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van Essen TA, Res L, Schoones J, de Ruiter G, Dekkers O, Maas A, Peul W, van der Gaag NA. 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? J Neurotrauma 2023; 40:22-32. [PMID: 35699084 DOI: 10.1089/neu.2022.0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
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.
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Affiliation(s)
- Thomas Arjan van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lodewijk Res
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Jan Schoones
- Directorate of Research Policy (Walaeus Library), and Leiden University Medical Center, Leiden, The Netherlands
| | - Godard de Ruiter
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Olaf Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Wilco Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands
| | - Niels Anthony van der Gaag
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden-The Hague, Department of Neurosurgery, Leiden, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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Baker C, Cox P, Gamboa NT, Bollo RJ. Pediatric Traumatic Brain Injury in a Geographically Dispersed Population: A Relationship Between Distance to Definitive Neurosurgical Treatment and Outcome. World Neurosurg 2022; 166:e924-e932. [PMID: 35940502 DOI: 10.1016/j.wneu.2022.07.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND There are limited data on the association between transport distance and outcomes in pediatric patients with severe traumatic brain injuries (sTBIs), despite children having to travel further to pediatric trauma centers (PTCs). OBJECTIVE To assess whether distance from a PTC is associated with outcomes in children who undergo cranial surgery after sTBI. METHODS Children with sTBI who underwent craniectomy/craniotomy at our PTC between 2010 and 2019 were identified retrospectively. Of these 92 patients, 83 sustained blunt injury and underwent surgery within 24 hours. The distance from injury location to PTC was based on injury zip code and calculated as Euclidean distance. Variables associated with transport, including distance, time, and rural-urban disparity, were analyzed for correlation with poor outcome. RESULTS Of the 83 patients identified, 81 had injury location information. Forty patients were injured within 30 miles and 41 were injured ≥30 miles from the PTC. Injury severity and pediatric trauma scores were not significantly different between groups. Sixty-eight children (82%) had a satisfactory outcome and 10 children (12%) died. There was a nonsignificant association between distance traveled and poor outcome, even when the cohort was stratified into those with subdural hematomas and those with nonabusive injuries. CONCLUSIONS Regardless of the distance from the PTC at which their injury occurred, most children in this cohort made a moderate to good recovery. Children injured at greater distances from the PTC did not have worse outcomes; however, studies with larger cohorts are needed to more definitively assess prehospital pediatric transport systems in this population.
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Affiliation(s)
- Cordell Baker
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Parker Cox
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Nicholas T Gamboa
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA.
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Choksi EJ, Mukherjee K, Kamal KM, Yocom S, Salazar R. Length of Stay, Cost, and Outcomes related to Traumatic Subdural Hematoma in inpatient setting in the United States. Brain Inj 2022; 36:1237-1246. [PMID: 35997302 DOI: 10.1080/02699052.2022.2110285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE In the US, the prevalence of traumatic subdural hematoma (TSDH) continues to increase. Using a nationally representative sample of discharge records of patients with TSDH, the study objectives were to estimate trend in number of TSDH cases, surgical management, inpatient cost, length of stay (LOS), mortality rate, and complication rate; and to identify the association of sociodemographic, clinical and hospital characteristics with complications and mortality. METHOD We identified patients with a primary diagnosis of TSDH from the National Inpatient Sample (NIS) database from 2010 to 2017. Quarterly and monthly trends were estimated using interrupted time series design. Multivariate logistic regressions measured association between various factors and inpatient death and complications. RESULTS Number of cases, mean LOS, rate of complication increased. Proportion of patients undergoing surgery, mean inpatient cost, inpatient mortality decreased. Mean inpatient cost was $23,182.40 and LOS was 6.41 days. Odds of inpatient death and complications increased with injury severity score and comorbid conditions requiring use of anticoagulants. Odds of inpatient death were highest among those ≥85 years old and in south and northeast region. CONCLUSION Given the increase in prevalence of TSDH in USA, additional resources should be allocated toward improving patient outcomes and lowering healthcare costs.
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Affiliation(s)
- Eshani J Choksi
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Kumar Mukherjee
- Pharmacy Practice, Philadelphia College of Osteopathic Medicine, Suwanee, Georgia
| | - Khalid M Kamal
- Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Morgantown, West Virginia, USA
| | - Steven Yocom
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania, USA.,Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Richard Salazar
- Department of Neurology, Jackson Clinic, Montgomery, Alabama, USA
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Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med 2021; 29:113. [PMID: 34348784 PMCID: PMC8340517 DOI: 10.1186/s13049-021-00930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00930-1.
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Affiliation(s)
- Charlie Aletta Sewalt
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Benjamin Yaël Gravesteijn
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Esmee Venema
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - Fiona E Lecky
- Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Aromatario M, Torsello A, D’Errico S, Bertozzi G, Sessa F, Cipolloni L, Baldari B. Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57020125. [PMID: 33535407 PMCID: PMC7912597 DOI: 10.3390/medicina57020125] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 01/20/2021] [Accepted: 01/22/2021] [Indexed: 04/09/2023]
Abstract
Epidural hematomas (EDHs) and subdural hematomas (SDHs), or so-called extra-axial bleedings, are common clinical entities after a traumatic brain injury (TBI). A forensic pathologist often analyzes cases of traumatic EDHs or SDHs due to road accidents, suicides, homicides, assaults, domestic or on-the-job accidents, and even in a medical responsibility scenario. The aim of this review is to give an overview of the published data in the medical literature, useful to forensic pathologists. We mainly focused on the data from the last 15 years, and considered the most updated protocols and diagnostic-therapeutic tools. This study reviews the epidemiology, outcome, and dating of extra-axial hematomas in the adult population; studies on the controversial interdural hematoma are also included.
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Affiliation(s)
| | - Alessandra Torsello
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Stefano D’Errico
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy;
| | - Giuseppe Bertozzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
- Correspondence:
| | - Francesco Sessa
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Luigi Cipolloni
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Ospedale Colonnello D’Avanzo, Via degli Aviatori 1, 71100 Foggia, Italy; (A.T.); (F.S.); (L.C.)
| | - Benedetta Baldari
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, 00186 Rome, Italy;
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Shahrestani S, Strickland BA, Micko A, Brown NJ, Zada G. Management of acute subdural hematoma in incarcerated patients. Clin Neurol Neurosurg 2020; 201:106441. [PMID: 33360952 DOI: 10.1016/j.clineuro.2020.106441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/05/2020] [Accepted: 12/13/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Incarcerated patients have been documented to have higher rates of mental illness, substance abuse disorders, trauma, and chronic illnesses compared to non-incarcerated populations. In this study, we evaluated the incidence of subdural hematoma (SDH) in incarcerated patients and compared the outcomes of these patients to those of non-incarcerated patients. METHODS We conducted a retrospective cohort study of incarcerated patients admitted to a hospital with acute SDH using the Nationwide Readmissions Database between 2016-2017. Nearest-neighbor propensity score matching for demographics was implemented to identify non-incarcerated control patients admitted with SDH. Analysis used chi-squared testing, Mann-Whitney U testing, and generalized binomial regression modeling. RESULTS A total of 962 incarcerated and non-incarcerated patients were identified at primary admission. No significant difference was found between the two cohorts with regards to rates of neurosurgical complications or readmissions. Incarcerated patients were found to receive a significantly lower number of procedures, including respiratory ventilation, intubation, central venous line placement, and imaging, during their primary admission (NPR = 2.7 ± 4.0) compared to non-incarcerated patients (NPR = 3.9 ± 4.9) (p = 0.00050), reduced length of stay (p = 0.0052), and reduced hospital costs (p = 0.00026) compared to non-incarcerated patients. Furthermore, female incarcerated patients with SDH had significantly worse outcomes compared to male patients with SDH, including higher rates of mortality (p = 0.0017) and 30-day readmission rates (p = 0.041). DISCUSSION Our study suggests that incarcerated patients may receive significantly fewer diagnostic and supportive procedures while admitted for SDH and may be discharged sooner than non-incarcerated patients with SDH. In addition, outcomes following SDH within incarcerated patients may be significantly worse for females.
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Affiliation(s)
- Shane Shahrestani
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Medical Engineering, California Institute of Technology, Pasadena, CA, USA.
| | - Ben A Strickland
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Alexander Micko
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Neurological Surgery, Medical University of Vienna, Vienna, Austria
| | - Nolan J Brown
- University of California Irvine School of Medicine, Irvine, CA, USA
| | - Gabriel Zada
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Lee H, Tan C, Tran V, Mathew J, Fitzgerald M, Leong R, Kambourakis T, Gantner D, Udy A, Hunn M, Rosenfeld JV, Tee J. The Utility of the Modified Frailty Index in Outcome Prediction for Elderly Patients with Acute Traumatic Subdural Hematoma. J Neurotrauma 2020; 37:2499-2506. [DOI: 10.1089/neu.2019.6943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hui Lee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
| | - Caleb Tan
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Vanessa Tran
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
| | - Joseph Mathew
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Trauma Services, Alfred Health, Melbourne, Victoria, Australia
| | - Ronald Leong
- Aged Care Services, Alfred Health, Melbourne, Victoria, Australia
| | | | - Dashiell Gantner
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Intensive Care Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Martin Hunn
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Jin Tee
- National Trauma Research Institute (NTRI), Melbourne, Victoria, Australia
- Department of Neurosurgery, Alfred Health, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Evaluating the safety of early surgery for ruptured intracranial aneurysms in patients with long-term aspirin use: a propensity score matching study. Chin Neurosurg J 2020; 6:37. [PMID: 33292864 PMCID: PMC7702666 DOI: 10.1186/s41016-020-00216-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/06/2020] [Indexed: 12/30/2022] Open
Abstract
Background Early microsurgical clipping is recommended for ruptured intracranial aneurysms to prevent rebleeding. However, dilemma frequently occurs when managing patients with current acetylsalicylic acid (aspirin) use. This study aimed to examine whether aspirin use was associated with worse outcomes after early surgery for aneurysmal subarachnoid hemorrhage (aSAH). Methods We retrieved a consecutive series of 215 patients undergoing early microsurgical clipping within 72 h after aneurysmal rupture from 2012 to 2018 in the neurosurgery department of Beijing Tiantan Hospital. The medical records of each case were reviewed. Twenty-one patients had a history of long-term aspirin use before the onset of aSAH, and 194 patients did not. To reduce confounding bias, propensity score matching (PSM) was performed to balance some characteristics of the two groups. The intraoperative blood loss, postoperative hemorrhagic events, postoperative hospital stay, and functional outcome at discharge were compared between aspirin and non-aspirin group. Results We matched all the 21 patients in aspirin group with 42 patients in non-aspirin group (1:2). Potential confounding factors were corrected between the two groups by PSM. No hospital mortality occurred after surgery. No significant differences were found in intraoperative blood loss (P = 0.540), postoperative hemorrhagic events (P > 0.999), postoperative hospital stay (P = 0.715), as well as functional outcome at discharge (P = 0.332) between the two groups. Conclusions Our preliminary results showed that long-term low-dose aspirin use was not associated with worse outcomes. Early surgery can be safe for ruptured intracranial aneurysms in patients with long-term aspirin use.
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Chen SH, Sun JM, Fang WK. The impact of time from injury to surgery in functional recovery of traumatic acute subdural hematoma. BMC Neurol 2020; 20:226. [PMID: 32498710 PMCID: PMC7271514 DOI: 10.1186/s12883-020-01810-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 05/28/2020] [Indexed: 11/27/2022] Open
Abstract
Background The time from injury to surgery (TIS) is critical in the functional recovery of individuals with traumatic acute subdural hematoma (TASDH). However, only few studies have confirmed such notion. Methods The data of TASDH patients who were surgically treated in Chia-Yi Christian Hospital between January 2008 and December 2015 were collected. The significance of variables, including age, sex, traumatic mechanism, coma scale, midline shift on brain computed tomography (CT) scan, and TIS, in functional recovery was assessed using the student’s t-test, Mann-Whitney U test, chi-square test, univariate and multivariate models, and receiver operating characteristic (ROC) curve. Results A total of 37 patients achieved functional recovery (outcome scale score of 4 or 5) and 33 patients had poor recovery (outcome scale score of 1–3) after at least 1 year of follow-up. No significant difference was observed in terms of age, sex, coma scale score, traumatic mechanism, or midline shift on brain CT scan between the functional and poor recovery groups. TIS was found to be significantly shorter in the functional recovery group than in the poor recovery group (145.5 ± 27.0 vs. 181.9 ± 54.5 min, P-value = 0.002). TIS was a significant factor for functional outcomes in the univariate and multivariate regression models. The analysis of TIS with the ROC curve between these two groups showed that the threshold time for functional recovery in comatose patients and those with TASDH who were surgically treated was 2 h and 57.5 min. Conclusions TIS is an important factor l for the functional recovery of comatose TASDH patients who underwent surgery.
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Affiliation(s)
- Shih-Han Chen
- Neurosurgical Department, Ditmanson Medical Foundation Chia-Yi Christian Hospital, No. 539, Zhongxiao Rd, Chia-Yi City, Taiwan, 60002.
| | - Jui-Ming Sun
- Neurosurgical Department, Ditmanson Medical Foundation Chia-Yi Christian Hospital, No. 539, Zhongxiao Rd, Chia-Yi City, Taiwan, 60002
| | - Wen-Kuei Fang
- Neurosurgical Department, Ditmanson Medical Foundation Chia-Yi Christian Hospital, No. 539, Zhongxiao Rd, Chia-Yi City, Taiwan, 60002
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10
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Simulation-based training is associated with lower risk-adjusted mortality in ACS pediatric TQIP centers. J Trauma Acute Care Surg 2020; 87:841-848. [PMID: 31589193 DOI: 10.1097/ta.0000000000002433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Although use of simulation-based team training for pediatric trauma resuscitation has increased, its impact on patient outcomes has not yet been shown. The purpose of this study was to determine the association between simulation use and patient outcomes. METHODS Trauma centers that participate in the American College of Surgeons (ACS) Pediatric Trauma Quality Improvement Program (TQIP) were surveyed to determine frequency of simulation use in 2014 and 2015. Center-specific clinical data for 2016 and 2017 were abstracted from the ACS TQIP registry (n = 57,916 patients) and linked to survey responses. Center-specific risk-adjusted mortality was estimated using multivariable hierarchical logistic regression and compared across four levels of simulation-based training use: no training, low-volume training, high-volume training, and survey nonresponders (unknown training use). RESULTS Survey response rate was 75% (94/125 centers) with 78% of the responding centers (73/94) reporting simulation use. The average risk-adjusted odds of mortality was lower in centers with a high volume of training compared with centers not using simulation (odds ratio, 0.58; 95% confidence interval, 0.37-0.92). The times required for resuscitation processes, evaluations, and critical procedures (endotracheal intubation, head computed tomography, craniotomy, and surgery for hemorrhage control) were not different between centers based on levels of simulation use. CONCLUSION Risk-adjusted mortality is lower in TQIP-Pediatric centers using simulation-based training, but this improvement in mortality may not be mediated by a reduction in time to critical procedures. Further investigation into alternative mediators of improved mortality associated with simulation use is warranted, including assessment of resuscitation quality, improved communication, enhanced teamwork skills, and decreased errors. LEVEL OF EVIDENCE Therapeutic/care management, Level III.
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Abstract
AbstractHead injury remains the most common cause of death and disability in young people. The most frequent consequences of traumatic brain injury (TBI) are extra-axial hemorrhage, i.e., an acute subdural hematoma (SDH) and epidural hematoma (EDH), which usually require a surgical treatment. The aim of the study is to present the distinguished clinical features associated with patients being surgically treated for post-traumatic EDH and SDH. The study included a group of 128 patients with isolated craniocerebral injuries. All the patients were operated. The following factors from the groups were analyzed: demographic data, physiological factors, laboratory factors, computed tomography scan characteristics, the time between trauma and surgery, and the in-hospital mortality. Using statistical analysis, we compared the studied factors in patients operated on due to EDH and SDH. Patients with SDH were older than patients with EDH. Most often, extra-axial hematomas affected men. Patients with SDH were more severe condition than patients with EDH on admission. Abnormal systolic blood pressure was the most common manifestation of dysautonomia in both groups. In the SDH group, we observed hypotension more often than hypertension. Hyperglycemia was one of the most common anomalies in laboratory factors in both groups. Hypotension and hyperglycemia were that factors significantly associated with outcome after head injuries. SDH caused greater midline shift and often pressed in basal cisterns. Patients with SDH died more often than patients with EDH.
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Altaf I, Shams S, Vohra AH. Role of surgical modality and timing of surgery as clinical outcome predictors following acute subdural hematoma evacuation. Pak J Med Sci 2020; 36:412-415. [PMID: 32292444 PMCID: PMC7150407 DOI: 10.12669/pjms.36.3.1771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background & Objective: A Craniotomy (CO) or decompressive craniectomy (DC) are the two main surgical procedures employed for evacuation of acute traumatic subdural hematoma (ASDH). However, the optimal surgical procedure remains controversial. The beneficial effect of early surgical evacuation of acute subdural hematoma in improving outcome also remains unclear. Our objective was to study the role of these two parameters in determining the outcome in patients undergoing surgical evacuation of acute traumatic subdural hematoma. Methods: A retrospective analysis of 58 patients presenting with acute traumatic subdural hematoma and with presenting Glasgow Coma Scale (GCS) ≤ 8 that had been operated in Lahore General Hospital between June 2014 and July 2015 was performed. The demographic data, preoperative GCS, type of surgical procedure performed and timing of surgery were analysed. Results: Forty (69%) patients underwent CO, and eighteen (31%) patients underwent DC. The CO and DC groups showed no difference in the demographic data and preoperative GCS. Six patients survived in the craniotomy group, while none survived in the decompressive craniectomy group (p=0.083). The relationship of timing of surgery with survival in the craniotomy group was found not to be clinically significant (p=0.87). Conclusion: In this study craniotomy was associated with a better outcome as compared to decompressive craniectomy, however, the difference did not reach statistical significance. Early surgery was also found not to be associated with an improved outcome.
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Affiliation(s)
- Imran Altaf
- Dr. Imran Altaf, MS. Department of Neurosurgery, Khawja Muhammad Safdar Medical College, Sialkot, Pakistan
| | - Shahzad Shams
- Dr. Shahzad Shams, FRCS, FCPS. Department of Neurosurgery, King Edward Medical University, , Lahore, Pakistan
| | - Anjum Habib Vohra
- Dr. Anjum Habib Vohra, FRCS. Department of Neurosurgery, Post Graduate Medical Institute, Lahore General Hospital, Lahore, Pakistan
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Shackelford SA, Del Junco DJ, Reade MC, Bell R, Becker T, Gurney J, McCafferty R, Marion DW. Association of time to craniectomy with survival in patients with severe combat-related brain injury. Neurosurg Focus 2019; 45:E2. [PMID: 30544314 DOI: 10.3171/2018.9.focus18404] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 09/12/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEIn combat and austere environments, evacuation to a location with neurosurgery capability is challenging. A planning target in terms of time to neurosurgery is paramount to inform prepositioning of neurosurgical and transport resources to support a population at risk. This study sought to examine the association of wait time to craniectomy with mortality in patients with severe combat-related brain injury who received decompressive craniectomy.METHODSPatients with combat-related brain injury sustained between 2005 and 2015 who underwent craniectomy at deployed surgical facilities were identified from the Department of Defense Trauma Registry and Joint Trauma System Role 2 Registry. Eligible patients survived transport to a hospital capable of diagnosing the need for craniectomy and performing surgery. Statistical analyses included unadjusted comparisons of postoperative mortality by elapsed time from injury to start of craniectomy, and Cox proportional hazards modeling adjusting for potential confounders. Time from injury to craniectomy was divided into quintiles, and explored in Cox models as a binary variable comparing early versus delayed craniectomy with cutoffs determined by the maximum value of each quintile (quintile 1 vs 2-5, quintiles 1-2 vs 3-5, etc.). Covariates included location of the facility at which the craniectomy was performed (limited-resource role 2 facility vs neurosurgically capable role 3 facility), use of head CT scan, US military status, age, head Abbreviated Injury Scale score, Injury Severity Score, and injury year. To reduce immortal time bias, time from injury to hospital arrival was included as a covariate, entry into the survival analysis cohort was defined as hospital arrival time, and early versus delayed craniectomy was modeled as a time-dependent covariate. Follow-up for survival ended at death, hospital discharge, or hospital day 16, whichever occurred first.RESULTSOf 486 patients identified as having undergone craniectomy, 213 (44%) had complete date/time values. Unadjusted postoperative mortality was 23% for quintile 1 (n = 43, time from injury to start of craniectomy 30-152 minutes); 7% for quintile 2 (n = 42, 154-210 minutes); 7% for quintile 3 (n = 43, 212-320 minutes); 19% for quintile 4 (n = 42, 325-639 minutes); and 14% for quintile 5 (n = 43, 665-3885 minutes). In Cox models adjusted for potential confounders and immortal time bias, postoperative mortality was significantly lower when time to craniectomy was within 5.33 hours of injury (quintiles 1-3) relative to longer delays (quintiles 4-5), with an adjusted hazard ratio of 0.28, 95% CI 0.10-0.76 (p = 0.012).CONCLUSIONSPostoperative mortality was significantly lower when craniectomy was initiated within 5.33 hours of injury. Further research to optimize craniectomy timing and mitigate delays is needed. Functional outcomes should also be evaluated.
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Affiliation(s)
| | - Deborah J Del Junco
- 1Joint Trauma System, Defense Center of Excellence, San Antonio.,2Department of Epidemiology and Biostatistics, University of Texas Health Science Center, San Antonio, Texas
| | - Michael C Reade
- 3Joint Health Command, Australian Defence Force, Brisbane, Queensland, Australia
| | - Randy Bell
- 4Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | - Jennifer Gurney
- 1Joint Trauma System, Defense Center of Excellence, San Antonio
| | - Randall McCafferty
- 6Neurosurgery, San Antonio Military Medical Center, San Antonio, Texas; and
| | - Donald W Marion
- 7Defense and Veterans Brain Injury Center, Silver Spring, Maryland
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Atalay T, Ak H, Gülsen I, Karacabey S. Risk factors associated with mortality and survival of acute subdural hematoma: A retrospective study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2019; 24:27. [PMID: 31007697 PMCID: PMC6450130 DOI: 10.4103/jrms.jrms_14_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 04/09/2016] [Accepted: 05/02/2016] [Indexed: 11/28/2022]
Abstract
Background: Acute subdural hematoma (ASDH) is mostly seen after head injury and is a major cause of morbidity and mortality. We studied the risk factors for ASDH and the effects of these factors on mortality as well as on survival with 100 cases from the rural area of Anatolia region. Materials and Methods: One-hundred cases of the ASDH that had been treated surgically between 2011 and 2014, at three different health-care centers from the rural area of Anatolia region, were retrospectively reviewed. Demographic data of patients, etiology, Glasgow Coma Scale (GCS) on admission, survival, presence of comorbid disease, unilaterality or bilaterality of the hematoma, and length of stay in the Intensive Care Unit (ICU) and/or neurosurgery clinic were recorded from the patients’ files. Results: The total mortality rate was 34%. Age, etiology, GCS on admission, and laterality of the hematoma (unilateral or bilateral) affected the mortality rates (P = 0.005, P = 0.001, P = 0.001, and P = 0.001, respectively). Advanced age, low GCS on admission, and bilaterality of the hematoma were related with high mortality rates (P = 0.005, P = 0.001, and P = 0.001, respectively). The presence of comorbid disease and gender had no effect on patient survival (P = 0.299 and P = 0.861). Conclusion: The most important factors affecting the mortality rate were GCS on admission, etiology, age, and laterality of the hematoma in this study. Advanced age, low GCS on admission, and bilaterality of the hematoma were related with high mortality rates. Etiology had an important role in mortality rates, especially in the pedestrian injury group.
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Affiliation(s)
- Tugay Atalay
- Gaziantep Sevgi Hospital Neurosurgery Department, Gaziantep, Turkey
| | - Hakan Ak
- Department of Neurosurgery, School of Medicine, Bozok University, Yozgat, Turkey
| | - Ismail Gülsen
- Department of Neurosurgery, School of Medicine, Yüzüncü Yıl University, Van, Turkey
| | - Sinan Karacabey
- Department of Eemrgency Medicine, Marmara University School of Medicine, Istanbul, Turkey
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Ho T, Frisbie J, Wasfie T, Boyer JJ, Knisely T, Cwalina N, Barber K, Shapiro B. A retrospective analysis of factors influencing readmission rates of acute traumatic subdural hematoma in the elderly: A cohort study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Liu X, Qiu Y, Zhang J, Zhang Q, Chen L, Chen L, Sun X. Emergent Single Burr Hole Evacuation for Traumatic Acute Subdural Hematoma with Cerebral Herniation: A Retrospective Cohort Comparison Analysis. World Neurosurg 2018; 120:e1024-e1030. [PMID: 30201582 DOI: 10.1016/j.wneu.2018.08.219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/26/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To investigate the clinical benefits of emergent single burr hole evacuation technology in traumatic acute subdural hematoma (ASDH) with cerebral herniation cases. METHODS We conducted a review comparing patients with ASDH with cerebral herniation who underwent single burr hole evacuation followed by decompressive craniectomy and intracranial hematoma removal surgery (n = 45, group A) and those who underwent decompressive craniectomy and intracranial hematoma removal surgery after rapid infusion of mannitol 250 mL (n = 53, group B) in our institution. Pre- and postoperative assessments included Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), activities of daily living (ADLs), and common complication incidences. RESULTS At 1 and 6 months after operation, the median GCS score of group A was significantly higher than group B (P = 0.04 and P = 0.03, respectively). After 6 months, the GOS score and ADLs between the 2 groups had significant differences (P < 0.05). There were no differences between the 2 groups in the common complication incidences. CONCLUSIONS Emergent single burr hole evacuation in combination with decompressive craniectomy surgery is a useful treatment for ASDH with cerebral herniation, which can achieve reduction of intracranial pressure as soon as possible and improve the prognosis.
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Affiliation(s)
- Xuemeng Liu
- Department of Neurosurgery, FeiXian People Hospital, FeiXian, China
| | - Yongyi Qiu
- Department of Neurosurgery, ZhongNan Hospital, WuHan University, WuHan, China
| | - Jibo Zhang
- Department of Neurosurgery, ZhongNan Hospital, WuHan University, WuHan, China
| | - Qingwen Zhang
- Department of Neurosurgery, FeiXian People Hospital, FeiXian, China
| | - Lin Chen
- Department of Neurosurgery, FeiXian People Hospital, FeiXian, China
| | - Lizhu Chen
- Department of Neurosurgery, FeiXian People Hospital, FeiXian, China
| | - Xiangyu Sun
- Department of Neurosurgery, FeiXian People Hospital, FeiXian, China.
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Kinoshita T, Hayashi M, Yamakawa K, Watanabe A, Yoshimura J, Hamasaki T, Fujimi S. Effect of the Hybrid Emergency Room System on Functional Outcome in Patients with Severe Traumatic Brain Injury. World Neurosurg 2018; 118:e792-e799. [PMID: 30026142 DOI: 10.1016/j.wneu.2018.07.053] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The timely treatment of severe traumatic brain injury (TBI) is essential for limiting the effects of damage; however, there is no consensus regarding an effective method for early intervention. In August 2011, our hospital launched a novel trauma workflow using the hybrid emergency room (ER), consisting of an interventional radiology-computed tomography (CT) unit installed in the trauma resuscitation room to facilitate early interventions. The aim of this study was to evaluate effects of the hybrid ER system on functional outcomes in patients with severe TBI. METHODS We conducted a retrospective historical control study of patients with severe TBI (Glasgow Coma Scale score ≤8) who received conventional treatment (August 2007-July 2011) or treatment in the hybrid ER (August 2011-July 2015). The primary end point was unfavorable outcome at 6 months after injury (death, vegetative state, or lower severe disability) as evaluated by the Glasgow Outcome Scale-Extended. Secondary end points included time from arrival to the start of CT examination and emergency intracranial operation. Potential confounders were adjusted with multivariable logistic regressions. RESULTS Among 158 included patients, 88 were in the conventional group and 70 were in the hybrid ER group. After model adjustment, the hybrid ER group was significantly associated with a reduction in unfavorable outcomes. Times to CT examination and intracranial operation were significantly shorter in the hybrid ER group than that in the conventional group. CONCLUSIONS The hybrid ER system is useful for realizing immediate CT examination and emergency surgery and improving functional outcomes in patients with severe TBI.
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Affiliation(s)
- Takahiro Kinoshita
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Motohisa Hayashi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan.
| | - Atsushi Watanabe
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
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Karnjanasavitree W, Phuenpathom N, Tunthanathip T. The Optimal Operative Timing of Traumatic Intracranial Acute Subdural Hematoma Correlated with Outcome. Asian J Neurosurg 2018; 13:1158-1164. [PMID: 30459885 PMCID: PMC6208231 DOI: 10.4103/ajns.ajns_199_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective Acute subdural hematoma (ASDH) has been associated with mortality in traumatic brain injury. The timing of surgical evacuation for ASDH has still been controversial. The object of this study was to determine the temporal and clinical factors associated with outcome following surgery for ASDH. Materials and Methods The study retrospectively viewed medical records and neuroimaging studies of ASDH patients who underwent surgical evacuation. Surgical outcomes were dichotomized into favorable and unfavorable outcomes, and operative times compared between the groups. Results The records of 145 ASDH patients who underwent surgery were reviewed. Almost two-thirds of the patients were admitted for surgical evacuation, of whom 71% underwent a decompressive operation. The temporal variables were as follows: mean time from scene of accident to emergency department (ED) was 70 (Standard deviation [SD] 256.0) min, mean time from ED to obtaining CT of the brain was 45.6 (SD 38.9) min, mean time from brain computed tomographic to operating room arrival was 68.6 (SD 50.0) min, and mean time from ED arrival to skin incision was 160.1 (SD 88.1) min. The mean time from ED arrival to skin incision was significantly shorter in the unfavorable outcome group. Because of this reverse association between time from ED to surgery, multivariate analysis was applied to adjust the timing factors with other clinical factors, and the results indicated that temporal factors were not associated with functional outcome, as features such as increased intracranial pressure due to obliterated basal cistern and brain herniation were significantly associated with functional outcome. Conclusions The optimal times for surgical evacuation of ASDH are challenging to estimate because compressed brainstem signs are more important than time factors. ASDH patients with compressed brainstem should have surgery as soon as possible.
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Affiliation(s)
- Worawach Karnjanasavitree
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Nakornchai Phuenpathom
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Thara Tunthanathip
- Department of Surgery, Neurosurgery Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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Alliez JR, Kaya JM, Leone M. Ematomi intracranici post-traumatici in fase acuta. Neurologia 2017. [DOI: 10.1016/s1634-7072(17)86804-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lee AT, Gagnidze A, Pan SR, Sookplung P, Nair B, Newman SF, Ben-Ari A, Zaky A, Cain K, Vavilala MS, Rozet I. Preoperative Low-Dose Aspirin Exposure and Outcomes After Emergency Neurosurgery for Traumatic Intracranial Hemorrhage in Elderly Patients. Anesth Analg 2017; 125:514-520. [DOI: 10.1213/ane.0000000000002053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Moussa WMM, Khedr WM, Elwany AH. Prognostic significance of hematoma thickness to midline shift ratio in patients with acute intracranial subdural hematoma: a retrospective study. Neurosurg Rev 2017; 41:483-488. [DOI: 10.1007/s10143-017-0873-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 06/19/2017] [Indexed: 10/19/2022]
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Fountain DM, Kolias AG, Lecky FE, Bouamra O, Lawrence T, Adams H, Bond SJ, Hutchinson PJ. Survival Trends After Surgery for Acute Subdural Hematoma in Adults Over a 20-year Period. Ann Surg 2017; 265:590-596. [PMID: 27172128 PMCID: PMC5300032 DOI: 10.1097/sla.0000000000001682] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We sought to determine 30-day survival trends and prognostic factors following surgery for acute subdural hematomas (ASDHs) in England and Wales over a 20-year period. SUMMARY OF BACKGROUND DATA ASDHs are still considered the most lethal type of traumatic brain injury. It remains unclear whether the adjusted odds of survival have improved significantly over time. METHODS Using the Trauma Audit and Research Network (TARN) database, we analyzed ASDH cases in the adult population (>16 yrs) treated surgically between 1994 and 2013. Two thousand four hundred ninety-eight eligible cases were identified. Univariable and multiple logistic regression analyses were performed, using multiple imputation for missing data. RESULTS The cohort was 74% male with a median age of 48.9 years. Over half of patients were comatose at presentation (53%). Mechanism of injury was due to a fall (<2 m 34%, >2 m 24%), road traffic collision (25%), and other (17%). Thirty-six per cent of patients presented with polytrauma. Gross survival increased from 59% in 1994 to 1998 to 73% in 2009 to 2013. Under multivariable analysis, variables independently associated with survival were year of injury, Glasgow Coma Scale, Injury Severity Score, age, and pupil reactivity. The time interval from injury to craniotomy and direct admission to a neurosurgical unit were not found to be significant prognostic factors. CONCLUSIONS A significant improvement in survival over the last 20 years was observed after controlling for multiple prognostic factors. Prospective trials and cohort studies are expected to elucidate the distribution of functional outcome in survivors.
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Affiliation(s)
- Daniel M. Fountain
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Angelos G. Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Fiona E. Lecky
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
- Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Omar Bouamra
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Thomas Lawrence
- The Trauma Audit and Research Network, University of Manchester, Salford, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
| | - Simon J. Bond
- Cambridge Clinical Trials Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- MRC Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital & University of Cambridge, Cambridge, UK
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Prognostic factors of early outcome and discharge status in patients undergoing surgical intervention following traumatic intracranial hemorrhage. J Clin Neurosci 2016; 31:152-6. [DOI: 10.1016/j.jocn.2016.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/08/2016] [Indexed: 12/27/2022]
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Godoy DA, Rubiano A, Rabinstein AA, Bullock R, Sahuquillo J. Moderate Traumatic Brain Injury: The Grey Zone of Neurotrauma. Neurocrit Care 2016; 25:306-19. [DOI: 10.1007/s12028-016-0253-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
PURPOSE OF REVIEW The indications for aspirin (ASA) for both primary and secondary prevention of thrombotic events continue to evolve. We review some of these indications and the recent literature regarding the perioperative administration of ASA. RECENT FINDINGS ASA for primary prevention of cardiac ischemia, stroke, cancer, and death remains controversial. When used for primary prevention, ASA may be safely discontinued perioperatively. Patients with coronary or carotid artery stents should continue to receive ASA perioperatively. For patients with ischemic heart disease currently receiving ASA for secondary prevention of cardiac ischemia and stroke undergoing general surgery, orthopedic surgery, ophthalmological surgery, cardiovascular surgery, major vascular surgery, or a urological procedure, continuation of ASA is probably well tolerated, but further study is required. There is no indication to initiate ASA perioperatively in patients with stable ischemic heart disease as the risks outweigh the benefits. Until further data become available, decisions regarding the perioperative continuation of ASA should be made on a case-by-case risk-benefit analysis. SUMMARY The continuation or discontinuation of ASA perioperatively remains a complicated issue. Further, well designed trials are needed for additional clarification.
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Craniotomy Versus Craniectomy for Acute Traumatic Subdural Hematoma in the United States: A National Retrospective Cohort Analysis. World Neurosurg 2015; 88:25-31. [PMID: 26748175 DOI: 10.1016/j.wneu.2015.12.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The optimal surgical management of acute traumatic subdural hematoma (ASDH) is controversial; both craniectomy and craniotomy are performed. The purpose of this study was to determine the current management of ASDH in the United States. METHODS This retrospective cohort study used the Nationwide Inpatient Sample from the years 2006-2011 to examine patients with a primary diagnosis of ASDH. All patients ≥18 years old with a primary diagnosis of ASDH were included in the analysis. Patients with procedure codes for craniectomy and craniotomy were isolated from the database. Propensity score matching based on logistic regression was used to match craniotomy to craniectomy in a 1:1 fashion. RESULTS There were 47,911,414 hospitalizations analyzed. Of 60,435 patients with ASDH identified, 1763 underwent craniotomy and 177 underwent craniectomy. The average age of patients who underwent craniectomy was 49.5 years (SD 20.8) compared with an average age of 68.9 years (SD 17.1) of patients who underwent craniotomy (P < 0.0001). Hospital mortality was significantly higher in patients who underwent craniectomy (35.0% vs. 10.9%, P < 0.0001). Patients who underwent craniectomy had longer hospital stays compared with patients who underwent craniotomy (median duration 14.3 days [interquartile range 25] for craniectomy vs. 10.9 days [interquartile range 9] for craniotomy, P < 0.0001). Patients who underwent craniectomy were also more likely to be discharged to a skilled nursing or rehabilitation facility (79.1% vs. 63.9%, P = 0.0011). CONCLUSIONS Craniotomy is the preferred surgical technique for management of ASDH in the United States, being performed 10 times more frequently than craniectomy. Craniectomy was associated with significantly higher in-hospital mortality after propensity score matched analysis.
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