Traumatic Acute Subdural Hematoma Research Articles

Morbidity and mortality in elderly patients undergoing evacuation of acute traumatic subdural hematoma.

Acute traumatic subdural hematoma (atSDH) can be a life-threatening neurosurgical emergency that necessitates immediate evacuation. The elderly population can be particularly vulnerable to tearing bridging veins. The aim of this study was to evaluate inpatient morbidity and mortality, as well as predictors of inpatient mortality, in a national trauma database. The authors queried the 2016-2017 National Trauma Data Bank registry for patients aged 65 years and older who had undergone evacuation of atSDH. Patients were categorized into three age groups: 65-74, 75-84, and 85+ years. A multivariable logistic regression model was fitted for inpatient mortality adjusting for age group, sex, race, presenting Glasgow Coma Scale (GCS) category (3-8, 9-12, and 13-15), Injury Severity Score, presence of coagulopathy, presence of additional hemorrhages (epidural hematoma [EDH], intraparenchymal hematoma [IPH], and subarachnoid hemorrhage [SAH]), presence of midline shift > 5 mm, and pupillary reactivity (both, one, or none). A total of 2508 patients (35% females) were analyzed. Age distribution was as follows: 990 patients at 65-74 years, 1096 at 75-84, and 422 at 85+. Midline shift > 5 mm was present in 72% of cases. With regard to additional hemorrhages, SAH was present in 21%, IPH in 10%, and EDH in 2%. Bilaterally reactive pupils were noted in 90% of patients. A major complication was observed in 14.4% of patients, and the overall mortality rate was 18.3%. In the multivariable analysis, the presenting GCS category was found to be the strongest predictor of postoperative inpatient mortality (3-8 vs 13-15: OR 3.63, 95% CI 2.68-4.92, p < 0.001; 9-12 vs 13-15: OR 2.64, 95% CI 1.79-3.90, p < 0.001; 30% of overall variation), followed by the presence of SAH (OR 2.86, 95% CI 2.21-3.70, p < 0.001; 25% of overall variation) and the presence of midline shift > 5 mm (OR 2.40, 95% CI 1.74-3.32, p < 0.001; 11% of overall variation). Model discrimination was excellent (c-index 0.81). Broken down by age decile group, mortality increased from 8.0% to 15.4% for GCS 13-15 to around 36% for GCS 9-12 to almost as high as 60% for GCS 3-8, particularly in those aged 85 years and older. The present results from a national trauma database will, the authors hope, assist surgeons in preoperative discussions with patients and their families with regard to expected postoperative outcomes following surgical evacuation of an atSDH.

Correlation of Initial Computed Tomography Findings with Outcomes of Patients with Acute Subdural Hematoma: A Prospective Study

Abstract Introduction In modern emergency service systems, patients are often treated with sedation, intubation, and ventilation at the accident site. But neurosurgical assessment before all these emergency services is important. Thus, this study was designed to investigate the relationships between various parameters of initial CT scan findings and the outcomes of the patients. Methodology A total of 56 adult patients of traumatic acute subdural hematoma (SDH) whose computed tomography (CT) scan was performed within 8 hours of injury were recruited. The patients with prolonged hypotension, open head injury or depressed skull fracture, bilateral side acute SDH, or contusions/hematoma/extradural hematoma on the contralateral side were excluded. Six separate CT findings were analyzed and recorded, including hematoma, midline shift, subarachnoid hemorrhage (SAH), presence of basal cistern obliteration (BCO), intraparenchymal hematoma/contusion in the same hemisphere, and presence of effacement of the sulcal spaces, and were followed up for three months for outcome analysis. Results The overall mortality and functional recovery rate were 27 and 50%, respectively. The patients with obliterated basal cisterns and the presence of underlying SAH in patients with acute SDH had statistically significant poorer outcomes as compared with others. However, the extent of midline shift, SDH thickness, and the presence of underlying contusions and sulcal effacement on initial CT scan showed no statistically significant correlation with patients’ outcomes. Conclusions BCO and presence of subarchnoid hemorrhage underlying acute SDH on the earliest scan in head injury patients signify the severity of brain parenchymal injury. Along with the initial Glasgow Coma Scale score after resuscitation, these two factors should be considered as the most significant ones for predicting the outcomes in traumatic acute SDH patients.

Comparison of Clinical Outcome between Craniectomy and Craniotomy as Surgical Management of Traumatic Acute Subdural Hematoma: A Systematic Review and Meta-analysis

BACKGROUND: Acute subdural hematoma (ASDH) is a major problem in traumatic brain injury. Surgical techniques for treating ASDH are varied, including cranioplastic craniotomy and large decompressive craniectomy. The superiority of craniectomy and craniotomy for treating ASDH is still controversial.&#x0D; AIM: The aim of this study was to compare the clinical outcome between craniectomy and craniotomy for treating traumatic ASDH through systematic review and meta-analysis.&#x0D; METHODS: This study used electronic articles published in PubMed, EBSCO, Google Scholar, and Directory of Open Access Journal. Articles included were full-text observational studies in Indonesian or English. Clinical outcome using the Glasgow Outcome Scale was compared between craniectomy and craniotomy. Statistical analysis was done using Review Manager 5.3.&#x0D; RESULTS: Six articles met our inclusion and exclusion criteria. We performed random effect model analysis because of high heterogeneity between studies (I2 = 77%; X2 = 21.98). The pooled risk ratio between craniectomy and craniotomy on poor outcomes was 1.41 (p = 0.02; 95% CI: 1.06–1.88).&#x0D; CONCLUSION: Craniectomy increases the risk of poor clinical outcomes in treating a traumatic ASDH.

Value of Adding Cisternostomy to Decompressive Hemicraniectomy in the Management of Traumatic Acute Subdural Hematoma Patients

BACKGROUND: Surgical evacuation of acute subdural hematoma has remained the mainstay of the treatment for acute subdural hematoma (ASDH) in patients with progressive neurological deficits, increasing intracranial pressure (ICP), or significant mass effect. Cisternostomy entails opening the basal cisterns aiming to their opening to atmospheric pressure and therefore reducing the intraparenchymal pressure.&#x0D; AIM: We aimed to evaluate value of adding cisternostomy to decompressive craniotomy on outcome of traumatic ASDH patients.&#x0D; METHODS: Prospective study included 40 patients who presented to Cairo University hospital emergency department with traumatic acute subdural hematoma in the period between January 2018 and June 2019 and matching our inclusion criteria: Age from 12 to 65 years, traumatic acute subdural hematoma with thickness ≥ 10 mm or midline shift ≥ 5 mm, and Glasgow Coma Scale (GCS) on admission &lt; 10, with no associated intraparenchymal hematoma ≥ 1 cm or severe comorbidities. Patients were randomized into one of two groups according to their order of coming. The first group patients were operated on by decompressive craniotomy (DHC) plus cisternostomy and the second group was operated on by decompressive craniotomy only. Glasgow Outcome Score (GOS) was used for outcome assessment.&#x0D; RESULTS: Outcome was better 2nd but not statistically significant – in the first group (DHC+ cisternostomy) in terms of mortality: 7/20 patients (35%) (p = 0.337) and median GOS: 3 (p = 0.337), compared to the second group (DHC only) in which mortality occurred in 10/20 (50%) and median GOS was 1. Adding cisternostomy to decompressive craniotomy increased surgery time with 35.5 minutes in average. In our study, older age and lower GCS on admission had significantly worse outcome.&#x0D; CONCLUSION: Adding cisternostomy to decompressive craniotomy in traumatic patients had better 2nd but not statistically significant outcome. Whether it should replace the routine decompressive craniotomy in these cases or not needs further larger clinical trials.

Optimal surgical indications of endoscopic surgery for traumatic acute subdural hematoma in elderly patients based on a single-institution experience.

Recently, treatment of acute subdural hematoma (ASDH) by minimally invasive surgery with endoscopy has been successfully demonstrated. However, few case series are available on this procedure for ASDH, and the surgical indication has not been established. We retrospectively analyzed the data of patients (n = 26) aged 65years or older who underwent endoscopic surgery (ES) for ASDH at our institution between January 2011 and March 2019. We then evaluated the surgical outcomes and procedure-related complications in patients who underwent ES. The mean hematoma reduction rate was over 90%. Percentage of favorable outcomes at discharge was 69.2% in ES-treated patients. The presence of a skull fracture, subarachnoid hemorrhage, midline shift/subdural hematoma thickness ratio > 1.0, and early surgery were associated with postoperative IPHs in patients who underwent ES or conventional surgery for ASDH. The present study revealed that ES for elderly patients with ASDH is likely to be an efficient and safe procedure when patients are selected appropriately. However, ES is not recommended in patients with significant IPHs on initial CT scan. Additionally, ES should be carefully considered in cases with the factors, where IPHs may progress following surgery.

The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma.

This study aimed to evaluate the utility of the 11-variable modified Frailty Index (mFI) in prognosticating elderly patients with traumatic acute subdural hematomas (aSDHs). A state-service level 1 trauma center registry was interrogated to investigate consecutive patients ≥65 years of age presenting with traumatic aSDH, with or without major extracranial injury, between January 2013 and December 2017. mFI on admission, demographics, and admission details, including Glasgow Coma Scale (GCS) and pupillary status and radiological findings, were retrospectively retrieved from institutional records. Clinical outcome data were retrieved from medical records and the Victorian State Trauma Registry (VSTR). Outcome measures were 1) 30-day mortality and 2) 6-month unfavorable outcome, defined by the Extended Glasgow Outcome Scale (GOS-E). Five hundred twenty-nine consecutive cases were identified from the registry. Demographic data included: 1) age (median; interquartile range) = 80.46; 74.17-85.89; 2) mFI (mean ± standard deviation) = 1.96 ± 1.42 of 11 variables. Four hundred sixteen cases (79%) had complete outcome data. As mFI increased from 0/11 variables to ≥5/11 variables (≥0.45), 30-day mortality risk increased from 17.72% to 39.29% (p = 0.023) and 6-month unfavorable outcome risk increased from 40.51% to 96.43% (p < 0.001). Multi-variate analysis showed that greater mFI score of ≥3/11 variables (≥0.27) suggested a significantly higher risk of 30-day mortality (p = 0.009) and unfavorable outcome (p < 0.001). We conclude that increasing frailty, as measured by the mFI, was associated with significantly higher risk of 30-day mortality and 6-month unfavorable outcome in elderly patients presenting with aSDH to a level 1 neurotrauma center. Assessment of mFI in elderly patients with aSDH may be a useful determinant of outcome for this rapidly growing population.

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

PurposeThe 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.MethodsPatients 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.Results27 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%).ConclusionOutcome 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.

The impact of time from injury to surgery in functional recovery of traumatic acute subdural hematoma

BackgroundThe time from injury to surgery (TIS) is critical in the functional recovery of individuals with traumatic acute subdural hematoma (TASDH). However, only few studies have confirmed such notion.MethodsThe data of TASDH patients who were surgically treated in Chia-Yi Christian Hospital between January 2008 and December 2015 were collected. The significance of variables, including age, sex, traumatic mechanism, coma scale, midline shift on brain computed tomography (CT) scan, and TIS, in functional recovery was assessed using the student’s t-test, Mann-Whitney U test, chi-square test, univariate and multivariate models, and receiver operating characteristic (ROC) curve.ResultsA total of 37 patients achieved functional recovery (outcome scale score of 4 or 5) and 33 patients had poor recovery (outcome scale score of 1–3) after at least 1 year of follow-up. No significant difference was observed in terms of age, sex, coma scale score, traumatic mechanism, or midline shift on brain CT scan between the functional and poor recovery groups. TIS was found to be significantly shorter in the functional recovery group than in the poor recovery group (145.5 ± 27.0 vs. 181.9 ± 54.5 min, P-value = 0.002). TIS was a significant factor for functional outcomes in the univariate and multivariate regression models. The analysis of TIS with the ROC curve between these two groups showed that the threshold time for functional recovery in comatose patients and those with TASDH who were surgically treated was 2 h and 57.5 min.ConclusionsTIS is an important factor l for the functional recovery of comatose TASDH patients who underwent surgery.

Does the skull Hounsfield unit predict shunt dependent hydrocephalus after decompressive craniectomy for traumatic acute subdural hematoma?

Posttraumatic hydrocephalus affects 11.9%-36% of patients undergoing decompressive craniectomy (DC) after traumatic brain injury and necessitates a ventriculo-peritoneal shunt placement. As bone and arachnoid trabeculae share the same collagen type, we investigated possible connections between the skull Hounsfield unit (HU) values and shunt-dependent hydrocephalus (SDHC) in patients that received cranioplasty after DC for traumatic acute subdural hematoma (SDH). We measured HU values in the frontal bone and internal occipital protuberance from admission brain CT. Receiver operating characteristic curve analysis was performed to identify the optimal cut-off skull HU values for predicting SDHC in patients receiving cranioplasty after DC due to traumatic acute SDH. We investigated independent predictive factors for SDHC occurrence using multivariable logistic regression analysis. A total of 162 patients (>15 years of age) were enrolled in the study over an 11-year period from two university hospitals. Multivariable logistic analysis revealed that the group with simultaneous frontal skull HU ≤797.4 and internal occipital protuberance HU ≤586.5 (odds ratio, 8.57; 95% CI, 3.05 to 24.10; P<0.001) was the only independent predictive factor for SDHC in patients who received cranioplasty after DC for traumatic acute SDH. Our study reveals a potential relationship between possible low bone mineral density and development of SDHC in traumatic acute SDH patients who had undergone DC. Our findings provide deeper insight into the association between low bone mineral density and hydrocephalus after DC for traumatic acute SDH.

Clinical Characterization of Traumatic Acute Interhemispheric Subdural Hematoma

Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH. This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected. Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient. IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.

Role of surgical modality and timing of surgery as clinical outcome predictors following acute subdural hematoma evacuation.

Background & Objective:A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma.Methods:A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed.Results:Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87).Conclusion:In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.

The initial factors affecting in-hospital mortality rate of patients undergoing surgery for post-traumatic extra-axial hematomas.

Traumatic brain injury (TBI) is one of the most important causes of disability and death among young adults and referred to as "silent" epidemic. The most frequent consequences of a TBI are extra-axial hematomas, comprising of acute subdural (SDH) and epidural hematoma (EDH). Most of the factors affecting the mortality have been analyzed in a wide group of TBI. The aim of this study is to identify factors affecting in-hospital mortality in patients undergoing surgery for acute traumatic subdural and epidural hematoma. The study included 128 patients operated on due to extra-axial hematomas. Twenty-eight patients were operated on for EDH and 100 on for SDH. Patients were treated at the Department of Neurosurgery Medical University in Lublin, during almost three years. The following factors were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics and time between the trauma and the surgery. All the factors were correlated with in-hospital mortality rate. The univariate analysis has confirmed the influence of many factors affecting the in-hospital mortality. It is interesting that factors such as GSC score, systolic blood pressure, respiratory rate and glycemia were associated with in-hospital mortality rate with highly statistically significant differences (Tab. 3, Fig. 2, Ref. 40).

Neurocritical Management of Traumatic Acute Subdural Hematomas.

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Expansion of traumatic acute subdural hematoma with Spot Sign positive during oral antithrombotic therapy

Expansion of traumatic acute subdural hematoma with Spot Sign positive during oral antithrombotic therapy

Rapid spontaneous resolution of traumatic acute subdural hematoma

Introduction: Acute subdural hematoma (ASDH) is the most common type of traumatic intra -cranial hematoma accounting for 24% cases of severe head injuries and caries highest mortality. The mortality rates are seen to be ranging from 40% to 90%, diagnosed on computed tomography (CT) as extra axial, hyperdense, crescent lesion between the Dura and brain parenchyma1. Acute SDH is an acute space occupying lesion to increase intracranial pressure (ICP), and is often complicated by co-existing intracranial lesions, including a variety of diffuse injuries, contusional hematomas, and edema. Acute subdural post-traumatic hematoma’s (SDH) continue to have a distressingly high morbidity and mortality.2 Clinical factors like presenting GCS, Pupils, time to operative interval, Hemodynamics and co-morbidities, plays a critical role in overall outcome from acute subdural hematoma.3Careful monitoring of the neurological status is mandatory even for selected acute SDH patients with intact consciousness and no brain shift because of the possibility of the unexpected worsening. Spontaneous resolution of an acute SDH has been reported in rare cases. We report a case series of spontaneous rapid reduction of acute SDH, also we discuss the prognosis of each patient according to a Clinicoradiological Prognostic Score developed by Gautam and Sharma3 as well as mechanisms related to the rapid resolution of acute SDH.

Analysis on clinical characteristics of rapid and non-rapid resolution of traumatic acute subdural hematoma

Objective To compare the clinical and imaging characteristics of traumatic acute subdural hematoma acute subdural hematoma with rapid resolution and those without rapid resolution. Methods A retrospective case-control analysis was conducted on the clinical data of 60 traumatic acute subdural hematoma patients with hematoma thickness≥5 mm admitted to Second Affiliated Hospital of Shantou University Medical College from January 2011 to May 2018. There were 37 males and 23 females, aged 18-80 years [(47.0±16.9)years]. There were 27 patients in the rapid resolution group and 33 patients in the non-rapid resolution group. Coagulation function [prothrombin time (PT) and international normalized ratio (INR)] on admission, hospital stay, Glasgow outcome scale (GOS), and brain CT results were compared between the two groups. Results The PT and INR values in the rapid resolution group were (11.9±2.1)s and 1.1±0.2 respectively, while those in the non-rapid resolution group were (10.8±1.0)s and 1.0±0.1 respectively, with significant differences (P 0.05). The thickness of subdural hematoma of the two groups in the first CT scanning was (8.2±2.3)mm and (7.3±1.8)mm, respectively, with no statistically significant difference (P>0.05). In the second CT scanning, the hematoma thickness in the rapid resolution group was significantly lower than that in the non-rapid resolution group [(2.7±1.9)mm vs. (6.6±2.1)mm] (P<0.01). The incidence of low density zone between the hematoma and intracranial plate was statistically higher in rapid resolution group than that in non-rapid resolution group (93% vs. 36%) (P<0.01). The incidence of subarachnoid hemorrhage(SAH) increase was significantly higher in rapid resolution group than that in non-rapid resolution group in the second CT scan (74% vs. 15%) (P<0.01). The conversion rate of acute subdural hematoma to subacute or chronic subdural hematoma was 4% in the rapid resolution group, which was significantly lower than 18% in the non rapid resolution group (P<0.05). Conclusions The abnormal coagulation function and low density zone indicated by CT are two important indicators of rapid resolution in patients with traumatic acute subdural hematoma. The risk of conversion from acute into subacute or chronic subdural hematoma is lower in rapid resolution of traumatic acute subdural hematoma, suggesting that rapid resolution may be one of the prognostic indicators of ASDH patients. Key words: Hematoma, subdural, acute; Tomography, spiral computed; Rapid spontaneous resolution

Comparative effectiveness of surgery in traumatic acute subdural and intracerebral haematoma: study protocol for a prospective observational study within CENTER-TBI and Net-QuRe

IntroductionControversy exists about the optimal treatment for patients with a traumatic acute subdural haematoma (ASDH) and an intracerebral haematoma/contusion (t-ICH). Treatment varies largely between different regions. The effect of this...

Comparison of Outcome of Decompressive Craniectomy with Wide Dural Flap Duraplasty Versus Dural Slits in the Management of Post Traumatic Acute Subdural Hematoma in Terms of Postoperative CSF Leak

Objective: To compare the frequency of postoperative cerebrospinal fluid (CSF) leak after decompressive craniectomy with wide dural flap duraplasty versus dural slits in patients with post traumatic acute subdural hematoma.Material and Methods: The study was conducted from August 2017 to February 2018 in the Department of Neurosurgery, PIMS, Islamabad. A total of ninety-two (n = 92) adult patients of either gender between age 15-55 years presented with isolated, unilateral traumatic acute sub dural hematoma (ASDH) with midline shift of 5mm were categorized into 2 groups; Group A (DC with open dural flap) and Group B (DC with dural slits). Patients were observed for CSF leakage for four weeks.Results: Results showed that the overall frequency of CSF leak was not significantly different in both groups and revealed that the CSF leak was observed in 10.9% (n = 5/46) in group A (DC plus open dural flap) and in 21.7% (n = 10/46) in group B (DC plus dural slits) (P = 0.158). The difference was not significant in terms of frequency of CSF leak in both groups when results were stratified with respect to gender, age, duration of trauma and baseline GCS. P value (chi-square) was found to be &gt; 0.05 in all cases.Conclusions: The postoperative CSF leak was observed in higher percentages in patients who underwent DC with dural slits as compared to the patients who underwent DC with open dural flaps for surgical management of ASDH. The difference, however, was not statistically significant.

Travmatik akut subdural hematomun hızlı rezolüsyonu: olgu sunumu

Akut travmatik subdural hematom nöroşirurji pratiğinde travma sonrası hastalarda görülen önemli bir morbitide ve mortalite sebebidir. Nörolojik kusur varlığında, acil cerrahi tedavi düşünülmelidir. Diğer yandan nörolojik tablonun daha iyi olduğu, dikkatli seçilmiş bazı hastalarda ise cerrahi girişim her zaman gerekmeyebilir. Yakın takip ile akut travmatik subdural hematomlarda spontan hızlı rezolüsyonun olabileceği bildirilmiştir. Boks müsabakasında yüzüne aldığı darbe sonrası akut travmatik subdural hematom tanısı konan hastanın 20. saat kontrol tomografisinde subdural hematomun tamamen gerilediği görüldü. Akut travmatik subdural hematomun hızlı rezolüsyonu için literatürde çeşitli mekanizmalar ve prediktif bulgular öne sürülmüştür fakat patofizyolojiyi açıklamada ileri çalışmalara ihtiyaç duyulmaktadır.

Prognostic Value of Admission Parameters in a Machine Learning Predictive Model in Patients With Severe Traumatic Brain Injury and Acute Subdural Hematomas

Abstract INTRODUCTION Acute subdural hematoma (aSDH) in the context of severe traumatic brain injury (TBI) is a neurosurgical emergency. Predictive models have been used in an attempt to modulate the morbidity and mortality of patient outcomes. We used machine learning (ML) to identify admission risk factors predictive of long-term morbidity in the severe TBI patient population with aSDH. METHODS Between 2013 and 2016, 85 patients with severe TBI and aSDH were included in the analysis. Random forest, ML architecture, was used to create a predictive model of long-term morbidity stratification. About 46 patients were included in the high morbidity group [Glasgow Outcome Scale (GOS) 1-2] and 39 patients were in the low morbidity group (GOS 3-5). We included 30 admission input variables including medical and surgical co-morbidities, neurological examination, laboratory values, and radiographic findings. RESULTS The predictive model showed a 78% precision. The highest scoring input variable was the pupillary examination in predicting high vs low morbidity (bilaterally unreactive vs symmetrically reactive; P &lt; .0001). GCS on admission was higher in the low morbidity group (4 [3-7] vs 7 [3-7]; P &lt; .0101). Rotterdam scores were higher in the high-morbidity group (3 [3-5] vs 4 [4-5]; P &lt; .0032). GCS motor examination on admission was higher in the low-morbidity group (5 [1-5] vs. 2 [1-5]; P &lt; .0106). The basal cisterns were found to be more patent in patients with the low-morbidity group (P = .0012). CONCLUSION ML is an efficient tool that can provide a reasonable level of accuracy in predicting long-term morbidity in patients with severe TBI and aSDH. Monitoring these admission criteria can help with risk-stratification of patients into higher and low risk tracks. Integration of ML into the treatment algorithm may allow the development of more refined guidelines to guide goal-directed therapy.