Department of Neurology, University of New Mexico School of Medicine, Albuquerque, NM, USA.
Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
Neurocrit Care. 2021 Oct;35(Suppl 2):105-111. doi: 10.1007/s12028-021-01339-5. Epub 2021 Oct 6.
Chronic subdural hematoma (cSDH) is a common neurosurgical condition responsible for excess morbidity, particularly in the geriatric population. Recovery after evacuation is complicated by fluctuating neurological deficits in a high proportion of patients. We previously demonstrated that spreading depolarizations (SDs) may be responsible for some of these events. In this study, we aim to determine candidate risk factors for probable SD and assess the influence of probable SD on outcome.
We used two cohorts who underwent surgery for cSDH. The first cohort (n = 40) had electrocorticographic monitoring to detect SD. In the second cohort (n = 345), we retrospectively identified subjects with suspected SD based on the presence of transient neurological symptoms not explained by structural etiology or ictal activity on electroencephalography. We extracted standard demographic and outcome variables for comparisons and modeling.
Of 345 subjects, 80 (23%) were identified in the retrospective cohort as having probable SD. Potential risk factors included history of hypertension, worse clinical presentation on the Glasgow Coma Scale, and lower Hounsfield unit density and volume of the preoperative subdural hematoma. Probable SD was associated with multiple worse-outcome measures, including length of stay and clinical outcomes, but not increased mortality. On a multivariable analysis, probable SD was independently associated with worse outcome, determined by the Glasgow Outcome Scale score at the first clinic follow-up (odds ratio 1.793, 95% confidence interval 1.022-3.146) and longer hospital length of stay (odds ratio 7.952, 95% confidence interval 4.062-15.563).
Unexplained neurological deficits after surgery for cSDH occur in nearly a quarter of patients and may be explained by SD. We identified several potential candidate risk factors. Patients with probable SD have worse outcomes, independent of other baseline risk factors. Further data with gold standard monitoring are needed to evaluate for possible predictors of SD to target therapies to a high-risk population.
慢性硬脑膜下血肿（cSDH）是一种常见的神经外科疾病，可导致发病率增加，特别是在老年人群中。在很大一部分患者中，血肿清除术后的神经功能恢复情况复杂，出现波动性神经功能缺损。我们之前的研究表明，扩散性去极化（SD）可能是这些事件的部分原因。在这项研究中，我们旨在确定可能与 SD 相关的候选风险因素，并评估可能的 SD 对预后的影响。
我们使用了两个接受 cSDH 手术的队列。第一组（n=40）进行了皮质脑电图监测以检测 SD。在第二组（n=345）中，我们根据短暂性神经症状（无法用结构病因或脑电图上的癫痫样活动解释），回顾性地识别疑似 SD 的患者。我们提取了标准的人口统计学和预后变量进行比较和建模。
在 345 名患者中，有 80 名（23%）在回顾性队列中被确定为可能存在 SD。潜在的危险因素包括高血压病史、格拉斯哥昏迷量表（Glasgow Coma Scale）评分较差的临床表现以及术前硬脑膜下血肿的 Hounsfield 单位密度和体积较低。可能的 SD 与多种预后不良的指标相关，包括住院时间和临床结局，但与死亡率增加无关。在多变量分析中，可能的 SD 与较差的预后独立相关，由首次临床随访时的格拉斯哥结局量表评分（优势比 1.793，95%置信区间 1.022-3.146）和更长的住院时间（优势比 7.952，95%置信区间 4.062-15.563）决定。
cSDH 手术后出现不明原因的神经功能缺损的患者近四分之一，可能由 SD 引起。我们确定了几个潜在的候选风险因素。有 SD 的患者预后较差，独立于其他基线风险因素。需要更多具有金标准监测的数据来评估 SD 的可能预测因素，以便针对高危人群进行靶向治疗。
