Management of Subdural Hematohygromas in Abusive Head Trauma.

BACKGROUND: The optimal management of nonacute subdural fluid collections in infantile abusive head trauma (AHT) remains controversial. OBJECTIVE: To review the outcomes and costs of the various treatments for symptomatic subdural fluid collections in children with AHT at a single center. METHODS: Our AHT database was queried to identify children requiring any intervention for hematohygromas. Demographic, hospital course, radiologic, cost, readmission, and follow-up information were collected. RESULTS: From January 2009 to March 2018, the authors identified 318 children with AHT, of whom 210 (66%) had a subdural collection of any type (blood or cerebrospinal fluid). A total of 50 required some form of intervention specifically for chronic hematohygromas. The initial management consisted of transfontanelle percutaneous aspiration (n = 31), burr holes with (n = 12) or without (n = 3) external subdural drainage, and mini-craniotomy (n = 4). Of those who were initially managed with 1 or more needle aspiration, 23 (74%) required further intervention-12 subduroperitoneal shunts and 11 nonshunt procedures. No patient who underwent burr holes/external drainage required further intervention (n = 16). Overall, the average number of interventions needed in these 50 children for definitive treatment was 1.8 (range, 1-4). A total of 15 children ultimately required a subduroperitoneal shunt. Complications (infectious, hemorrhagic, and thrombotic) were significant and occurred in all treatment groups except burr holes without drainage (n = 3). The average hospital charge for the entire cohort was $166 300.25 (range, $19 126-$739 248). CONCLUSION: Based on our experience to date, burr hole with controlled external subdural drainage is an effective and preferred treatment for traumatic hematohygromas; complications and need for additional intervention is low.

Emergent and Urgent Craniotomies in Pediatric Patients: Resource Utilization and Cost Analysis.

BACKGROUND: Pediatric neurosurgeons are occasionally tasked with performing surgery expeditiously to preserve a child's neurologic faculties and life. OBJECTIVE: This study examines the etiologies, outcomes, and costs for urgent or emergent craniotomies at a Level I Pediatric Trauma center over a 7-year time period. METHODS: A retrospective review was conducted for each patient who underwent an emergent or urgent craniotomy within 24 hours of presentation between January 2010 and April 2017. Demographic, clinical, and surgical details were recorded for a total of 48 variables. Any readmission within 90 days was analyzed. Hospital charges for each admission and readmission were collected and adjusted for inflation to October 2018 values. RESULTS: Among the 223 children who underwent urgent or emergent craniotomies, the majority were admitted for traumatic injuries (n = 163, 73.1%). The most common traumatic mechanism was fall (n = 51, 22.9%), and the most common non-traumatic cause was tumor (n = 21, 9.4%). Overall, craniotomies were typically performed for hematoma evacuation of one type or combination (n = 115, 51.6%) during off-peak times (n = 178, 79.8%). Seventy-seven (34.5%) subjects experienced 1 or more postoperative events, 22 of whom returned to the operating room. There were 13 (5.8%) and 33 (14.8%) readmissions within 30 days and 90 days of discharge, respectively. Non-trauma patients (compared with trauma patients) and polytrauma (compared with isolated head injury) had greater healthcare needs, resulting in higher charges. CONCLUSION: Most urgent or emergent pediatric craniotomies were performed for the treatment of traumatic injuries involving hematoma evacuation, but non-traumatic patients were more complex requiring greater resources.

Image Guidance for Ventricular Shunt Surgery: An Analysis of Hospital Charges.

BACKGROUND: Image guidance for shunt surgery results in more accurate proximal catheter placement. However, reduction in shunt failure remains unclear in the literature. There have been no prior studies evaluating the cost effectiveness of neuronavigation for shunt surgery. OBJECTIVE: To perform a cost analysis using available hospital charges of hypothetical shunt surgery performed with/without electromagnetic neuronavigation (EMN). METHODS: Hospital charges were collected for physician fees, radiology, operating room (OR) time and supplies, postanesthesia care unit, hospitalization days, laboratory, and medications. Index shunt surgery charges (de novo or revision) were totaled and the difference calculated. This difference was compared with hospital charges for shunt revision surgery performed under 2 clinical scenarios: (1) same hospital stay as the index surgery; and (2) readmission through the emergency department. RESULTS: Costs for freehand de novo and revision shunt surgery were $23 946.22 and $23 359.22, respectively. For stealth-guided de novo and revision surgery, the costs were $33 646.94 and $33 059.94, a difference of $9700.72. The largest charge increase was due to additional OR time (34 min; $4794), followed by disposable EMN equipment ($2672). Total effective charges to revise the shunt for scenarios 1 and 2 were $34 622.94 and $35 934.94, respectively. The cost ratios between the total revision charges for both scenarios and the difference in freehand vs EMN-assisted shunt surgery ($9700.72) were 3.57 and 3.70, respectively. CONCLUSION: From an economic standpoint and within the limitations of our models, the number needed to prevent must be 4 or less for the use of neuronavigation to be considered cost effective.