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J Neurosurg. 2018 Jun 1:1-10. doi: 10.3171/2018.1.JNS171884. [Epub ahead of print]

Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention.

Author information

1
1Trauma Research Department and.
2
4Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado.
3
6Trauma Research Department, Penrose Hospital, Colorado Springs, Colorado.
4
3Department of Neurosurgery and.
5
2Department of Neurosurgery, Swedish Medical Center, Englewood, Colorado.
6
5Trauma Research Department, Medical City Plano, Plano, Texas.
7
7Trauma Services Department, Research Medical Center, Kansas City, Missouri; and.
8
8Rocky Vista University College of Osteopathic Medicine, Parker, Colorado.

Abstract

OBJECTIVEIsolated subdural hematomas (iSDHs) are one of the most common intracranial hemorrhage (ICH) types in the population with mild traumatic brain injury (mTBI; Glasgow Coma Scale score 13-15), account for 66%-75% of all neurosurgical procedures, and have one of the highest neurosurgical intervention rates. The objective of this study was to examine how quantitative hemorrhage characteristics of iSDHs in patients with mTBI at admission are associated with subsequent neurosurgical intervention.METHODSThis was a 3.5-year, retrospective observational cohort study at a Level I trauma center. All adult trauma patients with mTBI and iSDHs were included in the study. Maximum length and thickness (in mm) of acute SDHs, the presence of acute-on-chronic SDH, mass effect, and other hemorrhage-related variables were double-data entered; discrepant results were adjudicated after a maximum of 4 reviews. Patients with coagulopathy, skull fractures, no acute hemorrhage, a non-SDH ICH, or who did not undergo imaging on admission were excluded. The primary outcome was neurosurgical intervention (craniotomy, burr hole, catheter drainage of SDH, placement of intracranial pressure monitor, shunt, or ventriculostomy). Multivariate stepwise logistic regression was used to identify significant covariates and to assess interactions.RESULTSA total of 176 patients were included in our study: 28 patients did and 148 patients did not receive a neurosurgical intervention. Increasing head Abbreviated Injury Scale score was significantly associated with neurosurgical interventions. There was a strong correlation between the first 3 reviews on maximum hemorrhage length (R2 = 0.82) and maximum hemorrhage thickness (R2 = 0.80). The neurosurgical intervention group had a mean maximum SDH length and thickness that were 61 mm longer and 13 mm thicker than those of the nonneurosurgical intervention group (p < 0.001 for both). After adjusting for the presence of an acute-on-chronic hemorrhage, for every 1-mm increase in the thickness of an iSDH, the odds of a neurosurgical intervention increase by 32% (95% CI 1.16-1.50). There were no interventions for any SDH with a maximum thickness ≤ 5 mm on initial presenting scan.CONCLUSIONSThis is the first study to quantify the odds of a neurosurgical intervention based on hemorrhage characteristics in patients with an iSDH and mTBI. Once validated in a second population, these data can be used to better inform patients and families of the risk of future neurosurgical intervention, and to evaluate the necessity of interhospital transfers.

KEYWORDS:

AIS = Abbreviated Injury Scale; AOC = acute-on-chronic; AUROC = area under the receiver operating characteristic; ED = emergency department; EDH = epidural hematoma; GCS = Glasgow Coma Scale; ICH = intracranial hemorrhage; ISS = Injury Severity Score; IVH = intraventricular hemorrhage; LOC = loss of consciousness; LOS = length of stay; SAH = subarachnoid hemorrhage; epidemiology; iSDH = isolated subdural hematoma; mTBI = mild traumatic brain injury; mild; neurosurgery; neurosurgical intervention; subdural hematoma; traumatic brain injury

PMID:
29905513
DOI:
10.3171/2018.1.JNS171884

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