Subdural Hematoma Patients Research Articles

Predictors of Outcomes and a Weighted Mortality Score for Moderate to Severe Subdural Hematoma.

As the incidence of subdural hematoma is increasing, it is important to understand symptomatology and clinical variables associated with treatment outcomes and mortality in this population; patients with subdural hematoma were selected from the National Inpatient Sample (NIS) Database between 2016 and 2020 using International Classification of Disease 10th Edition (ICD10) codes. Moderate-to-severe subdural hematoma patients were identified using the Glasgow Coma Scale (GCS). Multivariate regression was first used to identify predictors of in-hospital mortality and then beta coefficients were used to create a weighted mortality score. Of 29,915 patients admitted with moderate-to-severe subdural hematomas, 12,135 (40.6%) died within the same hospital admission. In a multivariate model of relevant demographic and clinical covariates, age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were independent predictors of mortality (p < 0.001 for all). Age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were assigned a "1" in a weighted mortality score. The ROC curve for our model showed an area under the curve of 0.64. Age greater than 70, diabetes mellitus, mechanical ventilation, hydrocephalus, and herniation were predictive of mortality. We created the first clinically relevant weighted mortality score that can be used to stratify risk, guide prognosis, and inform family discussions.

Embolization of Middle Meningeal Arteries for Symptomatic Subacute Subdural Hematoma in Patients with Cancer

PurposeThe purpose of this study was to evaluate the technical and clinical success of middle meningeal artery (MMA) embolization performed for symptomatic subacute subdural hematoma (SDH) in patients with cancer. MethodsThis study retrospectively included 23 consecutive patients (12 men, 11 women; median age 61 years, interquartile range: 55.5–75.5) who underwent 34 MMA angiograms for symptomatic SDH in 2022 and 2023. Median SDH thickness was 10.5mm (7-12). Median platelet count was 117 K/mcL (54.5–218). Ten patients (43.5%, 10/23) had hematologic malignancies, 7 patients (30.4%, 7/23) had surgery. Fluoroscopy time (FT), reference dose (RD), and kerma area product (Kap) were analyzed. Adverse events and outcomes were recorded. ResultsThe median imaging and clinical follow-up were 65 days (36.5–190.5) and 163 days (86–274), respectively. The technical success rate was 91.2% (31/34) as 3 MMA were not identified in 2 patients. Median procedure duration was 61 min (55.5–75.5). Median FT was 21.6 min (15.5–31.8); median RD was 158 mGy (96–256); and median Kap was 32.9 Gy.cm2 (20.4–45.1). No further intervention was needed. For 16 patients, SDH resolved after in median 59.5 days (50-90). For 7 patients, SDH remained visible on the last imaging follow-up performed at 24 days in median (6.5-36.5). No predictive factor of failure was identified. The adverse event rate was 1/23 (4.3%). Eight patients (34.8%, 8/23) died during follow-up from progression of cancer. ConclusionsMMA embolization of symptomatic SDH in patients with cancer appears safe and is associated with improvement in clinical symptoms.

Evaluation of the Glasgow Coma Scale-Pupils score for predicting inpatient mortality among patients with traumatic subdural hematoma at United States trauma centers.

The Glasgow Coma Scale-Pupils (GCS-P) score has been suggested to better predict patient outcomes compared with GCS alone, while avoiding the need for more complex clinical models. This study aimed to compare the prognostic ability of GCS-P versus GCS in a national cohort of traumatic subdural hematoma (SDH) patients. Patient data were obtained from the National Trauma Data Bank (2017-2019). Inclusion criteria were traumatic SDH diagnosis with available data on presenting GCS score, pupillary reactivity, and discharge disposition. Patients with severe polytrauma or nonsurvivable head injury at presentation were excluded. Sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of GCS-P versus GCS scores for inpatient mortality prediction were evaluated across the entire cohort, as well as in subgroups based on age and traumatic brain injury (TBI) type (blunt vs penetrating). Calibration curves were plotted based on predicted probabilities and actual outcomes. A total of 196,747 traumatic SDH patients met the study inclusion criteria. Sensitivity (0.707 vs 0.702), specificity (0.821 vs 0.823), and AUC (0.825 vs 0.814, p < 0.001) of GCS-P versus GCS scores for prediction of inpatient mortality were similar. Calibration curve analysis revealed that GCS scores slightly underestimated inpatient mortality risk, whereas GCS-P scores did not. In patients > 65 years of age with blunt TBI (51.9%, n = 102,148), both GCS-P and GCS scores underestimated inpatient mortality risk. In patients with penetrating TBI (2.4%, n = 4,710), the AUC of the GCS-P score was significantly higher (0.902 vs 0.851, p < 0.001). In this subgroup, both GCS-P and GCS scores underestimated inpatient mortality risk among patients with lower rates of observed mortality and overestimated risk among patients with higher rates of observed mortality. This effect was more pronounced in the GCS-P calibration curve. The GCS-P score provides better short-term prognostication compared with the GCS score alone among traumatic SDH patients with penetrating TBI. The GCS-P score overestimates inpatient mortality risk among penetrating TBI patients with higher rates of observed mortality. For penetrating TBI patients, which comprised 2.4% of our SDH cohort, a low GCS-P score should not justify clinical nihilism or forgoing aggressive treatment.

Endovascular treatment of subdural haematoma in patient under anti-platelet therapy: a case report

Introduction: The incidence of chronic subdural haematoma (cSDH) is relatively high among the elderly population. Other known risk factors for cSDH include male sex, dependency on anti-platelet or anticoagulant medication, and chronic alcoholism. Although, the standard mode of treatment for cSDH is surgery, embolization of the middle meningeal artery (MMA), either upfront or as an adjunct to surgical evacuation can be used for the treatment of cSDH. Case presentation: The authors present a case of a 75-year-old female with prior history of posterior-lateral wall myocardial infarction (MI) eight years back presented to our centre with the chief complaints of a gradual onset of cough and headache for 2 months. The patient had no history of trauma, loss of consciousness, seizures, and vomiting. There was no history of diabetes, hypertension, pulmonary tuberculosis, and other chronic illness. Discussion: The concurrent use of anti- platelet drug during a surgical procedure can make the treatment challenging. Endovascular treatment can be a primary treatment modality in such situation. Conclusion: Elimination of blood supply by middle meningeal artery embolization is emerging as a safe, minimally invasive alternative to treat cSDH.

Endoscopic evacuation of chronic subdural hematoma with rigid and flexible endoscope: case report

Introduction: Subdural haematoma (SDH) is a common neurosurgical condition after head trauma requiring evacuation to prevent secondary brain injury. The first choice of management in these patients is a large craniotomy or burr-hole evacuation. However, sometimes due to lack vision during drain tube insertion or irrigation the authors might land up in a complication like cortical bridging vein rupture, haemorrhage etc. Also, the management of septate chronic SDH (CSDH) with multiple neo-membranes does not have a well-defined surgical approach. Recently, endoscopic evacuation has been reported to a be a feasible method for evacuation in acute, subacute and chronic SDH patients. Presentation of case: A 65-years-old male patient presented with a history of recent head injury and symptoms of headache and urinary incontinence of 7 days (Glasgow Coma Scale Score 15/15). Computed tomography scan revealed CSDH at both fronto-parietal convexity more on right side. Discussion: The authors reported our initial experience on a typical case of an older patient with chronic subdural haematoma and its evacuation with the assistance of both rigid and flexible endoscope. The authors could visualize cortical bridging veins and neo-membranes intraoperatively and guided our drainage tube accordingly to avoid inadvertent haemorrhage. There was no recurrence of symptoms postoperatively. Thus we achieved apparent successful evacuation of the CSDH in this patient in a 6-month follow-up. Conclusion: Endoscopic evacuation of CSDH proves to be an effective minimally invasive modality and more studies are required on larger patient groups with long-term follow-up imaging to confirm its superiority.

Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals

Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients. We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury. Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted). Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.

An artificial intelligence (AI)-based approach to clinical trial recruitment: The impact of Viz RECRUIT on enrollment in the EMBOLISE trial.

EMBOLISE (NCT04402632) is an ongoing randomized controlled trial investigating the safety and efficacy of middle meningeal artery embolization for the treatment of subacute or chronic subdural hematoma (SDH). Viz RECRUIT SDH is an artificial intelligence (AI)-based software platform that can automatically detect SDH in noncontrast computed tomography (NCHCT) images and report the volume, maximum thickness, and midline shift. We hypothesized that the mobile recruitment platform would aid enrollment and coordinate communication and image sharing among the entire research team. Patient enrollment in EMBOLISE prior to and after implementation of Viz RECRUIT SDH at a large comprehensive stroke center was compared along with the performance of the software platform. The EMBOLISE trial was activated on May 5, 2021, and Viz RECRUIT SDH was activated on October 6, 2021. The pre-AI cohort consisted of all patients from EMBOLISE to AI activation (153 days), and the post-AI cohort consisted of all patients from AI activation until August 18, 2022 (316 days). All alerts for suspected SDH candidates were manually reviewed to determine the positive predictive value (PPV) of the algorithm. Prior to AI-software implementation, there were 5 patients enrolled (0.99 patients/month) and one screen failure. After the implementation of the software, enrollment increased by 36% to 1.35 patients/month (14 total enrolled), and there were no screen failures. Over the entire post-AI period, a total of 6244 NCHCTs were processed by the system with 207 total SDH detections (3% prevalence). 35% of all alerts for suspected SDH were viewed within 10 min, and 50% were viewed within an hour. The PPV of the algorithm was 81.4 (CI [75.3, 86.7]). The implementation of an AI-based software for the automatic screening of SDH patients increased the enrollment rate in the EMBOLISE trial, and the software performed well in a real-world, clinical trial setting.

Abstract Number ‐ 102: Middle Meningeal Artery Embolization Failure Profile: A Single Institution Retrospective Study

Introduction Middle Meningeal Artery (MMA) embolization has emerged as a qualitative treatment option for subdural hematomas (SDH). Multiple studies have compared MMA embolization to other alternatives, namely surgery, and conservative treatment, with some indicating that MMA embolization was as effective and safe as the other two options. This study aimed to identify predictors of failures in SDH patients undergoing an MMA embolization. Methods We retrospectively reviewed 52 patients receiving MMA embolization for subdural hematoma management at our institution from 2020 until July 5, 2022 either as primary or adjunctive management. Patients who were under the age of 18 were excluded. Our definition of failure was any MMA embolization requiring an additional surgical procedure to evacuate the hematoma or relieve persistent symptoms. Results 52 patients with mean age of 71±14 and male gender 36 (69.2%) were reviewed. Most common presenting symptom was headache27 (51.9%) followed by gait instability22 (42.3%).35 out of 52 patients underwent MMA embolization as primary management of chronic subdural hematoma without prior surgical treatment. Six out of the 35 patients (17.1%) required a rescue surgical treatment due to increased hematoma size or recurrence of symptoms. Our early trend shows that half of the patients whose MMA embolization failed had a possible onset of SDH between 2 to 4 weeks prior the embolization. This trend is similar to Khorasanizadeh et al. description in which they concluded that late‐stage SDH was more predicated to have a failure of MMA embolization compared to early‐stage SDH (1). Of the remaining three patients, one was diagnosed with metastatic prostate cancer to the bones and kidney. This patient passed away 12 days after the procedure despite a craniotomy post‐embolization. Conclusions More clinical trials are needed to further establish MMA embolization as standard of care in the management of cSDH in a subset profile of patients with higher success rates.

Abstract WP83: An Artificial Intelligence Based Approach To Clinical Trial Recruitment: The Impact Of Viz Recruit On Enrollment In The Embolise Trial

Background: EMBOLISE (NCT 04402632) is an ongoing randomized controlled trial investigating the safety and efficacy of middle meningeal artery embolization for the treatment of subacute or chronic subdural hematoma (SDH). We hypothesized that the implementation Viz RECRUIT SDH, an artificial-intelligence (AI)-based mobile recruitment platform, would aid enrollment by automatically pre-screening suspected candidates for SDH and coordinating communication and image sharing among the entire research team. Methods: Patient enrollment in EMBOLISE prior to and after implementation of Viz RECRUIT SDH at a primary (PSC) and comprehensive stroke center (CSC) was compared. Viz RECRUIT SDH automatically detects SDH in head non-contrast computed tomography (NCCT) images and reports the volume, maximum thickness, and midline shift. The EMBOLISE trial was activated on May 5, 2021, and Viz RECRUIT SDH was activated on October 6, 2021; therefore, the pre-Viz cohort consisted of all patients from EMBOLISE to Viz activation (131 days), and the post-Viz cohort consisted of all patients from Viz activation until August 18, 2022 (316 days). For the post-Viz cohort, additional data is presented on AI-based screening metrics. Results: Prior to implementation of the AI-based software, there were 5 patients enrolled (0.99 patients/month). After implementation of the software for trial screening, enrollment increased by 36% to 1.35 patients/month (14 total enrolled), and there were no screen failures. Over the entire post-Viz period, a total of 6804 NCCTs were prescreened by Viz with 208 total SDH detections (3% prevalence). A total of 50 detections were made at the PSC and 158 came from the CSC. 79% of all alerts for suspected SDH were viewed, and 48% of all viewed alerts occurred within 10 minutes. Conclusions: The implementation of an AI-based software for the automatic screening of SDH patients increased the enrollment rate in the EMBOLISE trial. Moreover, in a busy research institution with 13 active studies in 2022, the automatic alerts of all potential patients keep our attention on EMBOLISE with coordinated screening and communication in a single mobile application.

Postoperative Radiological Factors Associated with Early Mortality after Decompressive Craniectomy in Acute Subdural Hematoma

Background: Acute subdural hematoma (SDH) often leads to serious neurological deterioration or death. Patients with acute SDH are recommended decompressive craniectomy (DC) if their brain edema is severe. We investigated the association with early mortality through postoperative radiological studies after surgery.Methods: We retrospectively reviewed 31 out of 85 patients that underwent DC due to acute SDH at our neurosurgical department in January 2011–December 2020. The effect of decompression was estimated through comparison with preoperative and postoperative midline shift (MS) in brain computed tomography (CT). Brain edema was represented as an increased value, measured by comparing the lateral displaced parenchymal diameter with the normal brain diameter.Results: Of the total 31 patients, 15 died during hospitalization (group A) and 16 had the same or improved neurological status (group B). The reduction rate of MS was shown as higher in group B than in group A; it was significantly different between the two groups. The difference between the two values (DBD) was calculated by measuring the brain diameter of the operative site after DC and normal brain diameter for the progress of brain edema. The difference value of MS (DMS) was greater than DBD for 33.3% and 81.3% of group A and B patients, respectively. Conclusion: A lower MS reduction rate or higher DBD than DMS increases a patient’s early mortality rate. Therefore, early mortality in acute SDH patients who underwent DC could be predicted through analysis of postoperative brain CT.

Outcomes of chronic subdural hematoma and their correlations with old age

Objective: This study explored the prognostic factors of chronic subdural hematoma in patients who underwent burr hole drainage, both overall and in elderly patients.Methods: This study enrolled 120 patients with chronic subdural hematoma who underwent burr hole drainage at a single center between January 2016 and December 2020. Old age was defined as &gt;65 years, and a good prognosis was defined as a decrease in the modified Rankin scale from admission to the last follow-up. Factors correlated with good prognosis in elderly patients compared with total patients were evaluated using the chi-square test and logistic regression analysis.Results: Among the 120 patients, 66 (55.0%) were ≥65 years old, and 76 (63.3%) had severe symptoms on admission. Old age (≥65) was the only factor significantly correlated with severe symptoms (P=0.021; odds ratio [OR], 2.618; 95% confidence interval [CI], 1.154–5.942). The following variables were significantly associated with the prognosis in both groups: diabetes (total: P=0.008; OR, 0.207; 95% CI, 0.064–0.664; old age: P=0.011; OR, 0.017; 95% CI, 0.044–0.672) and severe symptoms on admission (total: P&lt;0.001; OR, 6.994; 95% CI, 2.771–17.399; old age: P=0.007; OR, 6.177; 95% CI, 1.656–23.046).Conclusion: No difference in prognostic factors was observed between the overall patients and elderly patients with chronic subdural hematoma who underwent burr hole drainage. In both groups, patients without diabetes or with severe symptoms during hospitalization showed better recovery after burr hole drainage.

Blood Pressure Control in Traumatic Subdural Hematomas

Background There is debate over optimal systolic blood pressure (SBP) after traumatic subdural hematoma. Increased SBP has the benefit of increasing cerebral perfusion pressure and limiting the detrimental secondary effects of traumatic brain injurybut poses a risk of hematoma expansion. While prior studies have shown that SBP<90mmHg is associated with worsened morbidity and mortality in subdural hematoma patients, clinical guidelines and expert opinion have differing initial SBP goals. The aim of this study is to leverage a large database to determine the effects of two such goals, namely SBP 100-150mmHg versus SBP<180mmHg in this patient population. Methods A de-identified database network (TriNetX Research Network) was used to retrospectively query all patients with a first instance diagnosis of acute traumatic SDH, who also had a recorded GCS, with maintenance of SBP 100-150 within the first 24 hours (cohort 1) versus patients with an SBP<180 (cohort 2). Data came from 68 health care organizations (HCOs) with a total of 105,897,964 patients on 9/1/2022. The primary outcome of interest was mortality within 30 days. Secondary outcomes include gastrostomy tube placement, craniotomy/craniectomy/burr hole drainage, venous thromboembolism, ischemic stroke, myocardial infarction, seizure, falls, cardiac arrest, and acute kidney injury within 30 days. Cohorts were propensity-score matched for confounders. Results After propensity score matching, 1,243 patients were identified in each cohort. Age at index was 57.97+/-23.21 years and 58.28+/-22.35 years for cohorts 1 and 2, respectively.Mortality was seen in 243 patients (19.756%) vs. 209 (16.992%) (OR 1.203, 95% CI (0.98,1.476), p=0.0767) in cohorts 1 and 2, respectively. There was no statistical difference in secondary outcomes. Conclusion The results of this study demonstrate that the primary outcome of mortality at 30 days is not statistically different in acute traumatic SDH patients, whether their SBP is kept at 100-150 or below 180. Likewise, it shows no statistical difference in the subsequent incidence of gastrostomy tube placement, craniotomy/craniectomy/burr holes, venous thromboembolism, ischemic stroke, myocardial infarction, seizure, falls, or acute kidney injury.

Comparison of One vs. Two Burr Hole Craniostomy in Chronic Subdural Hematoma Recurrence

Introduction/Objective: Chronic subdural hematoma (CSDH) is most frequent neurosurgical conditions. To find the recurrence rate of chronic subdural hematoma in patients who underwent one vs. two burr craniostomy.&#x0D; Material And Methods: A randomized controlled trial was conducted at the Neurosurgery department, Ayub Teaching Hospital, Abbottabad. In the current study, a total of 76 (38 in each group) patients were observed. ASA-I, ASA-II, ASA III patients, symptomatic radiologically proven Chronic subdural hematoma. Patients were randomly allocated into two groups of 38 patients each. randomization with blocks. Group A was treated with intraoperative epidural methylprednisolone while Group B was treated with normal saline only. Clinical information was recorded on a pre-designed proforma.&#x0D; Results: Mean age was 54 years in group A, and 56 years in group B. In group A, 74% were male and 26% of patients were female. In Group B, 76% were male and 24% were female. The group A, 5% of patients had recurrence while in Group B, 13% of patients had a recurrence. There existed a significant difference between effectiveness and not-effectiveness of one/two burr hole craniostomy among patients who were less than 40 years.&#x0D; Conclusion: The recurrence rate of chronic subdural hematoma is higher in patients undergoing two burr hole craniostomy as compared to one burr craniostomy.

Spontaneous acute spinal subdural hematoma in patient on oral anticoagulant therapy

Introduction: Spontaneous spinal subdural hematoma as a result of coagulation deficit is a very rare and serious condition, with an overall incidence of less than 1%. Symptoms can vary according to the level of the bleed. Prompt recognition of the presence of spinal subdural hematoma is crucial for treatment. MRI is the investigation of choice for diagnosis as well as for planning the surgery. The differential diagnosis includes abscess, lipomatosis, significant discal hernia and tumours. There are no definite guidelines for the management of spinal subdural hematomas. In cases with serious neurological deficits, prompt surgical evacuation may lead to the resolution of symptoms and complete neurological recovery.&#x0D; Case report: We present a case of a 75-years-old man with bilateral lower limb radiculopathy, paresthesias, and spinal claudications for four days, progressing to bilateral paraplegia with urine incontinency. The patient was diagnosed with cauda equina syndrome due to spontaneous spinal subdural hematoma in the region from Th12 to L2. He was immediately operated and the subdural hematoma was evacuated. Minimal recovery was achieved and the patient was referred for further rehabilitation with severe paraparesis and urine incontinence.&#x0D; Conclusion: Early diagnosis of spinal subdural hematoma is essential for treatment. Any delay of correct diagnosis can lead to a devastating neurological deficit. Spontaneous spinal subdural hematoma is one of the rare conditions where an emergency MRI is indicated and crucial for diagnosis.

Trauma Mechanisms and Surgical Outcomes in the Elderly Patient with Chronic Subdural Hematoma.

BackgroundChronic subdural hematoma is the preeminent neurosurgical condition in the older population. This retrospective single-centre study focuses on outcome after surgery of chronic subdural hematoma in patients over 70 years.MethodsPatients treated at a single neurosurgical referral centre between 2010 and 2014 were screened. Included patients were assessed for comorbid conditions, lifestyle factors, and outcomes including recurrence, mortality, and postoperative complications.ResultsA total of 511 patients (70–97 yrs) were identified. 50.7% of patients were treated with anticoagulants and/or antiplatelet therapy. A known probable cause for the hematoma was found in 68.1% of patient’s histories. Mortality rate was 3.1% and recurrence was seen in 49 patients (9.6%). Postoperative complications were more common in patients with excessive use of alcohol (p value = .02). Neurological function was improved in 78.1% of patients after the initial surgery. A strategy of delayed contralateral surgery in bilateral hematomas showed low rates of recurrence.ConclusionFall injuries are the most common underlying trauma mechanism in the elderly with chronic subdural hematoma. Recurrence is not more common in the elderly patient group compared to the general population. Excessive alcohol use is a risk factor for post-operative complications.

Outcomes of patients with nonepileptic transient neurologic symptoms after subdural hematoma evacuation.

Patients undergoing a subdural hematoma (SDH) evacuation can experience transient neurological symptoms (TNS) postoperatively. Electroencephalography (EEG) is used to rule out seizures. We aim to characterize patients with TNS and negative epileptiform activity on EEG and compare them to those with positive epileptiform EEG findings. We performed a retrospective study of adult patients who underwent EEG for evaluation of TNS after undergoing SDH evacuation. Patients were stratified based on SDH type (acute and non-acute) and whether or not their EEG demonstrated positive epileptiform activity. A multivariate analysis was performed to identify predictors of negative EEG findings. One hundred twenty-nine SDH patients were included (45 (34.9%) acute; 84 (65.1%) non-acute). Overall, 45 (24 acute and 21 non-acute SDH patients) had positive epileptiform EEG findings, and 84 (21 acute and 63 non-acute SDH patients) had a negative EEG. Acute and non-acute SDH patients with positive EEG findings were more likely to suffer from greater than five episodes of TNS, impaired awareness, and motor symptoms, while the negative EEG group was more likely to suffer from negative symptoms. Non-acute SDH patients with positive EEG had longer mean ICU stays (14.6 vs. 7.2; p = 0.005). Both acute and non-acute SDH-positive EEG patients had worse disposition upon discharge (p < 0.05), worse modified Rankin score at discharge (p < 0.05), and 3-month follow-up (p < 0.05) and were more likely to be discharged on more than one antiepileptic drug (p < 0.001). Postoperative acute and non-acute SDH patients with TNS and negative EEG results are likely to have a favorable clinical picture. This distinction is therapeutically and prognostically important as these patients may not respond to typical antiepileptic drugs and they have better functional outcomes.

Influence of Insurance Status on Subdural Hematoma Management: A National Trauma Data Bank Analysis

BackgroundTraumatic brain injury is a major public health concern with a rising incidence in the United States. Prior studies have looked at associations between insurance status and traumatic brain injury, but none have focused specifically on traumatic subdural hematomas (SDH). It is important to evaluate whether insurance and/or other social determinants of health play a role in treatment and outcomes of traumatic SDH. MethodsA retrospective analysis of the National Trauma Data Bank was conducted from 2012 to 2016 to look at associations between insurance status and management of SDH with surgery versus intracranial pressure (ICP)/EVD monitoring. Secondary outcomes of interest were emergency department (ED) length of stay (LOS), hospital LOS, ICU admission, ICU LOS, and mortality. ResultsWe identified 68,687 adult patients with a single diagnosis of subdural hematoma. Overall, self-pay patients with SDH were younger, predominately male, and more likely to be non-white compared to patients with public or private health insurance. More specifically, Black/African American SDH patients made up a large percentage of the self-pay category (15.5%; P < 0.001) compared to publicly and privately insured (7.5% and 8.0%, respectively). After adjusting for age, sex, injury severity score (ISS), Glasgow Coma Scale, alcohol intoxication, and trauma center level, publicly insured patients were 1.86 (95% CI 1.36-2.55, P < 0.001) times more likely to undergo a craniotomy or craniectomy compared to self-pay patients. However, insurance status did not appear to impact whether a patient received ICP/EVD monitoring (OR 0.52; 95% CI 0.24-1.18, P = 0.118). There was no statistically significant difference in ED LOS, Hospital LOS, and ICU LOS between insurance categories. ConclusionsPublicly insured patients have higher odds of undergoing surgical management for traumatic SDH compared to self-pay patients. Further studies evaluating this association are warranted.

Use of the Subdural Hematoma in the Elderly (SHE) Score to Predict 30-Day Mortality After Chronic Subdural Hematoma Evacuation

The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients >65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery. We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P < 0.05. Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score= 0, 4.3% of SHE score= 1, 14.5% of SHE score= 2, 39.3% of SHE score= 3, and 37.5% of SHE score= 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P < 0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P= 0.4). The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.

Imaging Features of Artificial Intelligence Algorithm in the Analysis of Cerebral Protective Effect of Craniotomy Hematoma Removal under Propofol Anesthesia in Patients with Chronic Subdural Hematoma

Objective. The aim of this work was to study the cerebral protective effect of craniotomy hematoma removal under propofol anesthesia based on the artificial intelligence algorithm analysis of the changes in imaging characteristics of chronic subdural hematoma (CSDH) patients. Methods. A total of 60 CSDH patients who were treated in hospital were recruited and were randomly rolled into an experimental group and a control group, with 30 people in each group. Patients in the experimental group were treated with propofol anesthesia + craniotomy hematoma removal, while those in the control group were treated with conventional anesthesia + craniotomy hematoma removal. Head CT examinations were performed on the next day, one week, one month, three months, and six months after the operation. A two-dimensional empirical mode decomposition (BEMD) algorithm was used for edge detection and denoising of brain CT images of CSDH patients. Then, the amount of hematoma was calculated, and the Markwalder grading was performed to evaluate the neurological function. The number of recurrence and reoperation cases within six months of follow-up was collected. Results. 1. The quality of CT images was remarkably improved after processing with artificial intelligence algorithms. 2. The amount of hematoma in the experimental group was remarkably lower than that in the control group at January, March, and June after surgery (12.89 ± 2.12 VS 20.32 ± 16.41; 7.55 ± 4.13 VS 15.88 ± 14.22; 3.39 ± 3.79 VS 6.55 ± 3.69, P &lt; 0.05 ). 3. The experimental group was remarkably better than the control group in Markwalder grading three months and six months after the operation ( P &lt; 0.05 ). Conclusion. Artificial intelligence algorithm had good effect on the brain CT image processing of CSDH patients, and craniotomy hematoma removal under propofol anesthesia had an ideal brain protection effect.

Diffusion-Weighted Imaging Reveals Distinct Patterns of Cytotoxic Edema in Patients with Subdural Hematomas.

Subdural hematomas (SDHs) are increasingly common and can cause ischemic brain injury. Previous work has suggested that this is driven largely by vascular compression from herniation, although this work was done before the era of magnetic resonance imaging (MRI). We thus sought to study SDH-related ischemic brain injury by looking at patterns of cytotoxic edema on diffusion-weighted MRI. To do so, we identified all SDH patients at a single institution from 2015 to 2019 who received an MRI within 2 weeks of presentation. We reviewed all MRIs for evidence of restricted diffusion consistent with cytotoxic edema. Cases were excluded if the restricted diffusion could have occurred as a result of alternative etiologies (e.g., cardioembolic stroke or diffuse axonal injury). We identified 450 SDH patients who received an MRI within 2 weeks of presentation. Twenty-nine patients (∼6.5% of all MRIs) had SDH-related cytotoxic edema, which occurred in two distinct patterns. In one pattern (N = 9), patients presented as comatose with severe midline shift and were found to have cytotoxic edema in the vascular territories of the anterior and posterior cerebral artery, consistent with herniation-related vascular compression. In the other pattern (N = 19), patients often presented as awake with less midline shift and developed cytotoxic edema in the cortex adjacent to the SDH outside of typical vascular territories (peri-SDH cytotoxic edema). Both patterns occurred in 1 patient. The peri-SDH cytotoxic edema pattern is a newly described type of secondary injury and may involve direct toxic effects of the SDH, spreading depolarizations, or other mechanisms.