J Korean Neurosurg Soc.  2017 Nov;60(6):723-729. 10.3340/jkns.2017.0506.011.

Risk Factors of Delayed Surgical Intervention after Conservatively Treated Acute Traumatic Subdural Hematoma

• Kwon H
• Choi KS
• Yi HJ
• Chun HJ
• Lee YJ
• Kim DW

• KMID: 2395793
• DOI: http://doi.org/10.3340/jkns.2017.0506.011

Abstract

OBJECTIVE
Acute subdural hematoma (ASDH) is generally considered a condition that should be managed surgically. However, some patients initially receive conservative treatment, a subset of whom require surgical intervention later. This study aimed to evaluate the predictors of delayed surgical intervention in ASDH patients who are initially managed conservatively.
METHODS
From January 2007 to December 2015, 842 patients diagnosed with ASDH were treated at our institution. Among them, 158 patients with convexity ASDH were initially treated conservatively. Patients were divided into a delayed surgery group and a conservative group. Demographic characteristics, past medication and medical histories, and radiological and laboratory data were collected by retrospective chart review. Independent risk factors were identified with univariate and multivariate analyses.
RESULTS
Twenty-eight patients (17.7%) underwent delayed surgical intervention. Their mean age was 69.0 years, and 82.1% were male. Hypertension, diabetes mellitus, and heart disease prevalence and use of anti-platelet agents did not significantly differ from the conservative group. However, age (p=0.024), previous cerebral infarction history (p=0.026), increased maximal hematoma thickness (p<0.001), midline shifting (p=0.001) and accompanying subarachnoid hemorrhage (p=0.022) on initial brain computed tomography (CT) scan, low hemoglobin level (p<0.001), high leukocyte count (p=0.004), and low glucose level (p=0.002) were significantly associated with delayed surgical intervention. In multivariate analysis, increased maximal hematoma thickness (odds ratio [OR]=1.279, 95% confidence interval [CI] 1.075-1.521; p=0.006), low hemoglobin level (OR=0.673, 95% CI 0.467-0.970; p=0.034), and high leukocyte count (OR=1.142, 95% CI 1.024-1.272; p=0.017) were independent risk factors for delayed surgical intervention.
CONCLUSION
Due to the high likelihood of delayed surgical intervention among minimal ASDH patients with a thicker hematoma on initial brain CT, lower hemoglobin level, and higher leukocyte count, these patients should receive more careful observation.

Keyword

Hematoma; Subdural; Surgical procedure; Operative; Conservative treatment; Risk factors; Outcome

MeSH Terms

Brain
Cerebral Infarction
Diabetes Mellitus
Glucose
Heart Diseases
Hematoma
Hematoma, Subdural*
Hematoma, Subdural, Acute
Humans
Hypertension
Leukocyte Count
Male
Multivariate Analysis
Prevalence
Retrospective Studies
Risk Factors*
Subarachnoid Hemorrhage
Glucose

Figure

• 

  Fig. 1 Flow chart of eligible patients included in the study. ASHD, acute subdural hematoma.

Reference

References

1. Bajsarowicz P, Prakash I, Lamoureux J, Saluja RS, Feyz M, Maleki M, et al. Nonsurgical acute traumatic subdural hematoma: What is the risk? J Neurosurg. 123:1176–1183. 2015.

2. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of acute subdural hematomas. Neurosurgery. 58(3 Suppl):S16–S24. discussion Si–iv. 2006.

3. Dent DL, Croce MA, Menke PG, Young BH, Hinson MS, Kudsk KA, et al. Prognostic factors after acute subdural hematoma. J Trauma. 39:36–42. discussion 42–33. 1995.

4. Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural haematoma: Inflammation, angiogenesis and implications for pharmacotherapy. J Neuroinflammation. 14:108. 2017.

5. Feliciano CE, De Jesús O. Conservative management outcomes of traumatic acute subdural hematomas. P R Health Sci J. 27:220–223. 2008.

6. Fujimoto K, Otsuka T, Yoshizato K, Kuratsu J. Predictors of rapid spontaneous resolution of acute subdural hematoma. Clin Neurol Neurosurg. 118:94–97. 2014.

7. Han SB, Choi SW, Song SH, Youm JY, Koh HS, Kim SH, et al. Prediction of chronic subdural hematoma in minor head trauma patients. Korean J Neurotrauma. 10:106–111. 2014.

8. Jeong SI, Kim SO, Won YS, Kwon YJ, Choi CS. Clinical analysis of risk factors for recurrence in patients with chronic subdural hematoma undergoing burr hole trephination. Korean J Neurotrauma. 10:15–21. 2014.

9. Kim BJ, Park KJ, Park DH, Lim DJ, Kwon TH, Chung YG, et al. Risk factors of delayed surgical evacuation for initially nonoperative acute subdural hematomas following mild head injury. Acta Neurochir (Wien). 156:1605–1613. 2014.

10. Laviv Y, Rappaport ZH. Risk factors for development of significant chronic subdural hematoma following conservative treatment of acute subdural hemorrhage. Br J Neurosurg. 28:733–738. 2014.

11. Lee JJ, Won Y, Yang T, Kim S, Choi CS, Yang J. Risk factors of chronic subdural hematoma progression after conservative management of cases with initially acute subdural hematoma. Korean J Neurotrauma. 11:52–57. 2015.

12. Lee KS. The pathogenesis and clinical significance of traumatic subdural hygroma. Brain Inj. 12:595–603. 1998.

13. Lee KS, Shim JJ, Yoon SM, Doh JW, Yun IG, Bae HG. Acute-on-chronic subdural hematoma: not uncommon events. J Korean Neurosurg Soc. 50:512–516. 2011.

14. Markwalder TM. Chronic subdural hematomas: a review. J Neurosurg. 54:637–645. 1981.

15. Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo). 41:371–381. 2001.

16. Müller W, Firsching R. Significance of eosinophilic granulocytes in chronic subdural hematomas. Neurosurg Rev. 13:305–308. 1990.

17. Murakami H, Hirose Y, Sagoh M, Shimizu K, Kojima M, Gotoh K, et al. Why do chronic subdural hematomas continue to grow slowly and not coagulate? Role of thrombomodulin in the mechanism. J Neurosurg. 96:877–884. 2002.

18. Niikawa S, Sugimoto S, Hattori T, Ohkuma A, Kimura T, Shinoda J, et al. Rapid resolution of acute subdural hematoma--report of four cases. Neurol Med Chir (Tokyo). 29:820–824. 1989.

19. Okano A, Oya S, Fujisawa N, Tsuchiya T, Indo M, Nakamura T, et al. Analysis of risk factors for chronic subdural haematoma recurrence after burr hole surgery: optimal management of patients on antiplatelet therapy. Br J Neurosurg. 28:204–208. 2014.

20. Roeloffzen WW, Kluin-Nelemans HC, Bosman L, de Wolf JT. Effects of red blood cells on hemostasis. Transfusion. 50:1536–1544. 2010.

21. Rozzelle CJ, Wofford JL, Branch CL. Predictors of hospital mortality in older patients with subdural hematoma. J Am Geriatr Soc. 43:240–244. 1995.

22. Sarkar C, Lakhtakia R, Gill SS, Sharma MC, Mahapatra AK, Mehta VS. Chronic subdural haematoma and the enigmatic eosinophil. Acta Neurochir (Wien). 144:983–988. discussion 988. 2002.

23. Stanisic M, Aasen AO, Pripp AH, Lindegaard KF, Ramm-Pettersen J, Lyngstadaas SP, et al. Local and systemic pro-inflammatory and anti-inflammatory cytokine patterns in patients with chronic subdural hematoma: a prospective study. Inflamm Res. 61:845–852. 2012.

24. Stanisic M, Lyngstadaas SP, Pripp AH, Aasen AO, Lindegaard KF, Ivanovic J, et al. Chemokines as markers of local inflammation and angiogenesis in patients with chronic subdural hematoma: a prospective study. Acta Neurochir (Wien). 154:113–120. discussion 120. 2012.

25. Torihashi K, Sadamasa N, Yoshida K, Narumi O, Chin M, Yamagata S. Independent predictors for recurrence of chronic subdural hematoma: a review of 343 consecutive surgical cases. Neurosurgery. 63:1125–1129. discussion 1129. 2008.

26. Tseng JH, Tseng MY, Liu AJ, Lin WH, Hu HY, Hsiao SH. Risk factors for chronic subdural hematoma after a minor head injury in the elderly: a population-based study. Biomed Res Int. 2014:218646. 2014.

27. Tsui EY, Fai Ma K, Cheung YK, Chan JH, Yuen MK. Rapid spontaneous resolution and redistribution of acute subdural hematoma in a patient with chronic alcoholism: a case report. Eur J Radiol. 36:53–57. 2000.

28. Wong CW. Criteria for conservative treatment of supratentorial acute subdural haematomas. Acta Neurochir (Wien). 135:38–43. 1995.

29. Yamamoto H, Hirashima Y, Hamada H, Hayashi N, Origasa H, Endo S. Independent predictors of recurrence of chronic subdural hematoma: results of multivariate analysis performed using a logistic regression model. J Neurosurg. 98:1217–1221. 2003.

30. Yamashima T, Kubota T, Yamamoto S. Eosinophil degranulation in the capsule of chronic subdural hematomas. J Neurosurg. 62:257–260. 1985.

31. Yu S, Arima H, Heeley E, Delcourt C, Krause M, Peng B, et al. White blood cell count and clinical outcomes after intracerebral hemorrhage: the interact2 trial. J Neurol Sci. 361:112–116. 2016.

32. Ziai WC. Hematology and inflammatory signaling of intracerebral hemorrhage. Stroke. 44(6 Suppl 1):S74–S78. 2013.