Predictors for functional recovery and mortality of surgically treated traumatic acute subdural hematomas in 256 patients

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

INTRODUCTION

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical characteristics and functional outcome of surgically treated adult head trauma patients with acute subdural hematoma: Ethiopian tertiary hospitals experience

Background

Acute subdural hematoma (ASDH) is one of the most common and devastating lesions in traumatic brain injury with a mortality rate upto 60 % especially in low-income countries. The present study aimed to determine the clinical characteristics and functional outcomes and the associated factors of surgically treated head trauma patients with ASDH.

Methods

Between January 2018 and January 2021 we identified 140 head trauma patients with ASDH who underwent surgical evacuation in three tertiary hospitals. Epidemiological data were collected; the six-month functional outcome was studied using an extended Glasgow outcome score (EGOS) and associated factors were also studied. Univariate analysis was performed at first, and variables with a P-value of <0.05 were entered into the multivariable logistic regression model.

Results

Male predominance was seen accounting for 87 % and assault was the most common mechanism of injury (35.7 %). Sixty-five (56.5 %) of patients achieved favorable functional recovery (EGOS of 5-8) and 50 (43.5 %) of patients had unfavorable recovery (EGOS of 1-4) after 6 months of follow-up. In multivariate logistic regression models, GCS <5, Pupillary abnormality, hypotension, oxygen saturation <90 at presentation, and hospital-acquired pneumonia were the independent factors associated with unfavorable functional outcomes.

Conclusion

In our setup, most of the patients are male from assault injuries. There is still a high rate of unfavorable outcomes in patients with acute subdural hematoma. GCS <5, pupillary abnormality, hypotension and desaturation at presentation, and postoperative hospital-acquired infection are predictors for unfavorable functional outcomes.

Outcomes After the Surgical Evacuation of Traumatic Acute Subdural Hematomas: The tASDH Risk Score

BACKGROUND

Acute subdural hematoma (ASDH) is a common pathology following traumatic brain injury (TBI). There is sparse data on the prediction of clinical outcomes following traumatic ASDH (tASDH) evacuation. We investigated prognosticators of outcome following evacuation of tASDHs, with subset analysis in a cohort of octogenarians. We developed a scoring system for stratifying the risk of in-hospital mortality for patients undergoing tASDH evacuation.

METHODS

A retrospective chart review was performed to identify all patients who underwent tASDH evacuation. Baseline clinical and demographic data including age, traumatic brain injury mechanism, admission Glasgow Coma Scale (GCS), and Rotterdam computed tomography Scale (RCS) were collected. In-hospital outcomes such as mortality and discharge disposition were collected. A scoring system (tASDH Score) which incorporates RCS (1-2 points), admissions GCS (0-1 points), and age (0-1 point) was created to predict the risk of in-hospital mortality following tASDH evacuation.

RESULTS

Being an octogenarian (OR = 6.91 [2.20-21.71], P = 0.0009), having a GCS of 9-12 (OR = 1.58 [1.32-4.12], P = 0.027) or 3-8 (OR = 2.07 [1.41-10.38], P = 0.018), and having an RCS of 4-6 (OR = 3.49 [1.45-8.44], P = 0.0055) were independently predictive of in-hospital mortality. The in-hospital mortality rate was lower for those with a tASDH score of 1 (10%), compared to those with a score of 2 (12%), 3 (42%), and 4 (100%).

CONCLUSIONS

Octogenarians with an RCS of 4-6 and an admission GCS <13 have a high risk of mortality following tASDH evacuation. Knowledge of which patients are unlikely to survive ASDH evacuation may help guide neurosurgeons in prognostication and goals of care discussions.

Deadliness of Traumatic Subdural Hematomas in the First Quarter of the Year: A Measurement by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP)

Background Traumatic acute subdural hematoma (ASDH) is a surgical emergency and has been associated with high morbidity and mortality. However, it is not known whether mortality from ASDH occurs more frequently in a particular season. Methodology We queried the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) from 2016 to 2019. They were identified in the NSQIP using the International Classification of Diseases (ICD-10) code S06.5 to capture all admissions with a primary diagnosis of traumatic subdural hematoma. Mortality rates were reviewed per season, defined as three consecutive months in the year. Demographics such as age, race, ethnicity, height, and weight were reviewed. Comorbidities such as diabetes, risk factors, including smoking history, and hospitalization characteristics, such as admission year, operation year, and inpatient/outpatient treatment type, were also reviewed. Results A total of 1,656 patients were included in this study. The mean age of all participants was 70.6 years, with 37% (604/1,656) being female. The mortality rate was highest in January, February, and March at 24.5% (104/425, P = 0.045) of admitted patients compared to mortality rates of 18.8% (70/373) in April to June, 18.4% (81/441) in July to September, and 17.5% (73/417) in October to December. Conclusions Mortality is significantly greater during the winter months of January, February, and March among patients with ASDH. Despite better survival rates of ASDH over the past two decades, postoperative mortality rates still remain high.

Prognostic Factors of Mortality and Functional Outcome for Acute Subdural Hematoma: A Review Article

Acute subdural hematoma (ASDH) is the most frequent intracranial traumatic lesion requiring surgery in high-income countries. To date, uncertainty remains regarding the odds of mortality or functional outcome of patients with ASDH, regardless of whether they are operated on. This review aims to shed light on the clinical and radiologic factors associated with ASDH outcome. A scoping review was conducted on Medline database from inception to 2023. This review yielded 41 patient series. In the general population, specific clinical (admission Glasgow Coma Scale [GCS], abnormal pupil exam, time to surgery, decompressive craniectomy, raised postoperative intracranial pressure) and radiologic (ASDH thickness, midline shift, thickness/midline shift ratio, uncal herniation, and brain density difference) factors were associated with mortality (grade III). Other clinical (admission GCS, decompressive craniectomy) and radiologic (ASDH volume, thickness/midline shift ratio, uncal herniation, loss of basal cisterns, petechiae, and brain density difference) factors were associated with functional outcome (grade III). In the elderly, only postoperative GCS and midline shift on brain computed tomography were associated with mortality (grade III). Comorbidities, abnormal pupil examination, postoperative GCS, intensive care unit hospitalization, and midline shift were associated with functional outcome (grade III). Based on these factors, the SHE (Subdural Hematoma in the Elderly) and the RASH (Richmond Acute Subdural Hematoma) scores could be used in daily clinical practice. This review has underlined a few supplementary factors of prognostic interest in patients with ASDH, and highlighted two predictive scores that could be used in clinical practice to guide and assist clinicians in surgical indication.

Surgery for acute subdural hematoma: the value of pre-emptive decompressive craniectomy by propensity score analysis

BACKGROUND

Acute subdural hematomas (ASDH) are found frequently following traumatic brain injury (TBI) and they are considered the most lethal type of mass lesions. The decision to perform a procedure to evacuate ASDH and the approach, either via craniotomy or decompressive craniectomy (DC), remains controversial.

METHODS

We reviewed a prospectively collected series of 343 moderate to severe TBI patients in whom ASDH was the main lesion (ASDH volumes ≥10 cc). Patients with early comfort measures (early mortality prediction >50% and not ICP monitored), bilateral ASDH or the presence of another intracranial hematoma with volumes exceeding two times the volume of the ASDH were excluded. Among them, 112 were managed conservatively, 65 underwent ASDH evacuation by craniotomy and 166 by DC (103 pre-emptive DC, 63 obligatory DC). We calculated the average treatment effect by propensity score (PS) analysis using the following covariates: age, year, hypoxia, shock, pupils, major extracranial injury, motor score, midline shift, ASDH volume, swelling, intraventricular and subarachnoid hemorrhage presence. Then, multivariable binary regression and ordinal logistic regression analysis were performed to estimate associations between predictors and mortality and 12 months-GOS respectively. The patients' inverse probability weights were included as an independent variable in both regression models.

RESULTS

The main variables associated with outcome were year, age, falls from patient´s own height, hypoxia, early deterioration, pupillary abnormalities, basal cistern effacement, compliance to ICP monitoring guidelines and type of surgical approach (craniotomy and pre-emptive DC).

CONCLUSIONS

According to sliding dichotomy analysis, we found that patients in the intermediate or worst bands of unfavorable outcome prognosis seemed to achieve better than expected outcome if they underwent pre-emptive DC rather than craniotomy.

Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute?

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

Craniotomy or Craniectomy for Acute Subdural Hematoma? Difference in Patient Characteristics and Outcomes at a Tertiary Care Hospital

Objective  This article compares the outcomes of patients with traumatic acute subdural hemorrhage (SDH) managed either with craniotomy (CO) or with decompressive craniectomy (DC). Methods  In this single-center, retrospective analysis we included all adult patients with acute traumatic SDH who were treated either using CO or DC. Sixteen-year hospital data was reviewed for patient demographics, injury details, and hospital course. Outcomes were noted in terms of intraoperative blood loss, intensive care unit stay, need for tracheostomy, post-surgery Glasgow Coma Score (GCS; calculated immediately after surgery), delayed GCS (DGCS; calculated 1 week after surgery), and delayed Glasgow Outcome Score (DGOS) after 6 months of surgery. Postoperative complications were noted during hospital stay, while mortality was noted within 6 months of surgery for each patient. Results  Patients who underwent DC were younger (mean age 34.4 ± 16.8 years vs. 42.4 ± 19.9 years in the CO group) ( p  = 0.006). Patients who underwent DC also had worst degree of traumatic brain injury as per Marshall grade (62.4% patients with Marshall grade 4 in the DC group vs. only 41.2% patients in the CO group) ( p  = 0.037). Mean size of hematoma was 23.8 ± 24.6 mm in the DC group versus 11.3 ± 8.2 mm in the CO group ( p  = 0.001). Mean postop GCS was lower in the DC group; 8.0 ± 4 versus 10.8 ± 4 in the CO group ( p  < 0.001). However, there was no significant difference in DGCS and DGOS between the DC and CO groups ( p  = 0.76 and 0.90, respectively). Mortality rate was 24 (30.8%) in the DC group versus 18 (20.7%) in the CO group ( p  = 0.14). Conclusion  The patients who underwent DC were younger, had larger size hematoma, and poor Marshall grade. We did not find any significant difference in the outcomes of CO and DC for management of subdural hematoma.

Analysis of the risk factors for intraoperative acute diffuse brain swelling in patients with isolated traumatic acute subdural haematomas

Background

The purpose of this retrospective study was to investigate the risk factors for intraoperative acute diffuse brain swelling in patients with isolated traumatic acute subdural haematomas (ASDH).

Methods

A total of 256 patients who underwent decompressive craniectomy for isolated traumatic ASDH between April 2013 and December 2020 were included. We evaluated the risk factors for intraoperative acute diffuse brain swelling using a multivariate logistic regression analysis.

Results

The incidence of intraoperative acute diffuse brain swelling in patients with isolated traumatic ASDH was 21.88% (56/256). Dilated pupils (OR = 24.78), subarachnoid haemorrhage (OR = 2.41), and the time from injury to surgery (OR = 0.32) were independent risk factors for intraoperative acute diffuse brain swelling, while no independent associations were observed between these risk factors and sex, age, the mechanism of injury, the Glasgow Coma Scale score, site of haematoma, thickness of haematoma, midline shift and the status of the basal cistern, although the mechanism of injury, the Glasgow Coma Scale score and the status of the basal cistern were correlated with the incidence of intraoperative acute diffuse brain swelling in the univariate analyses.

Conclusions

This study identified the risk factors for intraoperative acute diffuse brain swelling in patients with isolated traumatic ASDH. An increased risk of intraoperative acute diffuse brain swelling occurs in patients with bilaterally dilated pupils, subarachnoid haemorrhage and a shorter time from injury to surgery. These findings should help neurosurgeons obtain information before surgery about intraoperative acute diffuse brain swelling in patients with isolated traumatic ASDH.

Traumatic acute subdural hematoma and coma: retrospective cohort of surgically treated patients

BACKGROUND

A subdural hematoma is defined as clot formation in the subdural space after vessel rupture or brain parenchyma damage. Several demographic and tomographic factors were associated to poor prognosis, although some debate according to their specific roles still remains.

METHODS

Retrospective cohort study of comatose patients admitted to a single-institution, tertiary hospital center, between the years 2013 and 2019 with traumatic acute subdural hematoma requiring surgical evacuation were studied. Demographic and tomographic data were obtained from medical records. Univariate and multivariate statistical analysis were performed, using a value of P < 0.05 for significance.

RESULTS

Seventy-seven patients were selected using the criteria and a total of 37 (48%) head CT exams were evaluated. The overall mortality was 57.1% and achieved 100% at ≥75-years-old subgroup. Univariate analysis only found young age as a good prognosis factor (P = 0.002). Gender (P = 0.784), abnormal pupillary response (P = 0.643), midline shift (P = 0.874), clot thickness (P = 0.206), compressed basal cisterns (P = 0.643), hematoma side (P = 0.879), and subarachnoid hemorrhage (P = 0.510) showed no association. Multivariate analysis showed no statistically significant association between covariates.

CONCLUSION

Traumatic acute subdural hematoma is a life-threatening condition. Younger age was the only positive prognostic factor identified. More research is necessary to establish age as a rule-out criterion to surgical indication.

Diamond-Shaped Mini-Craniotomy: A New Concept in Neurosurgery

BACKGROUND

 We describe, step by step, a modified, less invasive, diamond-shaped mini-craniotomy that optimizes dural opening and can be performed in elderly patients affected by acute subdural or intracerebral hematomas, in therapy with antiplatelets or anticoagulants.

METHODS

 We retrospectively analyzed the clinical records of 67 patients (mean age of 78.5 years) treated in our institution, during a period of 10 years, with this novel diamond-shaped craniotomy. Seventeen patients were treated for intracerebral hemorrhage and 50 patients for acute subdural hematomas. All the patients were in therapy with antiplatelets or anticoagulants.

RESULTS

 Approach-related complications were not detected. Ten of 67 patients (14.9%) presented temporal muscle atrophy; there was no scar deformity, paresthesia, hyperalgesia, or ramus frontalis palsy around the scalp incision. Thirty-day mortality was 22%. The mean follow-up was 1.3 years. One-month postoperative brain computed tomography scans showed a satisfactory hematoma evacuation in 57 of 67 patients (85%).

CONCLUSIONS

 The diamond-shaped mini-craniotomy for acute subdural and intracerebral hematomas is safe and effective, and it should be considered as an alternative to traditional approaches, particularly in elderly patients.

Densitometric analysis of brain computed tomography as a new prognostic factor in patients with acute subdural hematoma

OBJECTIVE

Acute subdural hematoma (ASDH) is a major cause of mortality and morbidity after traumatic brain injury (TBI). Surgical evacuation is the mainstay of treatment in patients with altered neurological status or significant mass effect. Nevertheless, concerns regarding surgical indication still persist. Given that clinicians often make therapeutic decisions on the basis of their prognosis assessment, to accurately evaluate the prognosis is of great significance. Unfortunately, there is a lack of specific and reliable prognostic models. In addition, the interdependence of certain well-known predictive variables usually employed to guide surgical decision-making in ASDH has been proven. Because gray matter and white matter are highly susceptible to secondary insults during the early phase after TBI, the authors aimed to assess the extent of these secondary insults with a brain parenchyma densitometric quantitative CT analysis and to evaluate its prognostic capacity.

METHODS

The authors performed a retrospective analysis among their prospectively collected cohort of patients with moderate to severe TBI. Patients with surgically evacuated, isolated, unilateral ASDH admitted between 2010 and 2017 were selected. Thirty-nine patients were included. For each patient, brain parenchyma density in Hounsfield units (HUs) was measured in 10 selected slices from the supratentorial region. In each slice, different regions of interest (ROIs), including and excluding the cortical parenchyma, were defined. The injured hemisphere, the contralateral hemisphere, and the absolute differences between them were analyzed. The outcome was evaluated using the Glasgow Outcome Scale-Extended at 1 year after TBI.

RESULTS

Fifteen patients (38.5%) had a favorable outcome. Collected demographic, clinical, and radiographic data did not show significant differences between favorable and unfavorable outcomes. In contrast, the densitometric analysis demonstrated that greater absolute differences between both hemispheres were associated with poor outcome. These differences were detected along the supratentorial region, but were greater at the high convexity level. Moreover, these HU differences were far more marked at the cortical parenchyma. It was also detected that these differences were more prone to ischemic and/or edematous insults than to hyperemic changes. Age was significantly correlated with the side-to-side HU differences in patients with unfavorable outcome.

CONCLUSIONS

The densitometric analysis is a promising prognostic tool in patients diagnosed with ASDH. The supplementary prognostic information provided by the densitometric analysis should be evaluated in future studies.

Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma

BACKGROUND

Acute subdural hematoma (ASDH) is a traumatic lesion commonly found secondary to traumatic brain injury. Radiological findings on CT, such as hematoma thickness (HT) and structures midline shift (MLS), have an important prognostic role in this disease. The relationship between HT and MLS has been rarely studied in the literature. Thus, this study aimed to assess the prognostic accuracy of the difference between MLS and HT for acute outcomes in patients with ASDH in a low-income to middle-income country.

METHODS

This was a post-hoc analysis of a prospective cohort study conducted in a university-associated tertiary-level hospital in Brazil. The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis) statement guidelines were followed. The difference values between MLS and HT (Zumkeller index, ZI) were divided into three categories (<0.00, 0.01-3, and >3). Logistic regression analyses were performed to reveal the OR of categorized ZI in predicting primary outcome measures. A Cox regression was also performed and the results were presented through HR. The discriminative ability of three multivariate models including clinical and radiological variables (ZI, Rotterdam score, and Helsinki score) was demonstrated.

RESULTS

A total of 114 patients were included. Logistic regression demonstrated an OR value equal to 8.12 for the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; p=0.01), which proved to be an independent predictor of mortality in the adjusted model for surgical intervention, age, and Glasgow Coma Scale (GCS) score. Cox regression analysis demonstrated that this category was associated with 14-day survival (HR 2.92, 95% CI 1.38 to 6.16; p=0.005). A multivariate analysis performed for three models including age and GCS with categorized ZI or Helsinki or Rotterdam score demonstrated area under the receiver operating characteristic curve values of 0.745, 0.767, and 0.808, respectively.

CONCLUSIONS

The present study highlights the potential usefulness of the difference between MLS and HT as a prognostic variable in patients with ASDH.

LEVEL OF EVIDENCE

Level III, epidemiological study.

Influence of Decompressive Craniectomy Post Evacuation of Epidural Hematoma in Comatose Patients

BACKGROUND

Epidural hematoma causing brain herniation is a major cause of mortality and morbidity after severe traumatic brain injury, even if surgical treatment is performed quickly. Decompression may be effective in decreasing intracranial pressure, but its effect on outcomes remains unclear.

METHODS

A retrospective analysis of deeply comatose patients (Glasgow Coma Scale score 3-5) who underwent surgical treatment during a 12-year period, either via osteoplastic craniotomy (OC) or decompressive craniectomy, was carried out. Patient groups were compared on the basis of demographics, admission clinical state, head computed tomography imaging characteristics, and discharge outcome.

RESULTS

A total of 60 patients were examined. The first group of 31 patients (52%) needed decompression during primary surgery. The second group of 29 patients (48%) underwent OC with evacuation of epidural hematoma without decompression. Both patient groups were similar according to age (40.9 ± 13 vs. 40.6 ± 12.5 years), Glasgow Coma Scale score before surgery (4 [3-5] vs. 4 [3-5]), hematoma thickness (based on computed tomography) (3.44 ± 1 vs. 3.36 ± 1.62 cm), and midline shift (1.42 ± 0.83 vs. 1.36 ± 0.9 cm). Mortality was more evident in the decompression group (45.2% vs. 13.8%; P = 0.008), and the Glasgow Outcome Score was also lower, 2.26 ± 1.5 versus 3.45 ± 1.5 (P = 0.003).

CONCLUSIONS

Decompressive craniectomy following the evacuation of an acute epidural hematoma in deeply comatose patients demonstrated inferior outcomes in comparison with OC. Brain injury in the decompressive craniectomy patient group was more severe (concomitant subdural hematoma, early brain ischemia, and early brain herniation), which may have influenced the outcome. Further prospective studies are needed.

Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.

Hematological factors predicting mortality in patients with traumatic epidural or subdural hematoma undergoing emergency surgical evacuation: A retrospective cohort study

Hematological abnormalities at admission are common after traumatic brain injuries and are associated with poor outcomes. The objective of this study was to identify the predictive factors of mortality among patients who underwent emergency surgery for the evacuation of epidural hematoma (EDH) or subdural hematoma (SDH).This was a single-center retrospective cohort study of 200 patients who underwent emergency surgical evacuation of EDH or SDH between September 2010 and December 2018. Data on hematological parameters and clinical and intraoperative features were collected. The primary end-point was 1-year mortality after surgery. Univariate and multivariate analysis were performed, and the receiver operating characteristic (ROC) curves were assessed.Of the 200 patients included in this study, 102 (51%) patients died within 1 year of emergency surgery. Lymphocyte count at admission, creatinine levels, activated partial thromboplastin time (aPTT), age, intraoperative epinephrine use, and Glasgow Coma Scale (GCS) score were significantly associated with mortality in the multivariate analysis. The areas under the ROC curve for the GCS score, aPTT, and lymphocyte counts were 0.677 (95% confidence interval [CI] 0.602-0.753), 0.644 (95% CI 0.567-0.721), and 0.576 (95% CI 0.496-0.656), respectively.Patients with elevated lymphocyte counts on admission showed a higher rate of 1-year mortality following emergency craniectomy for EDH or SDH. In addition, prolonged aPTT and a lower GCS score were also related to poor survival.

Mortality and functional outcome after surgical evacuation of traumatic acute subdural hematomas in octa- and nonagenarians

Purpose

The incidence of acute subdural hematomas (aSDH) is rising. However, beneficial effects of surgery for the oldest aSDH patients remain unclear. We hence describe the postoperative outcome of octa- and nonagenarians with aSDH in comparison to a younger patient cohort.

Methods

Patients aged ≥ 80 years surgically treated for traumatic aSDH at a single institution between 2006 and 2016 were retrospectively reviewed. Clinical and imaging variables were assessed, and univariate analysis was performed to identify factors predicting outcome at discharge. Results were compared to a cohort of younger aSDH patients and statistical analysis was performed. Long-term outcome was prospectively evaluated with the GOSE and QOLIBRI.

Results

27 aSDH patients aged ≥ 80 years were identified. On admission, 41% were in a comatose state and in-hospital mortality was 33%. At discharge, 22% had a favorable outcome (GOS 4 + 5). In univariate statistical analysis, better neurological status (GCS > 8), ≤ 1 comorbidity and smaller aSDH volumes were significant predictors for a favorable outcome. Comparison to 27 younger aSDH patients revealed significant differences in the prevalence of comorbidities and antithrombotics. At long-term follow-up, quality of life of aSDH patients was reduced (median QOLIBRI 54%).

Conclusion

Outcome after surgical treatment of aSDH in octa- and nonagenarians is not detrimental per se. Predictors for a favorable outcome are a non-comatose state on admission (GCS > 8), ≤ 1 preexisting comorbidity and a lower aSDH volume in patients aged ≥ 80 years. In individual patients, surgical evacuation of aSDH might remain a treatment option even in high ages.

Acute Epidural and Subdural Hematomas After Head Injury: Clinical Distinguishing Features

Head injury remains the most common cause of death and disability in young people. The most frequent consequences of traumatic brain injury (TBI) are extra-axial hemorrhage, i.e., an acute subdural hematoma (SDH) and epidural hematoma (EDH), which usually require a surgical treatment. The aim of the study is to present the distinguished clinical features associated with patients being surgically treated for post-traumatic EDH and SDH. The study included a group of 128 patients with isolated craniocerebral injuries. All the patients were operated. The following factors from the groups were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics, the time between trauma and surgery, and the in-hospital mortality. Using statistical analysis, we compared the studied factors in patients operated on due to EDH and SDH. Patients with SDH were older than patients with EDH. Most often, extra-axial hematomas affected men. Patients with SDH were more severe condition than patients with EDH on admission. Abnormal systolic blood pressure was the most common manifestation of dysautonomia in both groups. In the SDH group, we observed hypotension more often than hypertension. Hyperglycemia was one of the most common anomalies in laboratory factors in both groups. Hypotension and hyperglycemia were that factors significantly associated with outcome after head injuries. SDH caused greater midline shift and often pressed in basal cisterns. Patients with SDH died more often than patients with EDH.

Management and outcomes of isolated interhemispheric subdural hematomas associated with falx syndrome

OBJECTIVE

Large interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report.

METHODS

A prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival.

RESULTS

Twenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months.

CONCLUSIONS

iSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

Unfavorable functional outcome is expected for elderly patients suffering from acute subdural hematoma even when presenting with preserved level of consciousness

Alongside an increase in life expectancy, median age of patients presenting with traumatic acute subdural hematomas (ASDH) has increased as well. Treatment guidelines are based on studies performed on relatively young patients. The optimal management of elderly (>70 years old) patients with ASDH, specifically those with relatively preserved level of consciousness, was not thoroughly investigated so far. We retrospectively examined elderly patients presented to our medical center between the years 2006-2016 with traumatic convexity ASDH and GCS of 13-15. 773 patients were included in the initial cohort and 54 patients were included in the final analysis. The mean age at presentation was 81.5 years and the means of hematoma thickness and midline shift were 15.5 mm and 6.6 mm, respectively. Patients in our cohort had an overall unfavorable outcome (mRS 5-6) of 28% and 56% at discharge and at 1 year following injury, respectively. The results were not significantly different for the subgroups of patients older than 80 years and patients with high ASA-PS. Surgical evacuation of the ASDH was undertaken in 28 patients with focal neurologic deficit and/or worsening on subsequent brain scans. At 1 year, 64% (18 patients) in the surgery group had unfavorable outcome compared to 48% (12 patients) in the conservative group. We believe that these numbers should be taken under consideration when assessing elderly patients with convexity ASDH and relatively preserved level of consciousness.

Consensus statement from the International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury : Consensus statement

BACKGROUND

Two randomised trials assessing the effectiveness of decompressive craniectomy (DC) following traumatic brain injury (TBI) were published in recent years: DECRA in 2011 and RESCUEicp in 2016. As the results have generated debate amongst clinicians and researchers working in the field of TBI worldwide, it was felt necessary to provide general guidance on the use of DC following TBI and identify areas of ongoing uncertainty via a consensus-based approach.

METHODS

The International Consensus Meeting on the Role of Decompressive Craniectomy in the Management of Traumatic Brain Injury took place in Cambridge, UK, on the 28th and 29th September 2017. The meeting was jointly organised by the World Federation of Neurosurgical Societies (WFNS), AO/Global Neuro and the NIHR Global Health Research Group on Neurotrauma. Discussions and voting were organised around six pre-specified themes: (1) primary DC for mass lesions, (2) secondary DC for intracranial hypertension, (3) peri-operative care, (4) surgical technique, (5) cranial reconstruction and (6) DC in low- and middle-income countries.

RESULTS

The invited participants discussed existing published evidence and proposed consensus statements. Statements required an agreement threshold of more than 70% by blinded voting for approval.

CONCLUSIONS

In this manuscript, we present the final consensus-based recommendations. We have also identified areas of uncertainty, where further research is required, including the role of primary DC, the role of hinge craniotomy and the optimal timing and material for skull reconstruction.

Predictive Factors of Poor Prognosis After Surgical Management of Traumatic Acute Subdural Hematomas: A Single-Center Series

BACKGROUND

Traumatic acute subdural hematomas (ASDHs) showed the highest mortality of intracranial hematomas. The aim of the current study was to identify predictive factors of poor prognosis among patients who were operated on.

METHODS

This is a single-center retrospective cohort study of 82 patients who underwent surgical evacuation of a traumatic ASDH between January 2009 and December 2016. The epidemiologic, clinical, radiologic, and surgical features were recorded. Postoperative outcome were assessed by the Glasgow Outcome Scale (GOS) score at 6 months. Univariate and multivariate analysis and a classification and regression tree (CART) were performed.

RESULTS

At 6 months, 76% of patients achieved an unfavorable outcome (GOS score 1-3). The context of polytrauma (P = 0.03) and ASDH thickness ≥20 mm (P = 0.02) were significantly associated with poor outcome in the multivariate analysis. The CART algorithm isolated 3 subgroups of patients with an unfavorable prognosis: polytrauma (91%), isolated head injury (HI) featuring an ASDH thickness ≥20 mm (89%), or isolated HI featuring a thickness <20 mm in a patient older than 54 years (71%). Isolated patients with HI younger than 54 years harboring an ASDH <20 mm thick had the most promising results, with 53% with a GOS score of 4 or 5.

CONCLUSIONS

The context of polytrauma, ASDH thickness, and age were major predictive factors of poor prognosis in patients with surgically evacuated traumatic ASDH. The CART algorithm using these features isolated subgroups with decreasingly unfavorable outcome, providing a relevant statistical tool to apply to future studies of traumatic ASDH.

Scandinavian Multicenter Acute Subdural Hematoma (SMASH) Study: Study Protocol for a Multinational Population-Based Consecutive Cohort

BACKGROUND

Traumatic acute subdural hematomas (ASDHs) are associated with high rate of morbidity and mortality, especially in elderly individuals. However, recent reports indicate that the morbidity and mortality rates might have improved.

OBJECTIVE

To evaluate postoperative (30-d) mortality in younger vs elderly (≥70 yr) patients with ASDH. Comparing younger and elderly patients, the secondary objectives are morbidity patterns of care and 6 mo outcome according to Glasgow outcome scale (GOS). Finally, in patients with traumatic ASDH, we aim to provide prognostic variables.

METHODS

This is a large-scale population-based Scandinavian study including all neurosurgical departments in Denmark and Sweden. All adult (≥18 yr) patients surgically treated between 2010 and 2014 for a traumatic ASDH in Denmark and Sweden will be included. Identification at clinicaltrials.gov is NCT03284190.

EXPECTED OUTCOMES

We expect to provide data on potential differences between younger vs elderly patients in terms of mortality and morbidity. We hypothesize that elderly patients selected for surgery have a similar pattern of care as compared with younger patients. We will provide functional outcome in terms of GOS at 6 mo in younger vs elderly patients undergoing ASDH evacuation. Finally, clinical useful prognostic factors for favorable (GOS 4-5) vs unfavorable (GOS 1-3) will be identified.

DISCUSSION

An improved understanding of the clinical outcome, treatment and resource allocation, clinical course, and the prognostic factors of traumatic ASDH will allow neurosurgeons to make better treatment decisions.

Functional Outcomes in Moderate-to-Severe Traumatic Brain Injury Survivors

Introduction:

We aimed to analyze the functional outcomes based on the admission characteristics in individuals with moderate-to-severe traumatic brain injury (TBI) over a 5-year period.

Methods:

A retrospective cohort study was conducted to assess the cognitive, physical, and functional outcomes based on traditional and novel metrics used in potential outcome prediction.

Results:

A total of 201 participants were enrolled with a mean age of 31.9 ± 11.9 years. Glasgow Coma Score (GCS) at emergency department did not correlate with the functional independence measure (FIM) score or Ranchos Los Amigos (RLA) scores at discharge. The absolute functional gain was significantly higher in individuals who sustained TBI with RLA 4–5 (34.7 ± 18.8 vs. 26.5 ± 15.9, P = 0.006). Participants with RLA 4–5 on admission to rehabilitation showed good correlation with the absolute FIM gain. On multivariate regression analysis, only age (odds ratio 0.96; 95% confidence interval: 0.93–0.98; P = 0.005) was found to be the independent predictor of good functional outcome.

Conclusions:

Initial GCS is not a predictor of functional outcome in individuals who sustained TBI. Consideration of age and development of novel functional measures might be promising to predict the outcomes in individuals with moderate-to-severe TBI.

Primary decompressive craniectomy is associated with worse neurological outcome in patients with traumatic brain injury requiring acute surgery

BACKGROUND

The role of decompressive craniectomy in treating raised intracranial pressure (ICP) after traumatic brain injuries (TBI) is controversial. The aim of this study was to assess the differences in prognosis of patients initially treated by decompressive craniectomy, craniotomy, or conservatively.

METHODS

We conducted a single-center retrospective study on adult blunt TBI patients admitted to a neurosurgical intensive care unit during 2009-2012. Patients were divided into three groups based on their initial treatment - decompressive craniectomy, craniotomy, and conservative. Primary outcome was 6-month Glasgow Outcome Scale (GOS) dichotomized to favorable outcome (independent) and unfavorable outcome (dependent). The association between initial treatment and outcome was assessed using a logistic regression model adjusting for case-mix using known predictors of outcome.

RESULTS

Of the 822 included patients, 58 patients were in the craniectomy group, 401 patients in the craniotomy group, and 363 patients in the conservatively treated group. Overall, 6-month unfavorable outcome was 48%. After adjusting for case-mix, patients in the decompressive craniectomy group had a statistical significantly higher risk for poor neurological outcome compared to patients in the conservative group (OR 3.06, 95% CI 1.45-6.42) and craniotomy group (OR 3.61, 95% CI 1.74-7.51).

CONCLUSION

In conclusion, patients requiring primary decompressive craniectomy had a higher risk for poor neurological outcome compared to patients undergoing craniotomy or were conservatively treated. It is plausible that the poor prognosis is related to the TBI severity itself rather than the intervention. Further prospective randomized trials are required to establish the role of decompressive craniectomy in the treatment of patients with TBI.

To Retain or Remove the Bone Flap During Evacuation of Acute Subdural Hematoma: Factors Associated with Perioperative Brain Edema

BACKGROUND

The fate of the bone flap is a significant decision during surgical treatment of acute subdural hematoma (SDH). A general guideline revolves around the surgeon's concern for brain edema. Limited studies, however, have focused on the factors that contribute to perioperative brain edema.

METHODS

From 2012 to 2015, 38 patients who underwent decompressive craniectomy for acute SDH were reviewed. Clinical data were extracted (age, sex, initial Glasgow Coma Scale (GCS) score, sodium level, hematocrit, and intraoperative blood loss). From the preoperative scan, SDH volume, midline shift (MLS), and volume within the skull (to estimate baseline brain volume) were measured. From the postoperative scan, brain volume (including any herniating regions) was measured. Δ% was defined as the percentage change in postoperative brain volume compared with preoperative volume. Evident contralateral injury, contusions, and intraventricular hemorrhage (IVH) were noted.

RESULTS

Fifteen patients demonstrated negative Δ%. Univariate analysis found significant correlations between Δ% and preoperative MLS, initial GCS, presence of IVH, and presence of contralateral injury (P < 0.05). A multiple regression for Δ% elicited a significant model (F [3, 34] = 17.387, P < 0.01) with R2 0.605, where Δ% = 16.197 - 1.246*GCS - 0.986 * MLS + 3.292 * IVH (with 0 = no IVH, 1 = presence of IVH).

CONCLUSIONS

A high proportion of patients can exhibit negative Δ%, or relative brain compression after decompression of SDH. For these patients, replacement of the bone flap may be reasonable to avoid obligatory interval cranioplasty. Preoperative MLS, initial GCS, and presence of IVH can help predict whether overall brain volume will swell or compress within the normal confines of the skull. This can guide the decision to retain or remove the bone flap.

Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis

OBJECTIVE

The optimal surgical management of acute traumatic subdural hematoma (ASDH) is controversial; both craniectomy and craniotomy are performed. The purpose of this study was to determine the current management of ASDH in the United States.

METHODS

This retrospective cohort study used the Nationwide Inpatient Sample from the years 2006-2011 to examine patients with a primary diagnosis of ASDH. All patients ≥18 years old with a primary diagnosis of ASDH were included in the analysis. Patients with procedure codes for craniectomy and craniotomy were isolated from the database. Propensity score matching based on logistic regression was used to match craniotomy to craniectomy in a 1:1 fashion.

RESULTS

There were 47,911,414 hospitalizations analyzed. Of 60,435 patients with ASDH identified, 1763 underwent craniotomy and 177 underwent craniectomy. The average age of patients who underwent craniectomy was 49.5 years (SD 20.8) compared with an average age of 68.9 years (SD 17.1) of patients who underwent craniotomy (P < 0.0001). Hospital mortality was significantly higher in patients who underwent craniectomy (35.0% vs. 10.9%, P < 0.0001). Patients who underwent craniectomy had longer hospital stays compared with patients who underwent craniotomy (median duration 14.3 days [interquartile range 25] for craniectomy vs. 10.9 days [interquartile range 9] for craniotomy, P < 0.0001). Patients who underwent craniectomy were also more likely to be discharged to a skilled nursing or rehabilitation facility (79.1% vs. 63.9%, P = 0.0011).

CONCLUSIONS

Craniotomy is the preferred surgical technique for management of ASDH in the United States, being performed 10 times more frequently than craniectomy. Craniectomy was associated with significantly higher in-hospital mortality after propensity score matched analysis.

Outcome following evacuation of acute subdural haematomas: a comparison of craniotomy with decompressive craniectomy

BACKGROUND

Acute subdural haematomas (ASDH) occur commonly following traumatic brain injury and may be evacuated by either craniotomy (CR) or decompressive craniectomy (DC). We reviewed a series of consecutive patients undergoing evacuation of a traumatic ASDH at a regional centre, comparing observed clinical outcomes (assessed by Glasgow Outcome Scale at six months) with those predicted by the CRASH-CT prognostic model.

METHODS

Retrospective review of prospectively collected data.

RESULTS

Ninety-one patients were identified (51 DC and 40 CR ). Eighty-five had available admission data sets from which predicted outcome could be calculated. The DC group were younger than the CR group (p = 0.015). The DC group also had a greater proportion of patients whose pre-intubation GCS was ≤8 (p = 0.001), with significant extracranial injuries (p = 0.001) and obliterated basal cisterns (p = 0.001) on their pre-operative CT scan. Bone flaps in the DC group (n = 45) were longer (mean 11.6 cm; 95 % CI: 11.1-12.1) in comparison to bone flaps in the CR (n = 34) group [(mean 10.2 cm; 95 % CI: 9.35 - 10.9); p = 0.0024] The mean CRASH-CT predicted risk of 14-day mortality and of unfavourable outcome at six months was significantly higher in the DC group compared with the CR group. Eighty-eight patients had available 6-month Glasgow Outcome Scale scores. Favourable outcomes were observed in 42 % of DC versus 45 % of CR (p = 0.83). The overall mortality rate was 38 % in DC versus 32 % in CR (p = 0.65). The standardised morbidity ratio (observed/expected unfavourable outcomes) was 0.75 (95 % CI: 0.51-1.07) for DC and 0.90 (95 % CI: 0.57-1.35) for CR.

CONCLUSIONS

CR and DC for traumatic ASDH are both commonly used for primary evacuation of ASDH. Primary DC may be more effective than CR for selected patients with ASDH. Class I evidence is required in order to refine the indications for DC following evacuation of ASDH.

Predictors of functional recovery in African patients with traumatic intracranial hematomas

BACKGROUND

Head injury is a critical public health problem responsible for up to 50% of fatalities among trauma patients and for a large component of continuing care among survivors. Intracranial hematomas are among the most common clinical entities encountered by any neurosurgical service and have a very high mortality rate and extremely poor prognosis among traumatic brain injuries.

OBJECTIVE

The purpose of this study was to investigate reliable factors influencing the functional outcome of the patients with traumatic intracranial hematomas (ICHs).

METHODS

A retrospective analysis was conducted of consecutive patients presenting at the Kenyatta National Hospital between January 2000 and December 2009. Following ethical approval, the records of patients admitted to the neurosurgical unit and diagnosed with traumatic ICH were retrieved and reviewed. The outcome measure was the Glasgow Outcome Scale (GOS) score at discharge. Data were collected in preformed questionnaires, and the coding and analysis were carried out using SPSS, version 11.5.

RESULTS

Of the 608 patients diagnosed with intracranial hematomas during the study period, there was a clear male predominance, with 89.3% male and 10.7% female patients. Majority of the patients (49%) were aged between 26 and 45 years, whereas 5.6% and 9.4% were younger than age 13 years and older than age 61 years, respectively. The most common cause of injury was assault (48%). Good functional recovery was achieved by 280 (46.1%) of the patients in our series, whereas moderate and severe disability accounted for 27% and 6.9%, respectively. Males were more likely to have functional recovery (46.4%) than were females (43.1%), though this finding was not statistically significant (P = 0.069). The proportion of patients who achieved functional recovery seemed to decrease with increasing age. Patients who were involved in motor vehicle accidents were less likely to have functional recovery (33.7%, P = 0.003) than those who fell (53.6%). There was a statistically significant difference in the proportion of patients who achieved functional recovery, with 65.2% of those who had mild head injury as compared to 46% and 15.1% (P ≤ 0.001) for those with moderate and severe head injury, respectively. Patients who had surgical intervention were more likely to achieve functional outcome (51.2%) as compared to 31.7% in those managed conservatively. Furthermore, the time elapsed from initial trauma to surgery significantly influenced outcome. The type of surgery done was not found to significantly influence patient outcome (P = 0.095).

CONCLUSION

An increased risk of poor outcome occurs in patients who are older than age 61 years, have lower preoperative GCS scores, pupillary abnormalities, and a long interval between trauma and decompression. The findings would help clinicians determine management criteria and improve survival.

Postoperative outcomes following closed head injury and craniotomy for evacuation of hematoma in patients older than 80 years

OBJECT

Advances in the management of trauma-induced intracranial hematomas and hemorrhage (epidural, subdural, and intraparenchymal hemorrhage) have improved survival in these conditions over the last several decades. However, there is a paucity of research investigating the relation between patient age and outcomes of surgical treatment for these conditions. In this study, the authors examined the relation between patient age over 80 years and postoperative outcomes following closed head injury and craniotomy for intracranial hemorrhage.

METHODS

A consecutive population of patients undergoing emergent craniotomy for evacuation of intracranial hematoma following closed head trauma between 2006 and 2009 was identified. Using multivariable logistic regression models, the authors assessed the relation between age (> 80 vs ≤ 80 years) and postoperative complications, intensive care unit stay, hospital stay, morbidity, and mortality.

RESULTS

Of 103 patients, 27 were older than 80 years and 76 patients were 80 years of age or younger. Older age was associated with longer length of hospital stay (p = 0.014), a higher rate of complications (OR 5.74, 95% CI 1.29-25.34), and a higher likelihood of requiring rehabilitation (OR 3.28, 95% CI 1.13-9.74). However, there were no statistically significant differences between the age groups in 30-day mortality or ability to recover to functional baseline status.

CONCLUSIONS

The findings suggest that in comparison with younger patients, patients over 80 years of age may be similarly able to return to preinjury functional baselines but may require increased postoperative medical attention in the forms of rehabilitation and longer hospital stays. Prospective studies concerned with the relation between older age, perioperative parameters, and postoperative outcomes following craniotomy for intracranial hemorrhage are needed. Nonetheless, the findings of this study may allow for more informed decisions with respect to the care of elderly patients with intracranial hemorrhage.

Nontraumatic spontaneous acute subdural hematoma in identical teenage twins 1 year apart

OBJECTIVES

Acute subdural hematoma (ASDH) is a life-threatening injury with a high mortality rate. Most ASDH cases are a result of trauma; nontraumatic causes are relatively rare with an incidence rate of 3% to 5%. We report an unusual series of 2 patients, identical twins, who had nontraumatic subdural hematomas 1 year apart, one at age 15 and the other at age 16. METHODS (CASE PRESENTATIONS): Identical twin brothers presented 1 year and 10 days apart to an academic medical center after incurring confusion, decreased mental functioning, and a subsequent comatose state. The injuries occurred while the patients were playing football, but there was no evidence of traumatic blow to the head in either brother.

RESULTS

Both patients had computed tomographic scans and both underwent emergency surgery for hematoma evacuation. Both patients recovered full neurological function and remained healthy 12 years after surgery.

CONCLUSIONS

Acute spontaneous subdural hematoma is an emergent medical condition that may result in rapid neurological decline and must be addressed in a timely fashion. After evacuation of the hematoma, intracranial pressure decreases and cerebral perfusion pressure increases, which may allow normal perfusion of the brain. Consequently, prompt recognition and evacuation of an ASDH can drastically improve prognosis. Rarely, subdural hematoma can occur without head injury and should be in the differential diagnosis of athletes who rapidly become comatose.

Analysis of complications following decompressive craniectomy for traumatic brain injury

OBJECTIVE

Adequate management of increased intracranial pressure (ICP) is critical in patients with traumatic brain injury (TBI), and decompressive craniectomy is widely used to treat refractory increased ICP. The authors reviewed and analyzed complications following decompressive craniectomy for the management of TBI.

METHODS

A total of 89 consecutive patients who underwent decompressive craniectomy for TBI between February 2004 and February 2009 were reviewed retrospectively. Incidence rates of complications secondary to decompressive craniectomy were determined, and analyses were performed to identify clinical factors associated with the development of complications and the poor outcome.

RESULTS

Complications secondary to decompressive craniectomy occurred in 48 of the 89 (53.9%) patients. Furthermore, these complications occurred in a sequential fashion at specific times after surgical intervention; cerebral contusion expansion (2.2 ± 1.2 days), newly appearing subdural or epidural hematoma contralateral to the craniectomy defect (1.5 ± 0.9 days), epilepsy (2.7 ± 1.5 days), cerebrospinal fluid leakage through the scalp incision (7.0 ± 4.2 days), and external cerebral herniation (5.5 ± 3.3 days). Subdural effusion (10.8 ± 5.2 days) and postoperative infection (9.8 ± 3.1 days) developed between one and four weeks postoperatively. Trephined and post-traumatic hydrocephalus syndromes developed after one month postoperatively (at 79.5 ± 23.6 and 49.2 ± 14.1 days, respectively).

CONCLUSION

A poor GCS score (≤ 8) and an age of ≥ 65 were found to be related to the occurrence of one of the above-mentioned complications. These results should help neurosurgeons anticipate these complications, to adopt management strategies that reduce the risks of complications, and to improve clinical outcomes.