Predicting Functional Impairment in patients with chronic subdural hematoma treated with burr hole Trepanation-The FIT-score.

OBJECTIVE: It remains difficult to estimate prolonged functional impairment in patients with chronic subdural hematoma (cSDH) treated with burr hole trepanation. We aim to establish a score that reliably predicts postoperative functional impairment. PATIENTS AND METHODS: Retrospectively analysis of a prospective institutional database. cSDH patients operated in 2013-2016 were identified. Clinical outcome was dichotomized into presence (modified-Rankin-Scale (mRS) ≥ 2) or absence of functional impairment (mRS 0-1) at discharge and last follow-up. A score was developed, based on the effect sizes of a set of outcome predictors. Its accuracy was tested using Area Under the Receiver-Operating Characteristic (AUROC) curve analysis. The 2017 cohort served for internal validation. RESULTS: A cohort of 253 patients (mean age 75 years, 75% male) was analyzed, of which 77 patients (30%) remained functionally impaired. In multivariate analysis, severe motor deficits at admission (OR 5.84, 95% CI 2.71-12.59, p < 0.001), age (≥85 years: 5.53, 2.14-14.32, p < 0.0001) and disorientation at admission (2.65, 11.39-5.05, p = 0.003) were associated with persistent functional impairment. Based on those variables, we created the "Functional Impairment after burr hole Trepanation" (FIT-score), which showed an AUROC of 0.77 (95% CI 0.70-0.83) for impairment at discharge and 0.76 (0.70-0.82) for impairment at follow-up. Internal validation confirmed the model with an AUROC of 0.79 (0.68-0.91) at discharge and 0.77 (0.64-91) at follow-up. CONCLUSIONS: The FIT-score is likely to assist the physician when counseling patients and relatives pertaining to the need for postoperative rehabilitation and mid- to long-term supportive home care.

Efficacy of Reinforced Restriction of Physical Activity on Chronic Subdural Hematoma: Prospective Pilot Study.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common entity in neurosurgical practice. However, as a result of the high rate in recurrence, morbidity, and mortality for surgical management, conservative management of CSDH is emerging as a new treatment strategy. Head trauma is a known risk factor of CSDH and plays as an initiator in the genesis of CSDH. We hypothesized that physical activity might also play an important role in the progression of an asymptomatic CSDH. METHODS: A prospective pilot study aiming to evaluate the efficacy of reinforced restriction of physical activity for the management of asymptomatic or mild symptomatic CSDH was conducted. Twenty-six patients were enrolled in this study. RESULTS: All 26 patients experienced complete resolution of the CSDH ranging from 32 to 182 days (73.1 ± 19.6 days) since the initiation of reinforced restriction of physical activity. Ages ranged from 43 to 84 years old (64.4 ± 9.6 years). No patient experienced recurrence of CSDH during the follow-up. CONCLUSIONS: According to our study, physical activity might play a role in the progression of CSDH. Further prospective randomized controlled study is warranted in stable patients without evident intracranial hypertension and impending cerebral herniation.

Postoperative rehabilitation for chronic subdural hematoma in the elderly. An observational study focusing on balance, ambulation and discharge destination.

BACKGROUND: Chronic subdural hematoma (CSDH) can have a negative impact on autonomy of the elderly. Ambulatory and functional status may remain limited despite successful surgical evacuation. AIM: To evaluate the outcome of a postoperative assisted rehabilitation program. DESIGN: Single-institution short-term observational study. SETTING: Inpatient (Neurosurgery Unit of a University Hospital). POPULATION: Thirty-five patients, aged 65 or older, who underwent burr-hole drainage for chronic subdural hematoma. METHODS: Postoperatively all participants underwent a rehabilitation program, described in details, aimed at recovering standing position and gait as soon as possible. The program involved daily 30-minute individual sessions assisted by a physiotherapist, until discharge from hospital. The Markwalder's Grading Scale was used to assess the neurological status preoperatively and at discharge. The Trunk Control Test, the Standing Balance by Bohannon Scale and the Modified Rankin Scale were used to evaluate balance and general function (primary outcome) in the immediate postoperative and at discharge. We also recorded the rate of pre-CSDH walking patients who maintained ambulation at discharge and the discharge destination (secondary outcome). RESULTS: Total scores of Markwalder's Grading Scale, Trunk Control Test, Standing Balance by Bohannon Scale and Modified Rankin Scale improved (P<0.05), indicating a global favorable outcome, especially for balance. Excluding the patients who were dependent pre-CSDH, the others maintained gait function in 74.2% of cases. Only 45.7% of the patients were discharged home, the others being divided between inpatient medical settings and rehabilitation. CONCLUSIONS: The rehabilitation program was well tolerated by the patients. Our study showed a clear improvement in trunk control and standing balance and an overall favorable outcome for neurological and ambulatory status at discharge. Despite an assisted postoperative rehabilitation program, the residual impairment in general function was the main factor that prevents us to discharge more elderly patients home rather than to assisted settings. CLINICAL REHABILITATION IMPACT: The results of this descriptive study suggest that an assisted rehabilitation program may be helpful in improving short-term postoperative balance and ambulatory status (more than functional status), but further studies, with a randomized controlled design, are certainly justified to understand the efficacy of rehabilitation in this context.

Post-operative day two versus day seven mobilization after burr-hole drainage of subacute and chronic subdural haematoma in Nigerians.

INTRODUCTION: The traditional care of patients with subacute/chronic subdural haematoma (S/CSDH) often involves delayed mobilization after burr-hole drainage. It is thought that delayed mobilization aids brain re-expansion thereby reducing the risk of recurrence. However, there is paucity of information regarding its efficacy and safety over early mobilization. We evaluated the efficacy and complications of each type of mobilization following burr-hole drainage of S/CSDH. METHOD: This was a prospective study from October 2004 and September 2010. A total of 50 patients who had burr-hole drainage of S/CSDH were sequentially allocated to either early (day 2) or late (day 7) mobilization (EM or LM) groups (25 patients in each group). Wound related complications, recurrence of haematoma, complications of prolonged bed rest and Glasgow Outcome Score (GOS) at discharge were studied in the two groups. Patients who could not obey commands to mobilize in the early post-operative period were excluded. RESULTS: There were 43 (86%) males and 7 (14%) females. The mean age was 57 years (range: 27-90 years). Fourteen (28%) of the patients were elderly (age > 65 years). Two complications, wound infection in a 76-year old man in the LM group and tension pneumocephalus requiring re-opening burr-hole drainage in a 55-year old man in the EM group were recorded. There was no recurrence or problem associated with prolonged bed rest in the two groups. Five (10%) patients had moderate disability (GOS 4) at discharge (1 EM, 4 LM) while the others (90%) had good recovery (GOS 5) (24 EM, 21 LM). These differences were not statistically significant (p-value: 0.349). CONCLUSION: It appears that both EM and LM are equally beneficial in the post-operative care of patients following burr-hole drainage of S/CSDH. There is no significant complication referable to the specific type of mobilization. The authors, therefore, advocate EM of patients to reduce the length of hospital stay.

Chronic subdural hematoma in the elderly: not a benign disease.

OBJECT: Chronic subdural hematoma (CSDH) is perceived to be a "benign," easily treated condition in the elderly, but reported follow-up periods are brief, usually limited to acute hospitalization. METHODS: The authors conducted a retrospective review of data obtained in a prospectively identified consecutive series of adult patients admitted to their institution between September 2000 and February 2008 and in whom there was a CT diagnosis of CSDH. Survival data were compared to life-table data. RESULTS: Of the 209 cases analyzed, 63% were men and the mean age was 80.6 years (range 65-96 years). Primary surgical interventions performed were bur holes in 21 patients, twist-drill closed-system drainage in 44, and craniotomies in 72. An additional 72 patients were simply observed. Reoperations were recorded in 5 patients-4 who had previously undergone twist-drill drainage and 1 who had previously undergone a bur hole procedure (p = 0.41, chi-square analysis). Thirty-five patients (16.7%) died in hospital, 130 were discharged to rehabilitation or a skilled care facility, and 44 returned home. The follow-up period extended to a maximum of 8.3 years (median 1.45 years). Six-month and 1-year mortality rates were 26.3% and 32%, respectively. In the multivariate analysis (step-wise logistic regression), the sole factor that predicted in-hospital death was neurological status on admission (OR 2.1, p = 0.02, for each step). Following discharge, the median survival in the remaining cohort was 4.4 years. In the Cox proportional hazards model, only age (hazard ratio [HR] 1.06/year, p = 0.02) and discharge to home (HR 0.24, p = 0.01) were related to survival, whereas the type of intervention, whether surgery was performed, size of subdural hematoma, amount of shift, bilateral subdural hematomas, and anticoagulant agent use did not affect the long- or short-term mortality rate. Comparison of postdischarge survival and anticipated actuarial survival demonstrated a markedly increased mortality rate in the CSDH group (median survival 4.4 vs 6 years, respectively; HR 1.94, p = 0.0002, log-rank test). This excess mortality rate was also observed at 6 months postdischarge with evidence of normalization only at 1 year. CONCLUSIONS: In this first report of the long-term outcome of elderly patients with CSDH the authors observed persistent excess mortality up to 1 year beyond diagnosis. This belies the notion that CSDH is a benign disease and indicates it is a marker of other underlying chronic diseases similar to hip fracture.

Efficacy and safety of postoperative early mobilization for chronic subdural hematoma in elderly patients.

BACKGROUND: The incidences of chronic subdural hematoma (CSDH) will probably increase with the aging of the population; thus, postoperative care of elderly CSDH patients may play a more important role in surgical management. The aim of this study was to evaluate the efficacy of and adverse effects after postoperative early mobilization (EM) for elderly CSDH patients. METHODS: This is a single-institution historical control study. One hundred eighty-two patients with CSDH aged 65 years and older underwent one burr-hole surgery between 2001 and 2008. This institution has prospectively conducted an EM protocol after surgery since 2005. The emphasis of the EM was helping patients not only to an upright position but also to walk beginning the day of operation. The incidences of postoperative complications and recurrence of CSDH were compared between the EM group (n = 91; 76.5 +/- 6.5 years old) and a delayed mobilization (DM) group (n = 91; 77.9 +/- 7.5 years old). RESULTS: Postoperative complications, such as pneumonia and urinary tract infection, was observed in 24 (26.4%) in the DM group and 11 (12.1%) in the EM group (p < 0.05). The rate of recurrence did not differ between the two groups (6.6% and 8.8%, respectively; p = 0.58). CONCLUSIONS: The results suggest that EM after one burr-hole surgery prevents postoperative complications without increasing the risk of recurrence in CSDH patients > or =65 years of age.

Number of burr holes as independent predictor of postoperative recurrence in chronic subdural haematoma.

Chronic subdural haematoma (cSDH) is one of the most frequent neurosurgical entities. Current treatment options include burr hole craniostomy, twist drill craniostomy or craniotomy. While burr hole craniostomy is the most often used technique, there are no studies analysing the use of one vs. two burr holes in respect to recurrence rates and complications. This retrospective study included 76 (age: 60 +/- 12 years) patients presenting with cSDH admitted in our institution from January 2004 to December 2005. A total of 21 (27%) patients underwent bilateral craniostomy. The patients were assessed using the Markwalder Scale (2 +/- 0.71), Glasgow Coma Scale (14 +/- 1) and measuring the haematoma thickness (1.8 +/- 0.7 cm). The decision to perform one or two burr hole was made according to the personal preference of the treating neurosurgeon. All patients underwent irrigation and placement of closed-system drainage. Out of the 97 haematoma, 63 (65%) haematomas were treated with two burr holes, whereas 34 (35%) were treated with one burr hole. Patients with one burr hole had a statistically significant (p < 0.05) higher recurrence rate (29 vs. 5%), longer average hospitalization length (11 vs. 9 days) and higher wound infection rate (9% vs. 0%). A multivariate regression analysis identified the number of holes as single predictor for postoperative recurrence rate (r(2) = 0.12; p < 0.001). In this study, the treatment of cSDH with one burr hole only is associated with a significantly higher postoperative recurrence rate, longer hospitalization length and higher wound infection rate.

[Chronic and subacute subdural haematoma. An epidemiological study in a captive population]. / Hematoma subdural crónico y subagudo. Estudio epidemiológico en una población cautiva.

INTRODUCTION: Although chronic and subacute subdural haematomas (CSSH) are amongst the commonest neurosurgical conditions, there are few studies on their incidence in the general population. OBJECTIVES: To determine the overall annual rate, the specific rates according to age and sex based on the Official Argentinian National Census of 1991 (OANC 91) for CSSH. PATIENTS AND METHODS: The Hospital Privado de Comunidad de Mar del Plata attends a captive population of 89,500 persons from the Instituto Nacional de Servicios Sociales de Jubilados y Pensionados (INSSJP) and the Prepaid Medical Schemes (PMP) of our institution. We studied the patients of INSSJP and PMP who had CSSH between 1992 and 1996. We determined the annual overall rate and the specific rates according to age and sex, and fitted to the OANC 91. RESULTS: 1. Annual overall rate: 14.1 CSSH/100,000 persons/year. 2. Specific rate for women: 11.6 CSSH/100,000 persons/year. 3. Specific rate for men: 18.1 CSSH/100,000 persons/year. 4. Specific rate 71-80 years old: 18.8 CSSH/100,000 persons/year. 5. Rate fitted to OANC9: 3.1 CSSH/100,000 persons/year. CONCLUSIONS: Our overall rate is higher, and the specific rate for the age group 71-80 years is intermediate, with regard to the rates found in other studies. Neuroepidemiological investigation should be stimulated so that more clinical studies are made regarding the results and costs based on the population.