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Nisson PL, Francis JJ, Michel M, Goel K, Patil CG. Extreme-aged patients (≥ 85 years) experience similar outcomes as younger geriatric patients following chronic subdural hematoma evacuation: a matched cohort study. GeroScience 2024; 46:3543-3553. [PMID: 38286851 PMCID: PMC11226415 DOI: 10.1007/s11357-024-01081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/12/2024] [Indexed: 01/31/2024] Open
Abstract
Subdural hematoma (SDH) evacuation represents one of the most frequently performed neurosurgical procedures. Several reports cite a rise in both the age and number of patient's requiring treatment, due in part to an aging population and expanded anticoagulation use. However, limited data and conflicting conclusions exist on extreme-aged geriatric patients (≥ 85 years of age) after undergoing surgery. Patients undergoing SDH evacuation at a tertiary academic medical center between November 2013-December 2021 were retrospectively identified. The study group consisted of patients ≥ 85 years (Group 1) diagnosed with a chronic SDH surgically evacuated. A control group was created matching patients by 70-84 years of age, gender, and anticoagulation use (Group 2). Multiple metrics were evaluated between the two including length-of hospital-stay, tracheostomy/PEG placement, reoperation rate, complications, discharge location, neurological outcome at the time of discharge, and survival. A total of 130 patients were included; 65 in Group 1 and 65 in Group 2. Patient demographics, medical comorbidities, SDH characteristics, international normalized ratio, partial thromboplastin time, and use of blood thinning agents were similar between the two groups. Kaplan Meier survival analysis at one-year was 80% for Group 1 and 76% for Group 2. No significant difference was identified using the log-rank test for equality of survivor functions (p = 0.26). All measured outcomes including GCS at time of discharge, length of stay, rate of reoperations, and neurological outcome were statistically similar between the two groups. Backwards stepwise conditional logistic regression revealed no significant association between poor outcomes at the time of discharge and age. Alternatively, anticoagulation use was found to be associated with poor outcomes (OR 3.55, 95% CI 1.08-11.60; p = 0.036). Several outcome metrics and statistical analyses were used to compare patients ≥ 85 years of age to younger geriatric patients (70-84 years) in a matched cohort study. Adjusting for age group, gender, and anticoagulation use, no significant difference was found between the two groups including neurological outcome at discharge, reoperation rate, and survival.
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Affiliation(s)
- Peyton L Nisson
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - John J Francis
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Michelot Michel
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Keshav Goel
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Chirag G Patil
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Trevisi G, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Dughiero M, DE Bonis P, Mangiola A, Sturiale CL. The role of the craniotomy size in the surgical evacuation of acute subdural hematomas in elderly patients: a retrospective multicentric study. J Neurosurg Sci 2024; 68:403-411. [PMID: 35380204 DOI: 10.23736/s0390-5616.22.05648-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Elderly patients operated for an acute subdural hematoma (ASDH) frequently have a poor outcome, with a high frequency of death, vegetative status, or severe disability (Glasgow Outcome Score [GOS] 1-3). Minicraniotomy has been proposed as a minimally invasive surgical treatment to reduce the impact of surgery in the elderly population. The present study aimed to compare the influence of the size of the craniotomy on the functional outcome in patients undergoing surgical treatment for ASDH. METHODS We selected patients ≥70 years old admitted to 5 Italian tertiary referral neurosurgical for the treatment of a post-traumatic ASDH between January 1, 2016, and December 31, 2019. We collected demographic data, clinical data (GCS, GOS, Charlson Comorbidity Index [CCI], antiplatelet/anticoagulant therapy, neurological deficits, seizure, pupillary size, length of stay), surgical data (craniotomy size, dividing the patients into 3 groups based on the corresponding tertile, and surgery duration), radiological data (ASDH side and thickness, midline shift, other post-traumatic lesions, extent of ASDH evacuation) and we assessed the functional outcome at hospital discharge and 6-month follow-up considering GOS=1-3 as a poor outcome. ANOVA and χ2 Tests and logistic regression models were used to assess differences in and associations between clinical-radiological characteristics and functional outcomes. RESULTS We included 136 patients (76 males) with a mean age of 78±6 years. Forty-five patients underwent a small craniotomy, 47 a medium size, and 44 a large craniotomy. Among the different craniotomy size groups, there were no differences in gender, anticoagulant/antithrombotic therapy, CCI, side of ASDH, ASDH thickness, preoperative GCS, focal deficits, seizures, and presence of other post-traumatic lesions. Patients undergoing small craniotomies were older than patients undergoing medium-large craniotomies; ASDH treated with medium size craniotomy were thinner than the others; patients undergoing large craniotomies showed greater midline shift and a higher rate of anisocoria. The three groups did not differ for functional outcome and postoperative midline shift, but the length of surgery and the rate of >50% of ASDH evacuation were lower in the small craniotomy group. CONCLUSIONS A small craniotomy was not inferior to larger craniotomies in determining functional outcomes in the treatment of ASDH in the elderly.
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Affiliation(s)
| | - Alba Scerrati
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Oriela Rustemi
- Unit of Neurosurgery1, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Luca Ricciardi
- Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Fabio Raneri
- Unit of Neurosurgery1, San Bortolo Hospital, Azienda ULSS8 Berica, Vicenza, Italy
| | - Alberto Tomatis
- Unit of Neurosurgery, Santo Spirito Hospital, Pescara, Italy
| | - Amedeo Piazza
- Unit of Neurosurgery, NESMOS Department, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | - Anna M Auricchio
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Stifano
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Michele Dughiero
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
| | - Pasquale DE Bonis
- Department of Neurosurgery, Sant'Anna University Hospital, Ferrara, Italy
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Annunziato Mangiola
- Unit of Neurosurgery, Santo Spirito Hospital, Pescara, Italy
- Department of Neurosciences, Imaging and Clinical Sciences, G. D'Annunzio University, Chieti, Italy
| | - Carmelo L Sturiale
- Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy -
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Powell K, Curtiss W, Sadek E, Hecht J. Is reversal of anticoagulants necessary in neurologically intact traumatic intracranial hemorrhage? Pharmacotherapy 2024; 44:241-248. [PMID: 38140830 DOI: 10.1002/phar.2901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 11/19/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Falls are the leading cause of injury in older individuals, with intracranial hemorrhage (ICH) being a common complication. Anticoagulants, such as vitamin K antagonist and direct oral anticoagulants, are increasingly utilized, and clinicians may question the necessity of reversal in patients with minor ICH, especially in the setting of increased risk of adverse events. This study aimed to identify a population of patients with minor traumatic ICH at low risk for poor-neurologic status where anticoagulant reversal may not improve outcomes. METHODS This retrospective cohort study utilized data accessed from 35 trauma centers from 2018 to 2021. Patients included had a preinjury anticoagulant regimen, ICH due to blunt trauma, Glasgow Coma Scale score of 15, an Abbreviated Injury Scale (AIS) head score from 2 to 4, and an AIS of ≤1 for non-head regions within 24 h of hospital arrival. Patients were excluded if they required an emergent neurosurgical procedure or were on a preinjury purinergic-P2 receptor-12 protein (P2Y12) inhibitor. The primary outcome was the rate of in-hospital mortality or hospice. RESULTS There were 654 patients on preinjury anticoagulation who were included with a minor traumatic ICH without neurologic deficits. Overall, 263 patients were reversed and 391 were not reversed. Twelve (4.6%) patients with in-hospital mortality or hospice were reversed compared with 19 (4.91%) patients who were not reversed (p = 0.861). A composite of hospital complications occurred in 21 (8%) reversed patients and 34 (8.7%) not reversed patients (p = 0.748). The average intensive care unit length of stay was 1.4 ± 3.4 days in the reversed group and 1.1 ± 1.8 days in the not reversed group (p = 0.069). CONCLUSION This study found no difference in hospital outcomes between patients with minor traumatic ICH on oral anticoagulants who were neurologically intact that were reversed versus those who were not reversed. Further studies should continue to define the subset of traumatic ICH patients who may not require reversal of anticoagulation.
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Affiliation(s)
- Kelly Powell
- Trinity Health Ann Arbor, Ypsilanti, Michigan, USA
| | | | - Erin Sadek
- Trinity Health Ann Arbor, Ypsilanti, Michigan, USA
| | - Jason Hecht
- Trinity Health Ann Arbor, Ypsilanti, Michigan, USA
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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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Heino I, Sajanti A, Lyne SB, Frantzén J, Girard R, Cao Y, Ritala JF, Katila AJ, Takala RS, Posti JP, Saarinen AJ, Hellström S, Laukka D, Saarenpää I, Rahi M, Tenovuo O, Rinne J, Koskimäki J. Outcome and survival of surgically treated acute subdural hematomas and postcraniotomy hematomas - A retrospective cohort study. BRAIN & SPINE 2023; 3:102714. [PMID: 38105801 PMCID: PMC10724206 DOI: 10.1016/j.bas.2023.102714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/13/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023]
Abstract
Background The morbidity and mortality of acute subdural hematoma (aSDH) remains high. Several factors have been reported to affect the outcome and survival of these patients. In this study, we explored factors potentially associated with the outcome and survival of surgically treated acute subdural hematoma (aSDH), including postcraniotomy hematomas (PCHs). Methods This retrospective cohort study was conducted in a single tertiary university hospital between 2008 and 2012 and all aSDH patients that underwent surgical intervention were included. A total of 132 cases were identified for collection of demographics, clinical, laboratory, and imaging data. Univariate and multivariable analyses were performed to assess factors associated with three-month Glasgow Outcome Scale (GOS) and survival at one- and five-year. Results In this study, PCH (n = 14, 10.6%) was not associated with a worse outcome according to the 3- month GOS (p = 0.37) or one (p = 0.34) and five-year (p = 0.37) survival. The multivariable analysis showed that the volume of initial hematoma (p = 0.009) and Abbreviated Injury Scale score (p = 0.016) were independent predictors of the three-month GOS. Glasgow Coma Scale (GCS) score (p < 0.001 and p = 0.037) and age (p = 0.048 and p = 0.003) were predictors for one and five-year survival, while use of antiplatelet drug (p = 0.030), neuroworsening (p = 0.005) and smoking (p = 0.026) were significant factors impacting one year survival. In addition, blood alcohol level on admission was a predictor for five-year survival (p = 0.025). Conclusions These elucidations underscore that, although PCHs are pertinent, a comprehensive appreciation of multifarious variables is indispensable in aSDH prognosis. These findings are observational, not causal. Expanded research endeavors are advocated to corroborate these insights.
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Affiliation(s)
- Iiro Heino
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Antti Sajanti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Seán B. Lyne
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Janek Frantzén
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Romuald Girard
- Neurovascular Surgery Program, Section of Neurosurgery, The University of Chicago Medicine and Biological Sciences, (5841 S. Maryland), Chicago, IL, 60637, USA
| | - Ying Cao
- Department of Radiation Oncology, Kansas University Medical Center, Kansas City, KS, 66160, USA
| | - Joel F. Ritala
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Ari J. Katila
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Riikka S.K. Takala
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Jussi P. Posti
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Neurocenter, Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520, Turku, Finland
| | - Antti J. Saarinen
- Department of Paediatric Orthopaedic Surgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Santtu Hellström
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Dan Laukka
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Ilkka Saarenpää
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Melissa Rahi
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Olli Tenovuo
- Neurocenter, Turku Brain Injury Center, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
- Department of Clinical Neurosciences, University of Turku, P.O. Box 52 (Kiinamyllynkatu 4-8), FI-20520, Turku, Finland
| | - Jaakko Rinne
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
| | - Janne Koskimäki
- Neurocenter, Department of Neurosurgery, Turku University Hospital and University of Turku, P.O. Box 52 (Hämeentie 11), FI-20521, Turku, Finland
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Juhasz KA, Iszkula ER, English GR, Desiderio DB, Estrada CY, Leshikar DE, Pfeiffer BT, Roesel EH, Wagle AE, Holmes JF. Risk factors, management, and outcomes in isolated parafalcine or tentorial subdural hematomas. Am J Emerg Med 2023; 66:135-140. [PMID: 36753929 DOI: 10.1016/j.ajem.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/30/2022] [Accepted: 01/07/2023] [Indexed: 01/15/2023] Open
Abstract
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.
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Affiliation(s)
- Kristin A Juhasz
- UPMC Hamot Department of Emergency Medicine, 201 State St, Erie, PA 16550, USA.
| | - Erik R Iszkula
- UPMC Hamot Department of Emergency Medicine, 201 State St, Erie, PA 16550, USA.
| | - Gregory R English
- UPMC Hamot Department of Surgery, Great Lakes Surgical Specialists, 300 State St., Suite 401, Erie, PA 16507, USA.
| | - Daniel B Desiderio
- UPMC Hamot Department of Emergency Medicine, 201 State St, Erie, PA 16550, USA
| | - Carmen Y Estrada
- UC Davis School of Medicine, 4610 X St, Sacramento, CA 95817, USA.
| | - David E Leshikar
- UC Davis Department of Surgery, 2335 Stockton Boulevard Sacramento, CA 95817, USA.
| | - Benjamin T Pfeiffer
- UPMC Hamot Department of Emergency Medicine, 201 State St, Erie, PA 16550, USA.
| | - Emily H Roesel
- UPMC Hamot Department of Emergency Medicine, 201 State St, Erie, PA 16550, USA
| | - Ashley E Wagle
- UPMC Hamot Department of Emergency Medicine, 201 State St, Erie, PA 16550, USA.
| | - James F Holmes
- UC Davis Department of Emergency Medicine, 4150 V Street Patient Support Services Bldg. (PSSB), Suite 2100, Sacramento, CA 95817, USA.
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Yang J, Wang K, Han C, Liu Q, Zhang S, Wu J, Jiang P, Yang S, Guo R, Mo S, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. Preoperative antiplatelet therapy may be a risk factor for postoperative ischemic complications in intracranial hemorrhage patients. Int J Neurosci 2022:1-7. [PMID: 36503400 DOI: 10.1080/00207454.2022.2157724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. METHODS This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients' postoperative outcomes was evaluated. RESULTS A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028<0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035<0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020<0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). CONCLUSIONS In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Chao Han
- Qingdao Central Hospital Group, Qingdao, P. R. China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
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Plowman K, Lindner D, Valle-Giler E, Ashkin A, Bass J, Ruthman C. Subdural hematoma expansion in relation to measured mean and peak systolic blood pressure: A retrospective analysis. Front Neurol 2022; 13:1026471. [PMID: 36324382 PMCID: PMC9618657 DOI: 10.3389/fneur.2022.1026471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/21/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Subdural hematomas (SDH) account for an estimated 5 to 25% of intracranial hemorrhages. Acute SDH occur secondary to rupture of the bridging veins leading to blood collecting within the dural space. Risk factors associated with SDH expansion are well documented, however, there are no established guidelines regarding blood pressure goals in the management of acute SDH. This study aims to retrospectively evaluate if uncontrolled blood pressure within the first 24 h of hospitalization in patients with acute SDH is linked to hematoma expansion as determined by serial CT imaging. Methods A single center, retrospective study looked at 1,083 patients with acute SDH, predominantly above age 65. Of these, 469 patients met the inclusion criteria. Blood pressure was measured during the first 24 h of admission along with PT, INR, platelets, blood alcohol level, anticoagulation use and antiplatelet use. Follow-up CT performed within the first 24 h was compared to the initial CT to determine the presence of hematoma expansion. Mean systolic blood pressure (SBP), peak SBP, discharge disposition, length of stay and in hospital mortality were evaluated. Results We found that patients with mean SBP <140 in the first 24 h of admission had a lower rate of hematoma expansion than those with SBP > 140. Patients with peak SBP > 200 had an increased frequency of hematoma expansion with the largest effect seen in patients with SBP > 220. Other risk factors did not contribute to hematoma expansion. Conclusions These results suggest that blood pressure is an important factor to consider when treating patients with SDH with medical management. Blood pressure management should be considered in addition to serial neurological exams, repeat radiological imaging, seizure prophylaxis and reversal of anticoagulation.
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Affiliation(s)
- Keegan Plowman
- Graduate Medical Education Internal Medicine Residency, NCH Healthcare System, Naples, FL, United States
- *Correspondence: Keegan Plowman
| | - David Lindner
- Division of Pulmonary Critical Care Medicine, NCH Healthcare System, Naples, FL, United States
| | - Edison Valle-Giler
- Division of Neurological Surgery, NCH Healthcare System, Naples, FL, United States
| | - Alex Ashkin
- Graduate Medical Education Internal Medicine Residency, NCH Healthcare System, Naples, FL, United States
| | - Jessica Bass
- Graduate Medical Education Internal Medicine Residency, NCH Healthcare System, Naples, FL, United States
| | - Carl Ruthman
- Division of Pulmonary Critical Care Medicine, NCH Healthcare System, Naples, FL, United States
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9
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Urquiaga JF, Patel MS, El Tecle N, Quadri N, Alexopoulos G, Bucholz RD, Mercier PJ, Kemp JM, Coppens J. Endoscope-Assisted Evacuation of Acute-on-Chronic Subdural Hematomas: A Single-Center Series. Cureus 2022; 14:e27575. [PMID: 36059304 PMCID: PMC9432857 DOI: 10.7759/cureus.27575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/05/2022] Open
Abstract
Purpose: Acute subdural hematomas are frequent, highly morbid, and affect all age groups. The most common mechanism of injury is a low-velocity fall, and the incidence of the disease is growing due to increasingly aggressive antithrombotic and anticoagulant therapies. In this study, we aimed to share our experience with the endoscopic-assisted evacuation of acute subdural hematoma, a less invasive procedure compared to standard craniotomy. Methods: We retrospectively reviewed data of all consecutive patients aged 18 years and older who underwent endoscopic-assisted evacuation of acute-on-chronic subdural hematoma at our institution from 2015 to 2019. Preoperative, intraoperative, postoperative, and follow-up data were collected and reported. Statistical tests were done using Python statistical packages. Results: Of the 35 patients that underwent this procedure, 32 were 18 years and older. The median age was 69.5 years and 37.5% were female. Twenty patients (62.5%) were on antiplatelet therapy, and six patients (18.75%) were on anticoagulants upon presentation. A fall was the most common cause of trauma (71.88%). The median operative time was 107 minutes. The median length of stay in days and Glasgow Coma Scale (GCS) at discharge were 8.5 and 15, respectively. There were no surgical site infections or in-hospital mortality in this series. At the latest follow-up, the median GCS and modified Rankin Scale were 15 and 1, respectively. Conclusion: Evacuation of acute-on-chronic subdural hematomas can be performed safely and efficiently via a smaller craniotomy and with the assistance of an endoscope. This may represent a less invasive alternative than standard craniotomy/craniectomy in selected patients.
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10
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Neth BJ, Ighodaro ET, Brinjikji W, Cloft H, Scharf EL. Management of Chronic Subdural Hematoma in Patients Requiring Therapeutic Anticoagulation. Neurologist 2022; 27:211-213. [PMID: 34855670 DOI: 10.1097/nrl.0000000000000380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A common risk factor of chronic, nontraumatic subdural hematoma (SDH) is anticoagulation therapy. Anticoagulation is generally held in patients who develop SDH, but this can lead to thromboembolic events. While prior studies have reported the clinical outcomes of patients with anticoagulation-related SDH, there remains little evidence regarding ongoing anticoagulation treatment. CASE REPORT We report the management of 2 patients who developed anticoagulation-related SDH and underwent middle meningeal artery (MMA) embolization and successful reinitiation of anticoagulation therapy. In both patients, we conservatively managed anticoagulation with heparin and/or enoxaparin as a bridge to warfarin after MMA embolization. Follow-up computed tomography head revealed interval decrease of SDH and stable neurological status. CONCLUSIONS These cases provide anecdotal evidence of a challenging clinical scenario where there is a necessary indication for therapeutic anticoagulation (ie, venous sinus thrombosis or atrial appendage thrombus) and comorbid SDH. Endovascular MMA embolization may be an effective adjunct therapy for clinical scenarios in patients with SDH and an urgent indication for anticoagulation. Longer follow-up, prospective series, and future randomized clinical trials are needed to objectively assess outcomes in this clinically challenging patient population.
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Affiliation(s)
| | | | | | - Harry Cloft
- Radiology
- Neurosurgery, Mayo Clinic, Rochester, MN
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11
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Khalighi E, Marzban-Rad S, Taheri HR. Acute Progressive retro-peritoneal hematoma in COVID19 patients with sub cutaneous ecchymosis. Ann Med Surg (Lond) 2022; 79:104107. [PMID: 35784949 PMCID: PMC9238019 DOI: 10.1016/j.amsu.2022.104107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/26/2022] [Accepted: 06/26/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction and importance: COVID19 is a multifunction disease where hematological disorders are reported. Coagulopathy is seen in these patients, indicated by thromboembolic events. Case presentation We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion Increased INR and bleeding and ecchymosis in Corona patients require discontinuation of anticoagulants and, FFP, essential and tri amino injections are needed. Conclusions Diagnosis and management of hematoma is important to avoid fatality. Global upsurge in COVID19 cases has been marked with systemic manifestations. We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions. We present COVID19 patients who were treated with anticoagulants and were seen to be presented with retroperitoneal hematoma.
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Affiliation(s)
- Ebrahim Khalighi
- Department of Anesthesiology, School of Allied Medical Sciences, Shahid Mostafa Khomaeini Hospital, Ilam University of Medical sciences, Ilam, Iran
| | - Saeid Marzban-Rad
- Department of Surgery, Imam-Reza Hospital, Aja University of Medical Sciences, Tehran, Iran
- Corresponding author.
| | - Hamid Reza Taheri
- Department of Surgery, School of Medicine, Shahed University, Tehran, Iran
- Corresponding author.
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12
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Marzban-Rad S, Bahmani S, Kazemi A, Taheri HR. Acute retroperitoneal hematoma following severe Covid-19 and the use of anticoagulants. Ann Med Surg (Lond) 2022; 78:103909. [PMID: 35693103 PMCID: PMC9173825 DOI: 10.1016/j.amsu.2022.103909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/27/2022] [Accepted: 06/02/2022] [Indexed: 01/08/2023] Open
Abstract
Introduction and Importance: Severe COVID19 patients under anticoagulant therapy are at the risk of developing hematoma. Case presentation We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body and retroperitoneal hematoma in the posterior wall of the abdomen and chest. Clinical discussion Cases of hematoma with severe COVID19 patients under anticoagulant therapy are reported in several case studies, particularly in geriatric population with the previous history of blood and/or cardiac disorders. Conclusion These patients should be carefully monitored for hematomas by skilled nurse and practitioner and timely treated and monitored. - Global upsurge in COVID19 cases has been marked with systemic manifestations. Clinical studies have indicated thromboembolic events and vascular injuries in COVID19 patients. We present case of 11 COVID19 who were presented with localized skin ecchymosis lesions in different areas of the body. Alterations in biochemical parameters should also be monitored closely.
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Affiliation(s)
- Saeid Marzban-Rad
- Department of Surgery, Imam-Reza Hospital, Aja University of Tehran Medical Sciences, Tehran, Iran
| | - Sahar Bahmani
- Zist Takhmir Pharmaceutical Company, Tehran University of Medical Sciences, Tehran, Iran
| | - Amenehsadat Kazemi
- Department of Psychology, Faculty of Medical, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Hamid Reza Taheri
- Department of Surgery, School of Medicine, Shahed University, Tehran, Iran
- Corresponding author.
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13
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Pfeilschifter W, Lindhoff-Last E, Alhashim A, Zydek B, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, von Heymann C, Birschmann I, Beyer-Westendorf J, Meybohm P, Greinacher A, Herrmann E. Intracranial bleeding under vitamin K antagonists or direct oral anticoagulants: results of the RADOA registry. Neurol Res Pract 2022; 4:16. [PMID: 35491419 PMCID: PMC9059415 DOI: 10.1186/s42466-022-00183-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background and purpose The use of direct oral anticoagulants (DOAC) has increased sharply and DOAC are the oral anticoagulant therapy (OAT) of choice for the majority of patients with newly-diagnosed atrial fibrillation. Intracranial hemorrhage is the most severe adverse event of OAT. Systematic data on the course of intracranial hemorrhage under DOAC compared to vitamin K antagonists (VKA) are warranted to enable shared decision making in AF patients needing OAT. Methods This is a secondary analysis of the patients with intracranial bleedings from the prospective multicenter emergency department-based RADOA registry, which collected data on patients admitted with major bleeding while taking VKA or DOAC. The primary endpoint was in-hospital mortality until day 30. We evaluated hematoma volume and short-term clinical outcomes in relation to the extent of active OAT according to coagulation parameters and OAT plasma levels measured by UPLC-MS/MS. Results Of 193 patients with major bleeding, 109 (56.5%) had intracranial hemorrhage [52.3% intracerebral (ICH), 33.9% subdural (SDH), 11.0% subarachnoidal (SAH)]. 64 (58.7%) were on VKA and 45 (41.2%) were on DOAC. On admission, we could confirm active anticoagulation in 97.7% of VKA-treated patients based on either INR > 1.3 or phenprocoumon levels and in 75.8% of DOAC-treated patients based on DOAC levels. Patients suffering an intracranial hemorrhage under VKA showed significantly larger hematoma volumes and a higher in-hospital mortality. Especially in intracerebral hemorrhage, we observed a higher initial severity and numerically greater proportion of early changes towards palliative therapy under VKA, which coincided with a numerically higher case fatality. Conclusions We show significantly smaller hematoma volumes for ICH and SDH under DOAC in comparison to VKA and a significantly lower 30-day in-hospital mortality rate of DOAC-ICH, even before the introduction of specific antidotes. These data strongly support the use of DOAC whenever possible in patients requiring OAT. Trial Registration: http://www.clinicaltrials.gov; Unique identifier: NCT01722786.
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Affiliation(s)
- Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Klinikum Lueneburg, Bögelstr. 1, 21339, Lüneburg, Germany. .,Pharmazentrum Frankfurt, Institute of General Pharmacology and Toxicology, Goethe University, Frankfurt am Main, Germany. .,Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.
| | - Edelgard Lindhoff-Last
- Coagulation Centre and Coagulation Research Center at the Cardiology Angiology Centre Bethanien Hospital (CCB), Im Prüfling 23, 60389, Frankfurt, Germany.
| | - Ali Alhashim
- Department of Neurology, University Hospital Frankfurt, Frankfurt, Germany.,Neurology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Barbara Zydek
- Coagulation Centre and Coagulation Research Center at the Cardiology Angiology Centre Bethanien Hospital (CCB), Im Prüfling 23, 60389, Frankfurt, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis and Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1; Division Haematology, Dresden University Clinic, Dresden, Germany.,Department of Haematology and Oncology, Kings College, London, UK
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany.,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
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14
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Khaki D, Ljungqvist J, Kirknes A, Bartek J, Corell A. Differences in Presentation, Radiological Features, and Outcomes in Traumatic Versus Spontaneous Acute Subdural Hematomas-A Single-Institution Population-Based Study. World Neurosurg 2022; 164:e235-e244. [PMID: 35487492 DOI: 10.1016/j.wneu.2022.04.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/19/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spontaneous acute subdural hematoma (sASDH) is a rare neurosurgical condition, with the literature mainly consisting of case reports. In the present study, we compared sASDH with traumatic ASDH (tASDH) to determine the differences in presentation, radiological features, and outcomes in a population-based setting. METHODS All adult patients (age ≥18 years) who had undergone surgery for ASDH (n = 266), either spontaneous or traumatic, from 2010 to 2020 were included retrospectively. The cohort was divided into 2 groups for comparative analysis: sASDH group (n = 24) versus tASDH group (n = 242). RESULTS Of the 266 patients, 24 (9.0%) had presented with sASDH. The sASDH group had a mean age of 66.2 years, and sudden headache was the most common presenting symptom (83.3%). The sASDH group had a higher Glasgow coma scale score at presentation compared with the tASDH group (Glasgow coma scale scores, 10 and 8, respectively; P < 0.01). The outcomes, assessed using the Glasgow outcome scale (GOS), revealed a greater incidence of more favorable outcomes (GOS score 4-5) for the sASDH group (72.7%) than for the tASDH group (41.5%). CONCLUSIONS In the present population-based study of surgically evacuated ASDH cases, 9% were spontaneous without previous trauma. The outcomes (GOS scores) were significantly more favorable for those with sASDH than for those with tASDH. In one half of the patients with sASDH, arterial bleeding was noted perioperatively, although the preoperative radiological examinations revealed no abnormalities for most patients. However, the lack of sufficient examinations such as computed tomography angiography made it difficult to establish the most common etiology of bleeding in those with sASDH. Further research is warranted to determine the reference standard method for the investigation of sASDH.
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Affiliation(s)
- Djino Khaki
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Ljungqvist
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Astrid Kirknes
- Department of Emergency Medical Service, Vestfold Hospital Trust, Tønsberg, Norway
| | - Jiri Bartek
- Department of Neurosurgery and Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Neurosurgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Alba Corell
- Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden; Institute of Neuroscience and Physiology, Department of Clinical Neuroscience, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.
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15
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Manivannan S, Spencer R, Marei O, Mayo I, Elalfy O, Martin J, Zaben M. Acute subdural haematoma in the elderly: to operate or not to operate? A systematic review and meta-analysis of outcomes following surgery. BMJ Open 2021; 11:e050786. [PMID: 34862284 PMCID: PMC8647543 DOI: 10.1136/bmjopen-2021-050786] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Acute subdural haematoma (ASDH) is a devastating pathology commonly found on CT brain scans of patients with traumatic brain injury. The role of surgical intervention in the elderly has been increasingly questioned due to its associated morbidity and mortality. Therefore, a systematic review and meta-analysis of the literature to quantify the mortality and functional outcomes associated with surgical management of ASDH in the elderly was performed. DESIGN/SETTING A multidatabase literature search between January 1990 and May 2020, and meta-analysis of proportions was performed to quantify mortality and unfavourable outcome (Glasgow Outcome scale 1-3; death/ severe disability) rates. PARTICIPANTS Studies reporting patients aged 60 years or older. INTERVENTIONS Craniotomy, decompressive craniectomy, conservative management. OUTCOME MEASURES Mortality and functional outcomes (discharge, long-term follow-up (LTFU)). RESULTS 2572 articles were screened, yielding 21 studies for final inclusion and 15 for meta-analysis. Pooled estimates of mortality were 39.83% (95% CI 32.73% to 47.14%; 10 studies, 308/739 patients, I2=73%) at discharge and 49.30% (95% CI 42.01% to 56.61%; 10 studies, 277/555 patients, I2=63%) at LTFU. Mean duration of follow-up was 7.1 months (range 2-12 months). Pooled estimate of percentage of poor outcomes was 81.18% (95% CI 75.61% to 86.21%; 6 studies, 363/451 patients, I2=45%) at discharge, and 79.25% (95% CI 72.42% to 85.37%; 8 studies, 402/511 patients, I2=66%) at LTFU. Mean duration of follow-up was 6.4 months (range 2-12 months). Potential risk factors for poor outcome included age, baseline functional status, preoperative neurological status and imaging parameters. CONCLUSIONS Outcomes following surgical evacuation of ASDH in patients aged 60 years and above are poor. This constitutes the best level of evidence in the current literature that surgical intervention for ASDH in the elderly carries significant risks, which must be weighed against benefits. PROSPERO REGISTRATION NUMBER CRD42020189508.
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Affiliation(s)
- Susruta Manivannan
- Department of Neurosurgery, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Robert Spencer
- Department of Neurosurgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Omar Marei
- School of Medicine, Cardiff University, Cardiff, UK
| | - Isaac Mayo
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Omar Elalfy
- School of Medicine, Cardiff University, Cardiff, UK
| | - John Martin
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Malik Zaben
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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16
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Yang J, Liu Q, Mo S, Wang K, Li M, Wu J, Jiang P, Yang S, Guo R, Yang Y, Zhang J, Liu Y, Cao Y, Wang S. The Effect of Preoperative Antiplatelet Therapy on Early Postoperative Rehemorrhage and Outcomes in Patients With Spontaneous Intracranial Hematoma. Front Aging Neurosci 2021; 13:681998. [PMID: 34276341 PMCID: PMC8283695 DOI: 10.3389/fnagi.2021.681998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose The effect of antiplatelet therapy (APT) on early postoperative rehemorrhage and outcomes of patients with spontaneous intracerebral hemorrhage (ICH) is still unclear. This study is to evaluate the effect of preoperative APT on early postoperative rehemorrhage and outcomes in ICH patients. Methods This was a multicenter cohort study. ICH patients undergoing surgery were divided into APT group and no antiplatelet therapy (nAPT) group according to whether patients received APT or not. Chi-square test, t-test, and Mann–Whitney U test were used to compare the differences in variables, postoperative rehematoma, and outcomes between groups. Multivariate logistics regression analysis was used to correct for confounding variables, which were different in group comparison. Results One hundred fifty ICH patients undergoing surgical treatment were consecutively included in this study. Thirty five (23.33%) people were included in the APT group, while 115 (76.67%) people were included in the nAPT group. The incidence of early postoperative rehemorrhage in the APT group was significantly higher than that in the nAPT group (25.7% VS 10.4%, p = 0.047 < 0.05). After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT had no significant effect on early postoperative rehemorrhage (p = 0.067). There was no statistical difference between the two groups in early poorer outcomes (p = 0.222) at 14 days after surgery. After adjustment for age, ischemic stroke history, and ventricular hematoma, preoperative APT also had no significant effect on early poorer modified Rankin Scale (mRS) (p = 0.072). Conclusion In conclusion, preoperative APT appears to be safe and have no significant effect on early postoperative rehematoma and outcomes in ICH patients.
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Affiliation(s)
- Junhua Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shaohua Mo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Kaiwen Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Maogui Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Pengjun Jiang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuzhe Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Rui Guo
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Jiaming Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yong Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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17
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Khattar NK, McCallum AP, Fortuny EM, White AC, Ball TJ, Adams SW, Meyer KS, Wei G, John KD, Bak E, Sieg EP, Ding D, James RF. Minimally Invasive Endoscopy for Acute Subdural Hematomas: A Report of 3 Cases. Oper Neurosurg (Hagerstown) 2021; 20:310-316. [PMID: 33372226 DOI: 10.1093/ons/opaa390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 09/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Acute subdural hematomas (aSDHs) occur in approximately 10% to 20% of all closed head injury and represent a significant cause of morbidity and mortality in traumatic brain injury patients. Conventional craniotomy is an invasive intervention with the potential for excess blood loss and prolonged postoperative recovery time. OBJECTIVE To evaluate the outcomes of minimally invasive endoscopy for evacuation of aSDHs in a pilot feasibility study. METHODS We retrospectively reviewed the records of consecutive patients with aSDHs who underwent surgical treatment at our institution with minimally invasive endoscopy using the Apollo/Artemis Neuro Evacuation Device (Penumbra, Alameda, California) between April 2015 and July 2018. RESULTS The study cohort comprised three patients. The Glasgow Coma Scale on admission was 15 for all 3 patients, median preoperative hematoma volume was 49.5 cm3 (range 44-67.8 cm3), median postoperative degree of hematoma evacuation was 88% (range 84%-89%), and median modified Rankin Scale at discharge was 1 (range 0-3). CONCLUSION Endoscopic evacuation of aSDHs can be a safe and effective alternative to craniotomy in appropriately selected patients. Further studies are needed to refine the selection criteria for endoscopic aSDH evacuation and evaluate its long-term outcomes.
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Affiliation(s)
- Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Abigail P McCallum
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Enzo M Fortuny
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Andrew C White
- Department of Radiology, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tyler J Ball
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Shawn W Adams
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kimberly S Meyer
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - George Wei
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Kevin D John
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Esther Bak
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Emily P Sieg
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Robert F James
- Department of Neurological Surgery, Indiana University School of Medicine, IU Health Physicians Neurosurgery, Indianapolis, Indiana
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Craniotomy size for traumatic acute subdural hematomas in elderly patients-same procedure for every age? Neurosurg Rev 2021; 45:459-465. [PMID: 33900496 PMCID: PMC8827226 DOI: 10.1007/s10143-021-01548-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/25/2021] [Accepted: 04/12/2021] [Indexed: 12/03/2022]
Abstract
Surgical treatment of acute subdural hematoma (aSDH) is still matter of debate, especially in the elderly. A retrospective study to compare two different surgical approaches, namely standard (SC, craniotomy size > 8 cm) and limited craniotomy (LC, craniotomy size < 8 cm), was conducted in elderly patients with traumatic aSDH to identify the role of craniotomy size in terms of clinical and radiological outcome. Sixty-four patients aged 75 or older with aSDH as sole lesion were retrospectively analyzed. Data were collected pre- and postoperatively including clinical and radiological criteria. The primary outcome parameter was 30-day mortality. Secondary outcome parameters were radiological. The mean age was 79.2 (± 3.1) years with no difference between groups and almost equal distribution of craniotomy size. Mortality rate was significantly higher in the SC group in comparison to the LC group (68.4% vs. 31.6%; p = 0.045). The preoperative HD (p = 0.08) and the MLS (p = 0.09) were significantly higher in the SC group, whereas postoperative radiological evaluation showed no significant difference in HD or MLS. A limited craniotomy is sufficient for adequate evacuation of an aSDH in the elderly achieving the same radiological and clinical outcome.
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Robinson D, Pyle L, Foreman B, Ngwenya LB, Adeoye O, Woo D, Kreitzer N. Antithrombotic regimens and need for critical care interventions among patients with subdural hematomas. Am J Emerg Med 2021; 47:6-12. [PMID: 33744487 DOI: 10.1016/j.ajem.2021.03.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Antithrombotic-associated subdural hematomas (SDHs) are increasingly common, and the possibility of clinical deterioration in otherwise stable antithrombotic-associated SDH patients may prompt unnecessary admissions to intensive care units. It is unknown whether all antithrombotic regimens are equally associated with the need for critical care interventions. We sought to compare the frequency of critical care interventions and poor functional outcomes among three cohorts of noncomatose SDH patients: patients on no antithrombotics, patients on anticoagulants, and patients on antiplatelets alone. METHODS We performed a retrospective cohort study on all noncomatose SDH patients (Glasgow Coma Scale > 12) presenting to an academic health system in 2018. The three groups of patients were compared in terms of clinical course and functional outcome. Multivariable logistic regression was used to determine predictors of need for critical care interventions and poor functional outcome at hospital discharge. RESULTS There were 281 eligible patients presenting with SDHs in 2018, with 126 (45%) patients on no antithrombotics, 106 (38%) patients on antiplatelet medications alone, and 49 (17%) patients on anticoagulants. Significant predictors of critical care interventions were coagulopathy (OR 5.1, P < 0.001), presence of contusions (OR 3, P = 0.007), midline shift (OR 3.4, P = 0.002), and maximum SDH thickness (OR 2.4, P = 0.002). Significant predictors of poor functional outcome were age (OR 1.8, P < 0.001), admission Glasgow Coma Scale score (OR 0.3, P < 0.001), dementia history (OR 4.2, P = 0.001), and coagulopathy (OR 3.5, P = 0.02). Isolated antiplatelet use was not associated with either critical care interventions or functional outcome. CONCLUSION Isolated antiplatelet use is not a significant predictor of need for critical care interventions or poor functional outcome among SDH patients and should not be used as a criterion for triage to the intensive care unit.
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Affiliation(s)
- David Robinson
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA.
| | - Logan Pyle
- Department of Pulmonology and Critical Care, University of Pittsburgh Medical Center Hamot, PA, USA.
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA; Collaborative for Research on Acute Neurological Injuries, OH, USA.
| | - Laura B Ngwenya
- Department of Neurosurgery, University of Cincinnati, OH, USA; Collaborative for Research on Acute Neurological Injuries, OH, USA.
| | - Opeolu Adeoye
- Department of Neurosurgery, University of Cincinnati, OH, USA; Department of Emergency Medicine, University of Cincinnati, OH, USA.
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, OH, USA.
| | - Natalie Kreitzer
- Department of Emergency Medicine, University of Cincinnati, OH, USA.
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Prior A, Fiaschi P, Iaccarino C, Stefini R, Battaglini D, Balestrino A, Anania P, Prior E, Zona G. How do you manage ANTICOagulant therapy in neurosurgery? The ANTICO survey of the Italian Society of Neurosurgery (SINCH). BMC Neurol 2021; 21:98. [PMID: 33658003 PMCID: PMC7927258 DOI: 10.1186/s12883-021-02126-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 02/23/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anticoagulant assumption is a concern in neurosurgical patient that implies a delicate balance between the risk of thromboembolism versus the risk of peri- and postoperative hemorrhage. METHODS We performed a survey among 129 different neurosurgical departments in Italy to evaluate practice patterns regarding the management of neurosurgical patients taking anticoagulant drugs. Furthermore, we reviewed the available literature, with the aim of providing a comprehensive but practical summary of current recommendations. RESULTS Our survey revealed that there is a lack of knowledge, mostly regarding the indication and the strategies of anticoagulant reversal in neurosurgical clinical practice. This may be due a lack of national and international guidelines for the care of anticoagulated neurosurgical patients, along with the fact that coagulation and hemostasis are not simple topics for a neurosurgeon. CONCLUSIONS To overcome this issue, establishment of hospital-wide policy concerning management of anticoagulated patients and developed in an interdisciplinary manner are strongly recommended.
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Affiliation(s)
- Alessandro Prior
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pietro Fiaschi
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy.
| | | | - Roberto Stefini
- Department of Neurosurgery, Ospedale Civile di Legnano, Milan, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Alberto Balestrino
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Pasquale Anania
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Enrico Prior
- Division of Cardiology, Department of Medicine University of Verona, Verona, Italy
| | - Gianluigi Zona
- Section of Neurosurgery, Department of Neuroscience (DINOGMI) IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Università di Genova, Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi, 1016132, Genoa, Italy
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Narula N, Tsikis S, Jinadasa SP, Parsons CS, Cook CH, Butt B, Odom SR. The Effect of Anticoagulation and Antiplatelet Use in Trauma Patients on Mortality and Length of Stay. Am Surg 2021; 88:1137-1145. [PMID: 33522831 DOI: 10.1177/0003134821989043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Though many trauma patients are on anticoagulation or antiplatelet therapy (AAT), there are few generalizable data on the risks for these patients. The purpose of this study was to analyze the impact of anticoagulation (AC) and antiplatelet (AP) therapy on mortality and length of stay (LOS) in general trauma patients. METHODS A retrospective review was performed of patients in the institutional trauma registry during 2019 to determine AAT use on admission and discharge. Outcomes were compared using standard statistics. RESULTS Of 2261 patients who met the inclusion criteria, 2 were excluded due to an incomplete medication reconciliation, resulting in 2259 patients. Patients on AAT had a higher mortality (4.5% vs 2.1%). On multivariable analysis, preadmission AC (odds ratio OR, 3.325, P = .001), age (OR 1.040, P < .001), and injury severity score ((ISS) 1.094, P < .001) were associated with mortality. Anticoagulation use was also associated with longer LOS on multivariable analysis (OR: 1.626, P = .005). Antiplatelet use was not associated with higher mortality or longer LOS. More patients on AAT were unable to be discharged home. However, patients on AAT did not have a greater blood transfusion requirement or need more hemorrhage control procedures. Lastly, 23.7% of patients on preadmission AAT were not discharged on any AAT. DISCUSSION These data demonstrate that patients on AC, but not AP, have greater mortality and longer hospital LOS. This may provide guidance for those being newly started on AAT. Further work to determine which patients benefit most from restarting AAT would lead to improvement in the care of trauma patients.
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Affiliation(s)
- Nisha Narula
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Savas Tsikis
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sayuri P Jinadasa
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Charles S Parsons
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Charles H Cook
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Bonnie Butt
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Stephen R Odom
- Department of Surgery, 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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Trevisi G, Sturiale CL, Scerrati A, Rustemi O, Ricciardi L, Raneri F, Tomatis A, Piazza A, Auricchio AM, Stifano V, Romano C, De Bonis P, Mangiola A. Acute subdural hematoma in the elderly: outcome analysis in a retrospective multicentric series of 213 patients. Neurosurg Focus 2020; 49:E21. [DOI: 10.3171/2020.7.focus20437] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe objective of this study was to analyze the risk factors associated with the outcome of acute subdural hematoma (ASDH) in elderly patients treated either surgically or nonsurgically.METHODSThe authors performed a retrospective multicentric analysis of clinical and radiological data on patients aged ≥ 70 years who had been consecutively admitted to the neurosurgical department of 5 Italian hospitals for the management of posttraumatic ASDH in a 3-year period. Outcome was measured according to the Glasgow Outcome Scale (GOS) at discharge and at 6 months’ follow-up. A GOS score of 1–3 was defined as a poor outcome and a GOS score of 4–5 as a good outcome. Univariate and multivariate statistics were used to determine outcome predictors in the entire study population and in the surgical group.RESULTSOverall, 213 patients were admitted during the 3-year study period. Outcome was poor in 135 (63%) patients, as 65 (31%) died during their admission, 33 (15%) were in a vegetative state, and 37 (17%) had severe disability at discharge. Surgical patients had worse clinical and radiological findings on arrival or during their admission than the patients undergoing conservative treatment. Surgery was performed in 147 (69%) patients, and 114 (78%) of them had a poor outcome. In stratifying patients by their Glasgow Coma Scale (GCS) score, the authors found that surgery reduced mortality but not the frequency of a poor outcome in the patients with a moderate to severe GCS score. The GCS score and midline shift were the most significant predictors of outcome. Antiplatelet drugs were associated with better outcomes; however, patients taking such medications had a better GCS score and better radiological findings, which could have influenced the former finding. Patients with fixed pupils never had a good outcome. Age and Charlson Comorbidity Index were not associated with outcome.CONCLUSIONSTraumatic ASDH in the elderly is a severe condition, with the GCS score and midline shift the stronger outcome predictors, while age per se and comorbidities were not associated with outcome. Antithrombotic drugs do not seem to negatively influence pretreatment status or posttreatment outcome. Surgery was performed in patients with a worse clinical and radiological status, reducing the rate of death but not the frequency of a poor outcome.
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Affiliation(s)
| | - Carmelo Lucio Sturiale
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Alba Scerrati
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Oriela Rustemi
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | - Luca Ricciardi
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Fabio Raneri
- 5UOC Neurochirurgia 1, Azienda ULSS 8 Berica Ospedale San Bortolo, Vicenza
| | | | - Amedeo Piazza
- 6UOC di Neurochirurgia, Azienda Ospedaliera Sant’Andrea, Dipartimento NESMOS, Sapienza-Roma; and
| | - Anna Maria Auricchio
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Vito Stifano
- 2Department of Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome
| | - Carmine Romano
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
| | - Pasquale De Bonis
- 3Department of Neurosurgery, S. Anna University Hospital, Ferrara
- 4Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Annunziato Mangiola
- 1Neurosurgical Unit, Ospedale Santo Spirito, Pescara
- 7Department of Neurosciences, Imaging and Clinical Sciences, “G. D’Annunzio” University, Chieti, Italy
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Rawanduzy C, McIntyre MK, Afridi A, Honig J, Halabi M, Hehir J, Schmidt M, Cole C, Miller I, Gandhi C, Al-Mufti F, Bowers C. The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis. World Neurosurg 2020; 143:e285-e293. [PMID: 32711137 DOI: 10.1016/j.wneu.2020.07.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH. METHODS Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home. RESULTS Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis. CONCLUSIONS iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.
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Affiliation(s)
- Cameron Rawanduzy
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | | | - Adil Afridi
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jesse Honig
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mohamed Halabi
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jacob Hehir
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA.
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Choi J, Pyen J, Cho S, Kim J, Koo Y, Whang K. Influence of Antithrombotic Medication on the Risk of Chronic Subdural Hematoma Recurrence after Burr-Hole Surgery. J Korean Neurosurg Soc 2020; 63:513-518. [PMID: 32455519 PMCID: PMC7365285 DOI: 10.3340/jkns.2019.0194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 12/31/2019] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) is one of the most common intracranial hemorrhages. It can be managed with a simple surgical treatment such as burr-hole trephination and drainage. However, it has a relatively high recurrence rate. The mechanisms and risk factors for the recurrence have not yet been clearly identified and studies have reported varying results. METHODS We analyzed 230 patients with CSDH who were treated with burr-hole trephination and drainage at our institution from March 2011 to March 2016. The patients were divided into recurrence and non-recurrence groups and the medical records of each group were used to analyze the risk factors associated with CSDH recurrence. RESULTS After burr-hole trephination and drainage, CSDH recurrence was observed in 49 (21.3%) of the 230 patients. In univariate analysis, none of the factors showed statistical significance with respect to CSDH recurrence. In multivariate analysis, preoperative antithrombotic medication was the only independent risk factor for CSDH recurrence (odds ratio, 2.407; 95% confidence interval, 1.047-5.531). CONCLUSION The present study found that preoperative antithrombotic medication was independently associated with CSDH recurrence.
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Affiliation(s)
- Jongwook Choi
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jinsu Pyen
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sungmin Cho
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jongyeon Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Younmoo Koo
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
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The changing face of neurosurgery for the older person. J Neurol 2020; 267:2469-2474. [PMID: 32335794 PMCID: PMC7223995 DOI: 10.1007/s00415-020-09854-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/30/2022]
Abstract
Increased life expectancy and illness prevention and treatment have led to a growing population of older patients. These changes in patient population are apparent in neurosurgery; however, relatively little is reported about specific outcomes and prognostication in this group. This review summarises the challenges and management changes occurring in the treatment of three common neurosurgical pathologies; aneurysmal subarachnoid haemorrhage, head injury, and haemorrhagic stroke. A move towards less invasive neurosurgical techniques has implications on the risk–benefit profile of interventions. This creates the opportunity to intervene in older patients with greater co-morbidity, as long as improved outcomes can be evidenced. A critical part of assessing appropriateness for surgical intervention in older patients may be to change from a mindset of age to one of frailty and growing interest in scales assessing this may aid treatment decisions in the future.
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Clinical practice for antiplatelet and anticoagulant therapy in neurosurgery: data from an Italian survey and summary of current recommendations - part I, antiplatelet therapy. Neurosurg Rev 2020; 44:485-493. [PMID: 31953783 DOI: 10.1007/s10143-019-01229-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 11/19/2019] [Accepted: 12/18/2019] [Indexed: 12/11/2022]
Abstract
The use of antiplatelet medication is widespread as reducing risk of death, myocardial infarction, and occlusive stroke. Currently, the management of neurosurgical patients receiving this type of therapy continues to be a problem of special importance. In this paper, we present the results of an Italian survey focused on the management neurosurgical patient under antiplatelet therapy and, for any item of the investigation, the relative advices coming from literature. This survey was conducted including 129 neurosurgery units in Italy. The present paper was designed by following each question posed in the survey by a brief discussion on literature data. There is a considerable lack of consensus regarding management of antiplatelet therapy in neurosurgery, with critical impact on patient's treatment. What is clearly evident from the present survey is the considerable variability in neurosurgical care for antiplatelet patients; it is reasonable to assume that this scenario reflects the paucity of evidence regarding this issue.
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Management of Patients with Acute Subdural Hemorrhage During Treatment with Direct Oral Anticoagulants. Neurocrit Care 2020; 30:322-333. [PMID: 30382531 DOI: 10.1007/s12028-018-0635-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Anticoagulation therapy is a major risk factor for unfavorable patient outcomes following (traumatic) intracranial hemorrhage. Direct oral anticoagulants (DOAC) are increasingly used for the prevention and treatment of thromboembolic diseases. Data on patients treated for acute subdural hemorrhage (SDH) during anticoagulation therapy with DOAC are limited. METHODS We analyzed the medical records of consecutive patients treated at our institution for acute SDH during anticoagulation therapy with DOAC or vitamin K antagonists (VKA) during a period of 30 months. Patient characteristics such as results of imaging and laboratory studies, treatment modalities and short-term patient outcomes were included. RESULTS A total of 128 patients with preadmission DOAC (n = 65) or VKA (n = 63) intake were compared. The overall 30-day mortality rate of this patient cohort was 27%, and it did not differ between patients with DOAC or VKA intake (26% vs. 27%; p = 1.000). Similarly, the rates of neurosurgical intervention (65%) and intracranial re-hemorrhage (18%) were comparable. Prothrombin complex concentrates were administered more frequently in patients with VKA intake than in patients with DOAC intake (90% vs. 58%; p < 0.0001). DOAC treatment in patients with acute SDH did not increase in-hospital and 30-day mortality rates compared to VKA treatment. CONCLUSIONS These findings support the favorable safety profile of DOAC in patients, even in the setting of intracranial hemorrhage. However, the availability of specific antidotes to DOAC may further improve the management of these patients.
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Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv 2020; 3:158-167. [PMID: 30658963 DOI: 10.1182/bloodadvances.2018024133] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/03/2018] [Indexed: 01/12/2023] Open
Abstract
A targeted antidote for reversal of direct factor Xa (FXa) inhibitors is now available for clinical use in the United States, but it is costly and has limited availability. In a systematic review, we evaluated the safety and effectiveness of 4-factor prothrombin complex concentrate (4F-PCC) as an alternative for managing direct FXa inhibitor-related major bleeding. A systematic literature search was conducted using Medline, Embase, and the Cochrane Register of Controlled Trials up to September 2018. No comparative studies were found. Ten case series with 340 patients who received PCC for direct FXa inhibitor-related major bleeding were included. The pooled proportion of patients with effective management of major bleeding was 0.69 (95% confidence interval [CI], 0.61-0.76) in 2 studies using the International Society on Thrombosis and Haemostasis (ISTH) criteria and 0.77 (95% CI, 0.63-0.92) in 8 studies that did not use the ISTH criteria; all-cause mortality was 0.16 (95% CI, 0.07-0.26), and thromboembolism rate was 0.04 (95% CI, 0.01-0.08). On the basis of evidence with very low certainty from single-arm case series, it is difficult to determine whether 4F-PCC in addition to cessation of direct oral FXa inhibitor is more effective than cessation of direct oral FXa inhibitor alone in patients with direct FXa inhibitor-related major bleeding.
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Hsieh CH, Rau CS, Wu SC, Liu HT, Huang CY, Hsu SY, Hsieh HY. Risk Factors Contributing to Higher Mortality Rates in Elderly Patients with Acute Traumatic Subdural Hematoma Sustained in a Fall: A Cross-Sectional Analysis Using Registered Trauma Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15112426. [PMID: 30388747 PMCID: PMC6265997 DOI: 10.3390/ijerph15112426] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 10/25/2018] [Accepted: 10/29/2018] [Indexed: 12/23/2022]
Abstract
Background: We aimed to explore the risk factors that contribute to the mortality of elderly trauma patients with acute subdural hematoma (SDH) resulting from a fall. Mortality rates of the elderly were compared to those of young adults. Methods: A total of 444 patients with acute traumatic subdural hematoma resulting from a fall, admitted to a level I trauma center from 1 January 2009 to 31 December 2016 were enrolled in this study. Patients were categorized into two groups: elderly patients (n = 279) and young adults (n = 165). The primary outcome of this study was patient mortality in hospital. The adjusted odds ratio (AOR) with 95% confidence interval (CI) for mortality was calculated according to gender and pre-existing comorbidities. Univariate and multivariate logistic regression analyses were performed to identify factors related to mortality in the elderly. Results: The odds ratio for mortality caused by falls in the elderly patients was four-fold higher than in the young adults, after adjusting for gender and pre-existing comorbidities. In addition, the presence of pre-existing coronary artery disease (OR 3.2, 95% CI 1.09–9.69, p = 0.035), end-stage renal disease (OR 4.6, 95% CI 1.48–14.13, p = 0.008), hematoma volume (OR 1.2, 95% CI 1.11–1.36, p < 0.001), injury severity score (OR 1.3, 95% CI 1.23–1.46, p < 0.001), and coagulopathy (OR 4.0, 95% CI 1.47–11.05, p = 0.007) were significant independent risk factors for mortality in patients with acute traumatic SDH resulting from a fall. Conclusions: In this study, we identified that pre-existing CAD, ESRD, hematoma volume, ISS, and coagulopathy were significant independent risk factors for mortality in patients with acute traumatic SDH. These results suggest that death following acute SDH is influenced both by the extent of neurological damage and the overall health of the patient at the time of injury.
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Affiliation(s)
- Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Hang-Tsung Liu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung 83301, Taiwan.
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Dubinski D, Won SY, Behmanesh B, Brawanski N, Geisen C, Seifert V, Senft C, Konczalla J. The clinical relevance of ABO blood type in 100 patients with acute subdural hematoma. PLoS One 2018; 13:e0204331. [PMID: 30286106 PMCID: PMC6171832 DOI: 10.1371/journal.pone.0204331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 09/06/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The correlation of depleted blood through midline shift in acute subdural hematoma remains the most reliable clinical predictor to date. On the other hand, patient's ABO blood type has a profound impact on coagulation and hemostasis. We conducted this study to evaluate the role of patient's blood type in terms of incidence, clinical course and outcome after acute subdural hematoma bleeding. METHODS 100 patients with acute subdural hematoma treated between 2010 and 2015 at the author's institution were included. Baseline characteristics and clinical findings including Glasgow coma scale, Glasgow outcome scale, hematoma volume, rebleeding, midline shift, postoperative seizures and the presence of anticoagulation were analyzed for their association with ABO blood type. RESULTS Patient's with blood type O were found to have a lower midline shift (p<0.01) and significantly less seizures (OR: 0.43; p<0.05) compared to non-O patients. Furthermore, patients with blood type A had the a significantly higher midline shift (p<0.05) and a significantly increased risk for postoperative seizures (OR: 4.01; p<0.001). There was no difference in ABO blood type distribution between acute subdural hematoma patients and the average population. CONCLUSION The ABO blood type has significant influence on acute subdural hematoma sequelae. Patient's with blood type O benefit in their clinical course after acute subdural hematoma whereas blood type A patients are at highest risk for increased midline shift and postoperative seizures. Further studies elucidating the biological mechanisms of blood type depended hemostaseology and its role in acute subdural hematoma are required for the development of an appropriate intervention.
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Affiliation(s)
- Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Nina Brawanski
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Christof Geisen
- Institute for Transfusion Medicine and Immunohematology, Goethe University, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Christian Senft
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany
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Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
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