Surgery For Acute Subdural Hematoma Research Articles

Aquaporin 2 in Cerebral Edema: Potential Prognostic Marker in Craniocerebral Injuries.

Despite continuous medical advancements, traumatic brain injury (TBI) remains a leading cause of death and disability worldwide. Consequently, there is a pursuit for biomarkers that allow non-invasive monitoring of patients after cranial trauma, potentially improving clinical management and reducing complications and mortality. Aquaporins (AQPs), which are crucial for transmembrane water transport, may be significant in this context. This study included 48 patients, with 27 having acute (aSDH) and 21 having chronic subdural hematoma (cSDH). Blood plasma samples were collected from the participants at three intervals: the first sample before surgery, the second at 15 h, and the third at 30 h post-surgery. Plasma concentrations of AQP1, AQP2, AQP4, and AQP9 were determined using the sandwich ELISA technique. CT scans were performed on all patients pre- and post-surgery. Correlations between variables were examined using Spearman's nonparametric rank correlation coefficient. A strong correlation was found between aquaporin 2 levels and the volume of chronic subdural hematoma and midline shift. However, no significant link was found between aquaporin levels (AQP1, AQP2, AQP4, and AQP9) before and after surgery for acute subdural hematoma, nor for AQP1, AQP4, and AQP9 after surgery for chronic subdural hematoma. In the chronic SDH group, AQP2 plasma concentration negatively correlated with the midline shift measured before surgery (Spearman's ρ -0.54; p = 0.017) and positively with hematoma volume change between baseline and 30 h post-surgery (Spearman's ρ 0.627; p = 0.007). No statistically significant correlation was found between aquaporin plasma levels and hematoma volume for AQP1, AQP2, AQP4, and AQP9 in patients with acute SDH. There is a correlation between chronic subdural hematoma volume, measured radiologically, and serum AQP2 concentration, highlighting aquaporins' potential as clinical biomarkers.

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.

Commentary: Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma.

Commentary: Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma.

Loss to Follow-up and Unplanned Readmission After Emergent Surgery for Acute Subdural Hematoma

Loss to follow-up (LTF) and unplanned readmission are barriers to recovery after acute subdural hematoma evacuation. The variables associated with these postdischarge events are not fully understood. To determine factors associated with LTF and unplanned readmission, emphasizing socioeconomic status (SES). A retrospective analysis was conducted of surgical patients with acute subdural hematoma managed operatively from 2009 to 2019 at a level 1 regional trauma center. Area Deprivation Index (ADI), which is a neighborhood-level composite socioeconomic score, was used to measure SES. Higher ADI corresponds to lower SES. To decrease the number of covariates in the model, principal components (PCs) analysis was used. Multivariable logistic regression analyses of PCs were performed for LTF and unplanned readmission. A total of 172 patients were included in this study. Thirty-six patients (21%) were LTF, and 49 (28%) patients were readmitted; 11 (6%) patients were both LTF and readmitted ( P = .9). The median time to readmission was 10 days (Q1: 4.5, Q3: 35). In multivariable logistic regression analyses for LTF, increased ADI and distance to hospital through PC2 (odds ratio [OR] 1.49; P = .009) and uninsured/Medicaid status and increased length of stay through PC4 (OR 1.73; P = .015) significantly contributed to the risk of LTF. Unfavorable discharge functional status and nonhome disposition through PC3 were associated with decreased odds of unplanned readmission (OR = 0.69; P = .028). Patients at high risk for LTF and unplanned readmissions, as identified in this study, may benefit from targeted resources individualized to their needs to address barrier to follow-up and to ensure continuity of care.

177 Impact of Socioeconomics on Loss to Follow-up Following Emergent Surgery for Acute Subdural Hematoma

INTRODUCTION: Loss to follow-up (LTF) represents an obstacle in the post-surgical management of patients following acute subdural hematoma (aSDH) evacuation. Identifying the factors associated with LTF is required to improve patient care. We sought to examine potential factors with an emphasis on socioeconomic status (SES). METHODS: A retrospective analysis of patients treated surgically for aSDH from 2009-2019 at a level 1 regional trauma center was conducted. The primary outcome was LTF, defined as being scheduled but not receiving any follow-up care post-discharge. The main exposure was Area Deprivation Index (ADI), a neighborhood level composite of education, employment, housing quality, and poverty; this was used to measure SES with higher ADI corresponding to lower SES. Additional candidate factors were identified in the literature and through univariate comparisons of group characteristics. To reduce the number of variables, principal components analysis (PCA) was used; the first six principal components (PCs) contained 82% of the total variance. Multivariable logistic regression was performed to identify the PCs associated with LTF. RESULTS: Of the 172 patients included in the study, 36 patients were LTF (21%). The predominant PCs were as follows: increasing age, craniotomy instead of craniectomy, and decreased LOS in PC1; ADI and distance to hospital in PC2; unfavorable discharge mRS and non-home disposition in PC3; uninsured/Medicaid status and increased LOS in PC4; number of comorbidities in PC5; and transfer from OSH and use of craniectomy instead of craniotomy for PC6. In multivariable analysis for LTF, greater ADI and distance to hospital via PC2 (P = 0.009) and uninsured/Medicaid status and increased LOS via PC4 (P = 0.009) were associated with increased odds of LTF. CONCLUSION: Socioeconomic factors including increased neighborhood disadvantage, increased distance to hospital and uninsured/Medicaid status impact LTF following emergent surgery for aSDH. These patients with limited resources are at increased risk of losing continuity of care. The health care system must direct efforts to reduce healthcare disparity in these high-risk population.

Endoscopic hematoma evacuation through dilated burr hole for acute subdural hematoma in elderly patients_ Feasibility of endoscopic procedure and its technical tips as less invasive surgery

ObjectWe describe results of endoscopic surgery for acute subdural hematoma in elderly patients, and simple technique of the endoscopic procedure for acute subdural hematoma (ASDH) through an extended burr hole in elderly patients and discuss its technical aspects. MethodsWe performed endoscopic evacuation of acute subdural hematoma in selected fifteen elderly patients. The following data were collected and evaluated: age, sex, laterality, administration of anti-thrombotic agents, injury severity score (ISS), pre and post-operative GCS, modified Rankin scale (mRS) before and post-treatment of ASDH, type of anesthesia, operation time, origin of bleeding. ResultsPostoperatively, satisfactory hematoma evacuation was accomplished. No hemorrhagic adverse effects related with endoscopic procedure were observed. Postoperative GCS was improved in all patients,and three patients were discharged with mRS 0–2 consistent withindependent gait. ConclusionEndoscopic evacuation of acute subdural hematoma for elderly patient is aless invasive treatment and might be technically feasible in selected cases.

Endoscopic surgery for acute subdural hematoma in elderly patients

Endoscopic surgery for acute subdural hematoma in elderly patients

764: Surgery for Acute Subdural Hematoma: When Is It Necessary?

Critical Care Medicine: January 2021 - Volume 49 - Issue 1 - p 378 doi: 10.1097/01.ccm.0000728944.76022.1c

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

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. 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. 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). 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.

Reoperations after surgery for acute subdural hematoma: reasons, risk factors, and effects.

To analyze the reasons and patient-related and injury-related risk factors for reoperation after surgery for acute subdural hematoma (SDH) and the effects of reoperation on treatment outcome. Among adult patients operated on for acute SDH between 2013 and 2017, patients reoperated within 14 days after the primary surgery were identified. In all patients, parameters were identified that related to the patient (age, anticoagulation, antiplatelet, and antiepileptic treatment, and alcohol intoxication), trauma (Glasgow Coma Score, SDH thickness, midline shift, midline shift /hematoma thickness rate, other surgical lesion, primary surgery-trephination, craniotomy, or decompressive craniotomy), and Glasgow Outcome Score (GOS). The reasons for reoperation and intervals between primary surgery and reoperation were studied. Of 86 investigated patients, 24 patients were reoperated (27.9%), with a median interval of 2 days between primary surgery and reoperation. No significant differences in patients and injury-related factors were found between reoperated and non-reoperated patients. The rate of primary craniectomies was higher in non-reoperated patients (P = 0.066). The main indications for reoperation were recurrent /significant residual SDH (10 patients), contralateral SDH (5 patients), and expansive intracerebral hematoma or contusion (5 patients). The final median GOS was 3 in non-reoperated and 1.5 in reoperated patients, with good outcomes in 41.2% of non-reoperated and 16.7% of reoperated patients. Reoperation after acute SDH surgery is associated with a significantly worse prognosis. Recurrent /significant residual SDH and contralateral SDH are the most frequently found reasons for reoperation. None of the analyzed parameters were significant reoperation predictors.

The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome.

Objective:Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH.Materials and Methods:The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups.Results:The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome.Conclusions:The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.

Endoscopic hematoma evacuation following emergent burr hole surgery for acute subdural hematoma in critical conditions: Technical note

Abstract Background Acute subdural hematoma (ASDH) is generally managed by large craniotomy with extended operating time and high relative blood loss. Recently, minimally invasive endoscopic hematoma evacuation of ASDH has been successfully demonstrated; however, non-elderly patients, moderate or massive cerebral contusion, and enlarging hematoma are generally not accepted as indications for endoscopic surgery. Clinical presentation We report our experience with two ASDH patients with impending herniation successfully evacuated via an endoscopic surgery following emergent burr hole craniostomy. Case 1: A 70-year-old man was admitted to our hospital because of severe head trauma. Neurological examination demonstrated a fixed, dilated right pupil and a CT scan showed ASDH. The entire procedure was completed in approximately 2.5 h. He was transferred to a rehabilitation hospital. Case 2: A 51-year-old comatose woman was transferred to our hospital after a motor vehicle accident. Radiological examination revealed ASDH and severe multiple trauma. Acute traumatic coagulopathy was confirmed by laboratory tests. The entire procedure was completed in approximately 1.5 h. Almost complete evacuation of the hematoma was achieved. Conclusion If intracranial pressure becomes sufficiently low after emergent burr hole craniostomy, endoscopic hematoma evacuation of ASDH may be a safe and effective method even in critically injured patients.

192 Craniotomy for Acute Subdural Hematoma-Outcomes in Patients Over 70 years

Abstract INTRODUCTION The mortality rate for elderly patients with surgery for acute subdural hematoma (aSDH) has been reported to be as high as 90%, but with the possibility of functional survivors, surgery is still frequently performed. Therefore, we examined our outcomes for patients 70 years and older who underwent craniotomy for aSDH. METHODS We retrospectively reviewed patients 70 years and older who had an open surgical intervention for aSDH between 2006 and 2016 at Memorial Hermann Hospital in Houston, Texas. A multivariable analysis of the clinical data and outcomes was then performed. RESULTS >Of the 112 patients reviewed, 95% sustained their injuries after a fall from standing. The mortality rate was 42%, but 24% of patients were discharged to home or to a rehabilitation facility. Multivariable analysis demonstrated that age, preexisting dementia, and surgery type had significant impact on outcome. Specifically, patient who were older than 80 years of age, had dementia or Parkinson's disease, or who required decompressive craniectomy (as opposed to craniotomy) had a worse outcome. CONCLUSION Elderly patients with aSDH requiring surgery have a high likelihood of death or significant disability. It is important to note that the mortality rate for large aSDHs is higher given that some patients with this disease were not deemed to be surgical candidates and therefore were not included in this study. However, up to one quarter of surgical patients will be functional enough to go home or to a rehabilitation facility from the hospital. The data suggest that age over 80 years old, dementia, or cerebral edema significant enough to warrant decompressive craniectomy are associated with an increased risk of death.

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

Objective:We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period.Summary of Background Data:ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time.Methods:Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data.Results:The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors.Conclusions:A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.

Surgery for Acute Subdural Hematoma: Replace or Remove the Bone Flap?

In surgery for acute subdural hematoma (ASDH), the bone flap can be fixed onto the skull, left riding to provide partial skull decompression, or removed. This study assessed whether removing the bone flap improved outcome. We conducted an observational study on consecutive patients who were operated for ASDH in our hospital from July 2011 to June 2014. We retrospectively collected data on demographics, injury severity, and predicted and observed outcomes at 6 months. The cohort was divided into 2 groups based on whether the bone flap was replaced (fixed and riding flap craniotomy) or removed (decompressive craniectomy). The differences in functional status, postoperative control of intracranial hypertension, and number of cranial reoperations were analyzed. A subgroup analysis compared decompressive craniectomy with riding flap craniotomy alone. Data were obtained for 99 patients; 69 had decompressive craniectomy, 17 had riding flap craniotomy, and 13 had fixed flap craniotomy. The decompressive craniectomy group had statistically worse injuries, more predicted poor outcomes (69% vs. 57%, P= 0.013), more observed poor outcomes (59% vs. 37%, P= 0.037), equivalent control of intracranial hypertension, and a similar number of reoperations compared with the craniotomy groups. Subgroup analysis between decompressive craniectomy and riding flap craniotomy showed no significant difference in baseline characteristics and outcomes. Our study concluded that removing the bone flap after ASDH evacuation was not associated with a better outcome. We recommend replacing the bone flap if brain conditions allow. Further research is required to evaluate the role of skull decompression in surgery for ASDH.

Delayed post-operative contralateral epidural hematoma in a patient with right-sided acute subdural hematoma: a case report

Head injury is one of the leading causes of death and disability in traumatic accidents. Post-operative contralateral epidural hematomas after surgery for acute subdural hematoma seem to be rare. In this case, expansion and spontaneous resolution of a fractural epidural hematoma contralateral to the side of acute subdural hematoma is presented. The importance of immediate post-operative computed tomography is also highlighted to detect delayed traumatic mass lesions.

Contralateral Acute Epidural Hematoma After Decompressive Surgery of Acute Subdural Hematoma: Clinical Features and Outcome

Delayed contralateral epidural hematoma (EDH) after decompressive surgery for acute subdural hematoma (SDH) is uncommon. If unrecognized, this delayed hematoma can cause devastating consequences. We present our experience with this group of patients and discuss the diagnosis and management of this dangerous condition. This study included 12 traumatic patients with acute SDH who developed delayed contralateral EDH after acute SDH evacuation. Clinical and radiographic information was obtained through a retrospective review of the medical records and the radiographs. There were seven males and five females. Nine patients had severe head injury (Glasgow Coma Scale {GCS} score < or = 8). Ten patients underwent acute SDH evacuation within 4 hours after the trauma. Intraoperative brain swelling during SDH evacuation was noted in 10 patients. A skull fracture at the site of the EDH on computed tomography (CT) was noted only in 10 patients. However, a skull fracture overlying the EDH was found during EDH evacuation in all patients. Only three patients with less severe head injury (GCS > 8) had good recovery. Other patients with severe head injury (GCS < or = 8) had poor outcome. Severe head injury, a skull fracture contralateral to the original hematoma, intraoperative brain protrusion, and a poor outcome are typical clinical findings in this disorder. In patients with acute SDH and a contralateral skull fracture, immediate postoperative CT scan is indicated to evaluate this rare but potentially lethal complication. According to the findings of the postoperative CT scan, the neurosurgeon can make an appropriate strategy of treatment promptly. Early detection and prompt treatment may improve the poor outcome in this group of patients.