often uncomfortable and associated with significant morbidity. The introduction of CT in 1971 revolutionized neuroradiology. Ventriculography and pneumoencephalography were rendered obsolete. The imaging revolution continued with the advent of MR imaging in the early 1980s. Noninvasive angiographic techniques have curtailed the use of conventional angiography, and physiologic imaging gives us a window into the function of the brain. In this historical review, we will trace the origin and evolution of the advances that have led to the quicker, less invasive diagnosis and resulted in more rapid therapy and improved outcomes.