Time interval to surgery and outcomes following the surgical treatment of acute traumatic subdural hematoma

Abstract

Although the pre-surgical management of patients with acute traumatic subdural hematoma prioritizes rapid transport to the operating room, there is conflicting evidence regarding the importance of time interval from injury to surgery with regards to outcomes. We sought to determine the association of surgical timing with outcomes for subdural hematoma. A retrospective review was performed of 522 consecutive patients admitted to a single center from 2006–2012 who underwent emergent craniectomy for acute subdural hematoma. After excluding patients with unknown time of injury, penetrating trauma, concurrent cerebrovascular injury, epidural hematoma, or intraparenchymal hemorrhage greater than 30 mL, there remained 45 patients identified for analysis. Using a multiple regression model, we examined the effect of surgical timing, in addition to other variables on in-hospital mortality (primary outcome), as well as the need for tracheostomy or gastrostomy (secondary outcome). We found that increasing injury severity score (odds ratio [OR] 1.146; 95% confidence interval [CI] 1.035–1.270; p = 0.009) and age (OR1.066; 95%CI 1.006–1.129; p = 0.031) were associated with in-hospital mortality in multivariate analysis. In this model, increasing time to surgery was not associated with mortality, and in fact had a significant effect in decreasing mortality (OR 0.984; 95%CI 0.971–0.997; p = 0.018). Premorbid aspirin use was associated with a paradoxical decrease in mortality (OR 0.019; 95%CI 0.001–0.392; p = 0.010). In this patient sample, shorter time interval from injury to surgery was not associated with better outcomes. While there are potential confounding factors, these findings support the evaluation of rigorous preoperative resuscitation as a priority in future study.

Association of time to craniectomy with survival in patients with severe combat-related brain injury

“…18 In particular, the delay to neurosurgery in previous studies has included various combinations of prehospital time, interfacility transfer time, and in-hospital time after reaching a place with neurosurgical capability. The time point used to calculate delays to neurosurgery has been variously defined as the injury occurrence time, 3,7,11,17,19,[21][22][23]25,29,30,32,33,[37][38][39][40][41][42][43][44][45] time of the call received by the emergency response system, 6 time of patients' ED arrival, 3,15,26,37,38 onset of the loss of consciousness, 13,28 and onset of traumatic decerebration. 12 Although all patients in the present study were treated with decompressive craniectomy, it remains controversial whether this procedure, when done specifically for elevated ICP, improves outcomes.…”

Surgical Outcome of Traumatic Intracranial Hematoma

“…The surgeon experience would also possibly affect the length of operative time. Similar to operative duration, a measure that has been broadly studied is the time it takes for patients to be taken to the operating room, classically known as injury-to-incision time [20] [21] found that subjects who underwent an early decompression with a mean injury-to-incision time of 4.5 hours had significantly favorable outcome than patients who underwent a delayed decompression.…”

“…Another work found that longer injury-to-incision time is really associated with better outcome [20]. This, however, can be a selection bias of patients with more severe injuries needing to be operated on sooner.…”

Risk factors associated with mortality and survival of acute subdural hematoma: A retrospective study

“…Age was considered a significant prognostic factor in some studies. [ 6 7 14 15 ] Wilberger et al compared patients with ASDH older than 65 years of age and younger than 34 years old and concluded that mortality and functional recovery index were significantly different between the two groups. [ 6 ] However, in other studies, age did not have a significant effect on mortality.…”