García-Pérez Daniel, Panero-Pérez Irene, Eiriz Fernández Carla, Moreno-Gomez Luis Miguel, Esteban-Sinovas Olga, Navarro-Main Blanca, Gómez López Pedro A, Castaño-León Ana M, Lagares Alfonso
J Neurosurg. 2020 Jul 31;134(6):1940-1950. doi: 10.3171/2020.4.JNS193445. Print 2021 Jun 1.
Acute subdural hematoma (ASDH) is a major cause of mortality and morbidity after traumatic brain injury (TBI). Surgical evacuation is the mainstay of treatment in patients with altered neurological status or significant mass effect. Nevertheless, concerns regarding surgical indication still persist. Given that clinicians often make therapeutic decisions on the basis of their prognosis assessment, to accurately evaluate the prognosis is of great significance. Unfortunately, there is a lack of specific and reliable prognostic models. In addition, the interdependence of certain well-known predictive variables usually employed to guide surgical decision-making in ASDH has been proven. Because gray matter and white matter are highly susceptible to secondary insults during the early phase after TBI, the authors aimed to assess the extent of these secondary insults with a brain parenchyma densitometric quantitative CT analysis and to evaluate its prognostic capacity.
The authors performed a retrospective analysis among their prospectively collected cohort of patients with moderate to severe TBI. Patients with surgically evacuated, isolated, unilateral ASDH admitted between 2010 and 2017 were selected. Thirty-nine patients were included. For each patient, brain parenchyma density in Hounsfield units (HUs) was measured in 10 selected slices from the supratentorial region. In each slice, different regions of interest (ROIs), including and excluding the cortical parenchyma, were defined. The injured hemisphere, the contralateral hemisphere, and the absolute differences between them were analyzed. The outcome was evaluated using the Glasgow Outcome Scale-Extended at 1 year after TBI.
Fifteen patients (38.5%) had a favorable outcome. Collected demographic, clinical, and radiographic data did not show significant differences between favorable and unfavorable outcomes. In contrast, the densitometric analysis demonstrated that greater absolute differences between both hemispheres were associated with poor outcome. These differences were detected along the supratentorial region, but were greater at the high convexity level. Moreover, these HU differences were far more marked at the cortical parenchyma. It was also detected that these differences were more prone to ischemic and/or edematous insults than to hyperemic changes. Age was significantly correlated with the side-to-side HU differences in patients with unfavorable outcome.
The densitometric analysis is a promising prognostic tool in patients diagnosed with ASDH. The supplementary prognostic information provided by the densitometric analysis should be evaluated in future studies.
急性硬膜下血肿（ASDH）是创伤性脑损伤（TBI）后死亡和致残的主要原因。手术清除是神经功能状态改变或有明显占位效应患者的主要治疗方法。然而，关于手术指征的担忧仍然存在。鉴于临床医生通常根据预后评估做出治疗决策，准确评估预后具有重要意义。不幸的是，缺乏具体且可靠的预后模型。此外，已证实常用于指导ASDH手术决策的某些知名预测变量之间存在相互依存关系。由于灰质和白质在TBI后的早期阶段极易受到继发性损伤，作者旨在通过脑实质密度定量CT分析评估这些继发性损伤的程度，并评估其预后能力。
作者对前瞻性收集的中重度TBI患者队列进行了回顾性分析。选择2010年至2017年间接受手术清除的孤立性单侧ASDH患者。共纳入39例患者。对每位患者，从幕上区域选择10个切片测量脑实质的亨氏单位（HU）密度。在每个切片中，定义了包括和不包括皮质实质的不同感兴趣区域（ROI）。分析损伤半球、对侧半球以及它们之间的绝对差异。使用TBI后1年的扩展格拉斯哥预后量表评估结局。
15例患者（38.5%）预后良好。收集的人口统计学、临床和影像学数据在良好和不良预后之间未显示出显著差异。相比之下，密度分析表明，两个半球之间更大的绝对差异与不良预后相关。这些差异在幕上区域均有发现，但在高凸面水平更大。此外，这些HU差异在皮质实质处更为明显。还发现这些差异更容易出现缺血和/或水肿性损伤而非充血性改变。年龄与不良预后患者的双侧HU差异显著相关。
密度分析是诊断为ASDH患者的一种有前景的预后工具。密度分析提供的补充预后信息应在未来研究中进行评估。
