Orlando Alessandro, Levy A Stewart, Rubin Benjamin A, Tanner Allen, Carrick Matthew M, Lieser Mark, Hamilton David, Mains Charles W, Bar-Or David
1Trauma Research Department and.
4Trauma Research Department, St. Anthony Hospital, Lakewood, Colorado.
J Neurosurg. 2018 Jun 15;130(5):1616-1625. doi: 10.3171/2018.1.JNS171884. Print 2019 May 1.
Isolated 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.
This 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.
A 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.
This 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.
孤立性硬膜下血肿（iSDH）是轻度创伤性脑损伤（mTBI；格拉斯哥昏迷量表评分为13 - 15分）人群中最常见的颅内出血（ICH）类型之一，占所有神经外科手术的66% - 75%，且神经外科干预率极高。本研究的目的是探讨mTBI患者入院时iSDH的定量出血特征与后续神经外科干预之间的关联。
这是一项在一级创伤中心进行的为期3.5年的回顾性观察队列研究。所有患有mTBI和iSDH的成年创伤患者均纳入研究。急性硬膜下血肿的最大长度和厚度（以毫米为单位）、急性加慢性硬膜下血肿的存在情况、占位效应以及其他与出血相关的变量均进行双数据录入；最多经过4次复查后对不一致的结果进行裁决。排除患有凝血病、颅骨骨折、无急性出血、非硬膜下血肿性ICH或入院时未进行影像学检查的患者。主要结局是神经外科干预（开颅手术、钻孔、硬膜下血肿导管引流、颅内压监测器置入、分流术或脑室造瘘术）。采用多变量逐步逻辑回归来确定显著的协变量并评估相互作用。
我们的研究共纳入176例患者：28例接受了神经外科干预，148例未接受。头部简明损伤量表评分增加与神经外科干预显著相关。首次3次复查中最大出血长度（R2 = 0.82）和最大出血厚度（R2 = 0.80）之间存在很强的相关性。神经外科干预组的急性硬膜下血肿平均最大长度和厚度比非神经外科干预组分别长61毫米和厚13毫米（两者p均< 0.001）。在调整急性加慢性出血的存在情况后，iSDH厚度每增加1毫米，神经外科干预的几率增加32%（95%置信区间1.16 - 1.50）。初始扫描时最大厚度≤5毫米的任何硬膜下血肿均未进行干预。
这是第一项基于iSDH和mTBI患者的出血特征对神经外科干预几率进行量化的研究。一旦在另一人群中得到验证，这些数据可用于更好地告知患者及其家属未来神经外科干预的风险，并评估院间转运的必要性。
