Objective Assessing the risk of postoperative recurrence of chronic subdural hematoma (CSDH) is a clinical focus. To screen the main factors associated with the perioperative hematoma recurrence. We also propose a new prognostic grading system and compare it with previous grading systems to deliver a quick and effective system.Methods We included 242 unilateral patients with CSDH as the training group for modeling. Factors predicting postoperative recurrence requiring reoperation (RrR) were determined using univariate and multivariate regression analyses. The cut-off value for the brain re-expansion rate was determined through receiver operating characteristic curve analysis. Based on these, we developed a new prognostic scoring system and conducted preliminary verification. A verification group including 119 patients with unilateral CSDH was used to verify the predictive performance of the new and other grading systems.Results The key factors for predicting unilateral CSDH recurrence were cerebral re-expansion rate (≤ 40%) at postoperative days 7 – 9 and the preoperative computed tomography density classification (isodense or hyperdense, or separated or laminar types). Cerebral atrophy played a key role in brain re-expansion. The CSDH prognostic grading system ranged from 0 to 3. An increased score was associated with a more accurate progressive increase in the RrR rate. Our grading system demonstrated the best predictive performance compared with other systems (area under the curve = 0.856).Conclusions Our prognostic grading system could quickly and effectively screen high-risk RrR patients with unilateral CSDH. However, increased attention should be paid to brain re-expansion rate after surgery in patients with CSDH.
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