Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review.

Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.

Mortality Reduction of Acute Surgery in Traumatic Acute Subdural Hematoma since the 19th Century: Systematic Review and Meta-Analysis with Dramatic Effect: Is Surgery the Obvious Parachute?

The rationale of performing surgery for acute subdural hematoma (ASDH) to reduce mortality is often compared with the self-evident effectiveness of a parachute when skydiving. Nevertheless, it is of clinical relevance to estimate the magnitude of the effectiveness of surgery. The aim of this study is to determine whether surgery reduces mortality in traumatic ASDH compared with initial conservative treatment. A systematic search was performed in the databases IndexCAT, PubMed, Embase, Web of Science, Cochrane library, CENTRAL, Academic Search Premier, Google Scholar, ScienceDirect, and CINAHL for studies investigating ASDH treated conservatively and surgically, without restriction to publication date, describing the mortality. Cohort studies or trials with at least five patients with ASDH, clearly describing surgical, conservative treatment, or both, with the mortality at discharge, reported in English or Dutch, were eligible. The search yielded 2025 reports of which 282 were considered for full-text review. After risk of bias assessment, we included 102 studies comprising 12,287 patients. The data were synthesized using meta-analysis of absolute risks; this was conducted in random-effects models, with dramatic effect estimation in subgroups. Overall mortality in surgically treated ASDH is 48% (95% confidence interval [CI] 44-53%). Mortality after surgery for comatose patients (Glasgow Coma Scale ≤8) is 41% (95% CI 31-51%) in contemporary series (after 2000). Mortality after surgery for non-comatose ASDH is 12% (95% CI 4-23%). Conservative treatment is associated with an overall mortality of 35% (95% CI 22-48%) and 81% (95% CI 56-98%) when restricting to comatose patients. The absolute risk reduction is 40% (95% CI 35-45%), with a number needed to treat of 2.5 (95% CI 2.2-2.9) to prevent one death in comatose ASDH. Thus, surgery is effective to reduce mortality among comatose patients with ASDH. The magnitude of the effect is large, although the effect size may not be sufficient to overcome any bias.

High Long-Term Mortality Rate in Elderly Patients with Mild Traumatic Brain Injury and Subdural Hematoma due to Ground-Level Fall: Neurosurgery's Hip Fracture?

BACKGROUND: Moderate-to-severe traumatic brain injury (TBI) is a major source of morbidity and mortality in elderly patients. Little is known about long-term mortality in elderly patients following mild, nonfatal TBI and how the injury mechanism predicts survival. This study aimed to compare long-term mortality in elderly patients with mild TBI and traumatic subdural hematoma (tSDH) due to ground-level fall (GLF) versus those with TBI and tSDH due to another cause (i.e., non-ground-level fall [nGLF]). METHODS: This retrospective study comprised 288 patients ≥60 years old from a single Level I trauma center with tSDH and Glasgow Coma Scale scores 13-15. RESULTS: Median follow-up after initial TBI presentation was 2.9 years for the GLF group and 2.4 years for the nGLF group. During follow-up, 98 patients died, and median survival for all elderly patients with mild TBI and tSDH was 4.6 years. The GLF group had a higher mortality rate than the nGLF group, with 93 patients in GLF group dying during follow-up compared with 5 in nGLF group (P < 0.0001). The annual death rate for patients in the GLF group was 12.5% per year. For patients 60-69 years old, 39% in GLF group died compared with 4% in nGLF group during follow-up (P = 0.0002). Likewise, for patients 70-79 years old, 29% in GLF group died compared with 7% in nGLF group (P = 0.021). Finally, 56% of patients >80 years old in GLF group compared with 18% in nGLF group (P = 0.11). CONCLUSIONS: Elderly patients with mild TBI and tSDH due to GLF have significantly higher long-term mortality than patients with injuries due to nGLF.

The Impact of Preinjury Antiplatelet and Anticoagulant Use on Elderly Patients with Moderate or Severe Traumatic Brain Injury Following Traumatic Acute Subdural Hematoma.

BACKGROUND: Although it is often assumed that preinjury anticoagulant (AC) or antiplatelet (AP) use is associated with poorer outcomes among those with acute subdural hematoma (aSDH), previous studies have had varied results. This study examines the impact of preinjury AC and AP therapy on aSDH thickness, 30-day mortality, and extended Glasgow Outcome Scale at 6 months in elderly patients (aged ≥65). METHODS: A level 1 trauma center registry was interrogated to identify consecutive elderly patients who presented with moderate or severe traumatic brain injury (TBI) and associated traumatic aSDH between the first of January 2013 and the first of January 2018. Relevant demographic, clinical, and radiological data were retrieved from institutional medical records. The 3 primary outcome measures were aSDH thickness on initial computed tomography scan, 30-day mortality, and unfavorable outcome at 6 months (extended Glasgow Outcome Scale). RESULTS: One hundred thirty-two elderly patients were admitted with moderate or severe TBI and traumatic aSDH. The mean (±SD) age was 78.39 (±7.87) years, and a majority of patients (59.8%, n = 79) were male. There was a statistically significant difference in mean aSDH thickness, but there were no significant differences in 30-day mortality (P = 0.732) and unfavorable outcome between the AP, AC, combined AP and AC, and no antithrombotic exposure groups (P = 0.342). CONCLUSIONS: Further studies with larger sample sizes are necessary to confirm these observations, but our findings do not support the preconceived notion in clinical practice that antithrombotic use is associated with poor outcomes in elderly patients with moderate or severe TBI.

Factors Affecting Outcomes in Geriatric Traumatic Subdural Hematoma in a Neurosurgical Intensive Care Unit.

BACKGROUND AND OBJECTIVE: Geriatric patients (age ≥65 years) who sustain a traumatic brain injury have an increased risk of poor outcomes and higher mortality compared with younger cohorts. We aimed to evaluate the risk factors for discharge outcomes in a geriatric traumatic subdural hematoma population, stratified by age and pretraumatic medical comorbidities. This was a single-center retrospective cohort study of geriatric patients (N = 207). METHODS: Patient charts were evaluated for factors including patient characteristics, comorbidities, injury-related and seizure-related factors, neurosurgical intervention, and patient disposition on discharge. RESULTS: Bivariate and multivariate analyses showed that age was nonpredictive of patient outcomes. Underlying vasculopathic comorbidities were the primary determinant of posttraumatic seizure, surgical, and discharge outcomes. Multifactor analysis showed that patients who went on to develop status epilepticus (n = 11) had a higher frequency of vasculopathic comorbidities with strong predictive power in poor patient outcomes. CONCLUSIONS: Our findings suggest a need to establish unique prognostic risk factors based on patient outcomes that guide medical and surgical treatment in geriatric patients.

Putting 'CSF-Shift Edema' Hypothesis to Test: Comparing Cisternal and Parenchymal Pressures After Basal Cisternostomy for Head Injury.

BACKGROUND: Increased brain edema in head injury is due to shift of cerebrospinal fluid (CSF) from cisterns at high pressure to brain parenchyma at low pressure. By opening basal cisterns and decreasing the increased cisternal pressure, basal cisternostomy (BC) results in reversal of CSF shift from parenchyma to cisterns, leading to decreased brain edema. Though the CSF-shift edema hypothesis is based on pressure difference between cisterns and brain parenchyma, the relationship of these pressures has not been studied. METHODS: A prospective clinical study was conducted from November 2018 to March 2020 including adult patients with head injury who were candidates for standard decompressive hemicraniectomy (DHC). All patients had neurological assessment and head computed tomography preoperatively and postoperatively. All patients underwent BC with DHC. Postoperatively, parenchymal and cisternal pressures and neurological condition were monitored hourly for 72 hours. RESULTS: Nine (5 men, 4 women) patients with head injury (mean age, 45.7 years; range, 25-72 years) underwent DHC-BC. Median Glasgow Coma Scale score of patients at admission was 8 (range, 4-14), and median midline shift on computed tomography was 8 mm (range, 7-12 mm). There was a significant difference between opening (25.70 ± 10.48 mm Hg) and closing (11.30 ± 5.95 mm Hg) parenchymal pressures (t9 = 3.963, P = 0.003). Immediate postoperative cisternal pressure was 1-11 mm Hg and was lower than immediate postoperative parenchymal pressure in all except 1 patient. Postoperatively, if cisternal pressure remained low, parenchymal pressure also decreased, and patients showed clinical improvement. Patients showing increased cisternal pressure showed increased parenchymal pressure and clinical worsening. CONCLUSIONS: Our study supports the CSF-shift edema hypothesis. Following DHC-BC, cisternal pressure is lowered to near-atmospheric pressure, and its relationship to parenchymal pressure predicts the future course of patients by reversal or re-reversal of CSF shift.

The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma.

This study aimed to evaluate the utility of the 11-variable modified Frailty Index (mFI) in prognosticating elderly patients with traumatic acute subdural hematomas (aSDHs). A state-service level 1 trauma center registry was interrogated to investigate consecutive patients ≥65 years of age presenting with traumatic aSDH, with or without major extracranial injury, between January 2013 and December 2017. mFI on admission, demographics, and admission details, including Glasgow Coma Scale (GCS) and pupillary status and radiological findings, were retrospectively retrieved from institutional records. Clinical outcome data were retrieved from medical records and the Victorian State Trauma Registry (VSTR). Outcome measures were 1) 30-day mortality and 2) 6-month unfavorable outcome, defined by the Extended Glasgow Outcome Scale (GOS-E). Five hundred twenty-nine consecutive cases were identified from the registry. Demographic data included: 1) age (median; interquartile range) = 80.46; 74.17-85.89; 2) mFI (mean ± standard deviation) = 1.96 ± 1.42 of 11 variables. Four hundred sixteen cases (79%) had complete outcome data. As mFI increased from 0/11 variables to ≥5/11 variables (≥0.45), 30-day mortality risk increased from 17.72% to 39.29% (p = 0.023) and 6-month unfavorable outcome risk increased from 40.51% to 96.43% (p < 0.001). Multi-variate analysis showed that greater mFI score of ≥3/11 variables (≥0.27) suggested a significantly higher risk of 30-day mortality (p = 0.009) and unfavorable outcome (p < 0.001). We conclude that increasing frailty, as measured by the mFI, was associated with significantly higher risk of 30-day mortality and 6-month unfavorable outcome in elderly patients presenting with aSDH to a level 1 neurotrauma center. Assessment of mFI in elderly patients with aSDH may be a useful determinant of outcome for this rapidly growing population.

Ratio of Optic Nerve Sheath Diameter to Eyeball Transverse Diameter by Ultrasound Can Predict Intracranial Hypertension in Traumatic Brain Injury Patients: A Prospective Study.

BACKGROUND: Measuring optic nerve sheath diameter (ONSD), an indicator to predict intracranial hypertension, is noninvasive and convenient, but the reliability of ONSD needs to be improved. Instead of using ONSD alone, this study aimed to evaluate the reliability of the ratio of ONSD to eyeball transverse diameter (ONSD/ETD) in predicting intracranial hypertension in traumatic brain injury (TBI) patients. METHODS: We performed a prospective study on patients admitted to the Surgery Intensive Care Unit. The included 52 adults underwent craniotomy for TBI between March 2017 and September 2018. The ONSD and ETD of each eyeball were measured by ultrasound and computed tomography (CT) scan within 24 h after a fiber optic probe was placed into lateral ventricle. Intracranial pressure (ICP) > 20 mmHg was regarded as intracranial hypertension. The correlations between invasive ICP and ultrasound-ONSD/ETD ratio, ultrasound-ONSD, CT-ONSD/ETD ratio, and CT-ONSD were each analyzed separately. RESULTS: Ultrasound measurement was successfully performed in 94% (n = 49) of cases, and ultrasound and CT measurement were performed in 48% (n = 25) of cases. The correlation efficiencies between ultrasound-ONSD/ETD ratio, ultrasound-ONSD, CT-ONSD/ETD ratio, and ICP were 0.613, 0.498, and 0.688, respectively (P < 0.05). The area under the curve (AUC) values of the receiver operating characteristic (ROC) curve for the ultrasound-ONSD/ETD ratio and CT-ONSD/ETD ratio were 0.920 (95% CI 0.877-0.964) and 0.896 (95% CI 0.856-0.931), respectively. The corresponding threshold values were 0.25 (sensitivity of 90%, specificity of 82.3%) and 0.25 (sensitivity of 85.7%, specificity of 83.3%), respectively. CONCLUSION: The ratio of ONSD to ETD tested by ultrasound may be a reliable indicator for predicting intracranial hypertension in TBI patients.

Lumbar Subdural Hematoma Detected After Surgical Treatment of Chronic Intracranial Subdural Hematoma.

BACKGROUND: Spinal subdural hematoma (SSDH), which can cause lower back pain, leg pain, and leg weakness, is rare and will usually be associated with a bleeding tendency, trauma, spinal vascular malformation, intraspinal tumor, or iatrogenic invasion. Only a few cases of SSDH after intracranial chronic subdural hematoma (CSDH) have been reported. We report a case of lumbar SSDH in the absence of predisposing factors after reoperation for recurrent intracranial CSDH, which improved with conservative treatment. CASE DESCRIPTION: Approximately 1 month after falling, a 63-year-old woman was experiencing left hemiparesis and impaired orientation that was diagnosed as right intracranial CSDH using computed tomography. Surgical treatment of the CSDH led to immediate improvement of her symptoms. On postoperative day 29, the right CSDH had recurred with left hemiparesis, and successful reoperation relieved the symptoms within a few hours postoperatively. However, 1 day after the second operation, very small acute subdural hematomas in regions along the left tentorium cerebelli and left falx cerebri were found on computed tomography. On day 31, she complained of sitting-induced bilateral radiating lower limb pain. Magnetic resonance imaging on day 34 showed an acute SSDH at the L4-L5 level and a sacral perineural cyst filled with hematoma, although her radiating pain was showing improvement. She was treated conservatively and was discharged without symptoms on day 44. CONCLUSIONS: Although SSDH is rare, it is important for neurosurgeons and physicians to consider the possibility of a SSDH when lower limb pain or paresis occurs after procedures that will result in rapid intracranial pressure alterations such as drainage of an intracranial CSDH.

Traumatic Retroclival Subdural Hematoma in a Child with Hemophilia.

BACKGROUND: Retroclival hematomas are a rare entity and may occur in 3 compartments, namely the epidural, subdural, and subarachnoid spaces. They are frequently secondary to trauma. Hemophilia is a clinical syndrome affecting usually men and characterized by the inherited tendency to bleed excessively after slight injury. Hemophilia is caused by a specific defect of coagulation factor VIII. The main concern associated with the disease is bleeding, especially after trauma and surgeries. The most serious site of bleeding is the central nervous system. CASE PRESENTATION: An 11-year-old boy diagnosed with hemophilia presented after sustaining a fall. On arrival to the emergency department, his vitals where within normal range and he was fully conscious. Neurologic examination was significant for bilateral abducens nerve palsy; the rest of the examination was unremarkable. Imaging studies with computed tomography (CT) scan and brain magnetic resonance imaging showed subacute retroclival subdural hemorrhage with left cerebellar and upper cervical spine extension. Follow-up imaging with CT scan showed progressive resolution of the hematoma, and the patient had a stable clinical course while receiving factor VII replacement. CONCLUSIONS: Retroclival subdural hematomas are rare and may present either spontaneously or after trauma. Conservative treatment is the usual course of treatment. Patients with hemophilia A are under a constant threat from bleeding, either spontaneous or after trivial injury. The most common cause of death in this patient population is intracranial hemorrhage. The most important aspect of intracranial hematoma management is the early replacement therapy of deficient coagulation factors in patients with hemophilia.

Clival SubduralHematoma after Drainage of Concomitant Intracranial and Spinal Cord Subdural Hematomas ­ Rare Case Report

Concomitant traumatic spinal cord and intracranial subdural hematomas associated with a retroclival hematoma are very uncommon. Their pathophysiology is not totally elucidated, but one hypothesis is the migration of the hematoma from the head to the spine. In the present case report, the authors describe the case of a 51-year-old man presenting with headache, nauseas and back pain after a head trauma who presented with intracranial and spinal cord subdural hematomas. Drainage was performed but, 1 week later, a retroclival subdural hematoma was diagnosed. The present paper discusses the pathophysiology, the clinical presentation, as well as the complications of concomitant traumatic spinal cord and intracranial subdural hematomas associated with a retroclival hematoma, and reviews this condition.

Spontaneous Intracranial and Lumbar Subdural Hematoma Presenting as Vaginal Pain.

BACKGROUND: Spontaneous spinal and intracranial subdural hematomas are rarely reported, especially occurring simultaneously. Anticoagulation use has been associated with spontaneous hemorrhages. Prompt diagnosis is required to prevent permanent neurological sequelae. In this case report, we describe a spontaneous spinal and intracranial subdural hematoma in a woman taking warfarin and initially presenting with severe vaginal pain. CASE REPORT: A 42-year-old woman who had a history of mechanical valve replacement and was therefore taking warfarin, came to an emergency department for relief of severe vaginal pain. Mild concurrent lumbar pain increased concern about spinal pathology, so magnetic resonance imaging of her spine was performed. It revealed a subdural hematoma extending from L1-S1 with arachnoiditis, which suggested intracranial pathology, though the patient had no complaint of a headache. Computed tomography of her brain demonstrated a large right subdural hemorrhage with midline shift. Subsequent imaging revealed no aneurysm or source of the intracranial bleeding. We concluded that the patient experienced spontaneous anticoagulation-related intracranial hemorrhage resulting in lumbar subdural hematoma and arachnoiditis with referred vaginal pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pelvic, vaginal, or perineal pain may be the presenting symptom in patients with lower spinal pathology. It is important to consider causes other than gynecological ones in the differential diagnosis of these patients, as well as to be cognizant of the relationship between spinal and intracranial subdural hemorrhages. In patients with back pain or radiating lumbar pain, especially coupled with neurological effects, clinicians should consider spinal subdural hemorrhage and arachnoiditis to expedite imaging studies and treatment of these rare entities.

Traumatic Subacute Spinal Subdural Hematoma Concomitant with Symptomatic Cranial Subdural Hematoma: Possible Mechanism.

BACKGROUND: Spinal subdural hematoma (SDH) concomitant with cranial SDH is extremely rare. Although some theories have been proposed, the pathophysiology underlying this condition remains unclear. We present a case of traumatic subacute spinal SDH followed by symptomatic subacute cranial SDH. CASE DESCRIPTION: A 56-year-old woman was admitted with severe back pain 2 weeks after sustaining a minor head injury. The pain was worse with walking or standing and was relieved a little bit by sitting. There was no clinical evidence of back injury. There was no neurologic deficit. Magnetic resonance imaging of the spine showed subacute spinal SDH from T12 to S1. Owing to progressive worsening of back pain, bilateral laminectomy of L1-S1 and drainage of subacute spinal SDH were performed. The pain was completely relieved after surgery. On postoperative day 4, the patient was noted to be unconscious with Glasgow Coma Scale score of 10 (E2V3M5). Computed tomography scan of the head showed subacute bilateral cranial SDH. Burr hole drainage was performed. The patient experienced a complete recovery. CONCLUSIONS: This case suggests the possibility that spinal SDH can develop as a result of cranial SDH migration to the most dependent spinal subdural space. The physician should be aware of the possibility of symptomatic cranial SDH developing following spinal SDH evacuation.

Concomitant Intracranial and Lumbar Chronic Subdural Hematoma Treated by Fluoroscopic Guided Lumbar Puncture: A Case Report and Literature Review.

A 40-year-old man presented with a severe headache, lower back pain, and lower abdominal pain 1 month after a head injury caused by falling. Computed tomography (CT) of the head demonstrated bilateral chronic subdural hematoma (CSDH) with a significant amount in the left frontoparietal region. At the same time, magnetic resonance imaging (MRI) of the lumbar spine also revealed CSDH from L2 to S1 level. A simple drainage for the intracranial CSDH on the left side was performed. Postoperatively, the headache was improved; however, the lower back and abdominal pain persisted. Aspiration of the liquefied spinal subdural hematoma was performed by a lumbar puncture under fluoroscopic guidance. The clinical symptoms were dramatically improved postoperatively. Concomitant intracranial and spinal CSDH is considerably rare so only 23 cases including the present case have been reported in the literature so far. The etiology and therapeutic strategy were discussed with a review of the literature. Therapeutic strategy is not established for these two concomitant lesions. Conservative follow-up was chosen for 14 cases, resulting in a favorable clinical outcome. Although surgical evacuation of lumbosacral CSDH was performed in seven cases, an alteration of cerebrospinal fluid (CSF) pressure following spinal surgery should be reminded because of the intracranial lesion. Since CSDH is well liquefied in both intracranial and spinal lesion, a less invasive approach is recommended not only for an intracranial lesion but also for spinal lesion. Fluoroscopic-guided lumbar puncture for lumbosacral CSDH following burr hole surgery for intracranial CSDH could be a recommended strategy.

Traumatic Entrapment of the Vertebral Artery Demonstrated by a 3D Angiographic Study.

BACKGROUND: Vertebrobasilar artery entrapment resulting from a clivus fracture is rare. The entrapped lesions are not radiographically depicted precisely because they are only identified by autopsy or completely occluded. In addition, no changes in the features have been revealed clearly because radiologic examinations were performed only in the acute stage. CASE DESCRIPTION: We report a case of traumatic entrapment of the vertebral artery depicted precisely by a three-dimensional angiographic study in the subacute stage, presenting the serial changes in the morphologic features and a review of the published cases. CONCLUSION: It is necessary to manage vertebrobasilar artery entrapment cautiously because it is suggested that the entrapped lesion is accompanied by arterial dissection.