Midline shift in relation to thickness of traumatic acute subdural hematoma predicts mortality.

Ronald Hma Bartels,Michael Edwards,Mathias Prokop,Hans Van Der Hoeven,Frederick Ja Meijer

doi:10.1186/s12883-015-0479-x

Ronald Hma Bartels, Michael Edwards + Show 3 more

Open Access

https://doi.org/10.1186/s12883-015-0479-x

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Abstract

BackgroundTraumatic acute subdural hematoma has a high mortality despite intensive treatment. Despite the existence of several prediction models, it is very hard to predict an outcome. We investigated whether a specific combination of initial head CT-scan findings is a factor in predicting outcome, especially non-survival.MethodsWe retrospectively studied admission head CT scans of all adult patients referred for a traumatic acute subdural hematoma between April 2009 and April 2013. Chart review was performed for every included patient. Midline shift and thickness of the hematoma were measured by two independent observers. The difference between midline shift and thickness of the hematoma was calculated. These differences were correlated with outcome. IRB has approved the study.ResultsA total of 59 patients were included, of whom 29 died. We found a strong correlation between a midline shift exceeding the thickness of the hematoma by 3 mm or more, and subsequent mortality. For each evaluation, specificity was 1.0 (95 % CI: 0.85–1 for all evaluations), positive predictive value 1.0 (95 % CI between 0.31–1 and 0.56–1), while sensitivity ranged from 0.1 to 0.23 (95 % CI between 0.08–0.39 and 0.17–0.43), and negative predictive value varied from 0.52 to 0.56 (95 % CI between 0.38–0.65 and 0.41–0.69).ConclusionsIn case of a traumatic acute subdural hematoma, a difference between the midline shift and the thickness of the hematoma ≥ 3 mm at the initial CT predicted mortality in all cases. This is the first time that such a strong correlation was reported. Especially for the future development of prediction models, the relation between midline shift and thickness of the hematoma could be included as a separate factor.

Highlights

Traumatic acute subdural hematoma has a high mortality despite intensive treatment
Measurements of midline shift (MLS) and the thickness of the hematoma were obtained at the level of the frontal horns using the following protocol: on the initial CT scan, MLS was measured at the level of the frontal horns using standard window widths (WW) and window levels (WL) to evaluate brain parenchyma (WW 86, WL 30)
This study clearly showed that the value of MLS in relation to the thickness of the traumatic acute subdural hematoma (ASDH) needs to be re-considered

Summary

Introduction

Traumatic acute subdural hematoma has a high mortality despite intensive treatment. Despite the existence of several prediction models, it is very hard to predict an outcome. We investigated whether a specific combination of initial head CT-scan findings is a factor in predicting outcome, especially non-survival. An acute subdural hematoma (ASDH) is a devastating clinical entity with a clinical outcome that is difficult to predict clinical ranging from completely independent functioning and death. Trauma patients often sustain multiple injuries, the prediction of survival appears to be largely dependent on the extent of the intracranial abnormality. The MLS in relation to the thickness of the hematoma has not explicitly been included in most models. We hypothesize that the correlation between the magnitude of MLS and thickness of the hematoma is a predictor of mortality and should be incorporated as such in future prognostic models

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