Nonsurgical acute traumatic subdural hematoma: what is the risk?

Abstract

T raumaTic subdural hematomas (SDHs) are a common pathological entity in neurosurgical practice. Between 12% and 29% of patients admitted with a severe traumatic brain injury (TBI) have an acute SDH. When combining all patients with TBI, 11% present with an SDH. 10 Acute traumatic SDH has been traditionally considered a lesion that should be treated surgically, although some might be approached conservatively. In a study by Wong, 17 a midline shift greater than 5 mm in patients with a Glasgow Coma Scale (GCS) score below 15 was associated with deterioration and the need for surgical evacuation. In another study, 11 it was the initial thickness of the SDH that was predictive of the need for surgery, with all SDHs greater than 10 mm in thickness requiring surgical evacuation. Based on these findings, Servadei et al.12 attempted to establish a treatment protocol for comatose patients with SDH. They selected 15 comatose patients with abbreviatioNs AUC = area under the curve; BCR = bicaudate ratio; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; ISS = Injury Severity Score; ROC = receiver operating characteristic; SDH = subdural hematoma; SFR = sylvian fissure ratio; TBI = traumatic brain injury. obJect The Brain Trauma Foundation has published guidelines on the surgical management of traumatic subdural hematoma (SDH). However, no data exist on the proportion of patients with SDH that can be selected for conservative management and what is the outcome of these patients. The goals of this study were as follows: 1) to establish what proportion of patients are initially treated conservatively; 2) to determine what proportion of patients will deteriorate and require surgical evacuation; and 3) to identify risk factors associated with deterioration and delayed surgery. methods All cases of acute traumatic SDH (869 when inclusion criteria were met) presenting over a 4-year period were reviewed. For all conservatively treated SDH, the proportion of delayed surgical intervention and the Glasgow Outcome Scale score were taken as outcome measures. Multiple factors were compared between patients who required delayed surgery and patients without surgery. results Of the 869 patients with acute traumatic SDH, 646 (74.3%) were initially treated conservatively. A good outcome was achieved in 76.7% of the patients. Only 6.5% eventually required delayed surgery, and the median delay for surgery was 9.5 days. Factors associated with deterioration were as follows: 1) thicker SDH (p < 0.001); 2) greater midline shift (p < 0.001); 3) location at the convexity (p = 0.001); 4) alcohol abuse (p = 0.0260); and 5) history of falls (p = 0.018). There was no significant difference in regard to age, sex, Glasgow Coma Scale score, Injury Severity Score, abnormal coagulation, use of blood thinners, and presence of cerebral atrophy or white matter disease. coNclusioNs The majority of patients with SDH are treated conservatively. Of those, only 6.5% later required surgery, for raised intracranial pressure or SDH pr...

Predicting Outcome and Conservative Treatment Failure in Patients with Skull Fracture after Traumatic Brain Injury: A Retrospective Cohort Study

“…The current literature states that the incidence of CTF ranges from 6.5% to 26%. [12][13][14] In our study it was the case in 19.3% of the patients. Outcomes in both the CTF and immediate surgery groups were similar, although those who underwent delayed surgery were in relatively better neurologic condition on admission (p ¼ 0.033).…”

Biomechanics of Acute Subdural Hematoma in the Elderly: A Fluid-Structure Interaction Study

“…Epidemiological studies have shown a much higher incidence rate of BV-sourced ASDH in the elderly compared to younger adults, along with elevated morbidity and mortality, and poorer treatment outcomes. [3][4][5][6][7][8][9] Clinical studies suggest brain atrophy as a primary etiology contributing to the increased ASDH risk in elderly trauma patients. 9,10 However, this hypothesis remains to be verified and associated mechanisms are yet to be better uncovered.…”

Comparative Effectiveness of Surgery for Traumatic Acute Subdural Hematoma in an Aging Population

“…Recent comparable series of patients with ASDH of varying severities report mean ages of 55-58 years. 19,33,34 The advanced age in this study should come as no surprise considering the aging population in developed countries, but should be kept in mind when applying its results. Also, for a clinician to determine to which patients these results are relevant she/he needs to consider for what kind of ASDH patients neurosurgery is consulted in the Netherlands.…”

“…This explains the relatively small number of conservatively treated patients (24% overall) in our cohort compared with recent studies, reporting 74-83% of ASDHs being treated nonoperatively. 33,34 And, although much less common, this also applies to very severe cases, not operated on because of an extremely poor prognosis. Because the mild cases constitute the majority of TBIs, and this patient category undoubtedly has an above-average prognosis, applying the favorable results of surgery to all ASDH patients would not be reasonable.…”