Chronic Subdural Hematoma ICU Management

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1-Craniotomy

BACKGROUND

Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale.

OBJECTIVE

To analyze independent factors predicting 30-day hospital readmissions after surgical treatment of nontraumatic SDH in patients who survived their index surgery and evaluate hospital readmission rates and charges.

METHODS

Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables.

RESULTS

Among 49 013 patients, 10 643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38 370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period ( P = .74). The most common primary causes of 30-day readmissions were recurrent SDH (n = 3949, 37.1%), venous thromboembolism (n = 1373, 12.9%), and delayed hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (n = 1363, 12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure ( P ≤ .03). Household income in the 51st to 75th percentile was associated with a decreased risk of readmission.

CONCLUSION

National trends in 30-day readmission rates after nontraumatic SDH treatment by craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

Retrospective analysis of 195 surgically treated cases of chronic subdural hematoma

INTRODUCTION

The incidence of chronic subdural hematoma (CSDH) is increasing. This study evaluates the etiologic causes and findings of CSDH and compared unilateral CSDH with bilateral CSDH. This study aims to draw attention to this increasingly prevalent condition.

METHODS

We retrospectively analysed 195 surgically treated cases of CSDH in our clinic between 2008 and 2018.

RESULTS

The average age of the patients was 65.7 ± 19.6 years. The most common symptom was headache (53.3%). The case background was the use of anticoagulant (37.9%), head trauma (34.3%). The hematomas were 28.7% right side, 44.6% left side, and 26.7% bilateral. The mean Glasgow Coma Score (GCS) was 13.4 ± 2.9, early postop 13.8 ± 2.5, and late postop was 14.6 ± 1.1. Postoperative complications included acute subdural hematoma (5.1%), cerebral infarction (1.5%), wound infection (0.5%) and others (13.3%). Re-expansion of the brain were statistically significantly less frequent and impaired consciousness, anticoagulant use, early and late postop thickness were statistically significantly more frequent in patients with bilateral CSDH.

CONCLUSIONS

CSDH is seen more patients of advanced age, those who use anticoagulants, patients with hypertension and diabetes and in patients with a history of head trauma. Prognosis is worse in bilateral CSDH. We estimate that the incidence of CSDH will go up in the future.

Influence of Antiplatelet and Anticoagulant Drug Use on Outcomes after Chronic Subdural Hematoma Drainage

We aim to describe the outcomes after chronic subdural hematoma drainage (CSDH) management in a large cohort of patients on antithrombotic drugs, either antiplatelets or anticoagulants, at presentation and to inform clinical decision making on the timing of surgery and recommencement of these drugs. We used data from a previous UK-based multi-center, prospective cohort study. Outcomes included recurrence within 60 days, functional outcome at discharge, and thromboembolic event during hospital stay. We performed Cox regression on recurrence and multiple logistic regression on functional outcome. There were 817 patients included in the analysis, of which 353 (43.2%) were on an antithrombotic drug at presentation. We observed a gradual reduction in risk of recurrence for patients during the 6 weeks post-CSDH surgery. Neither antiplatelet nor anticoagulant drug use influenced risk of CSDH recurrence (hazard ratio, 0.93; 95% confidence interval [CI], 0.58–1.48; p = 0.76) or persistent/worse functional impairment (odds ratio, 1.08; 95% CI, 0.76–1.55; p = 0.66). Delaying surgery after cessation of antiplatelet drug did not affect risk of bleed recurrence. There were 15 in-hospital thromboembolic events recorded. Events were more common in the group pre-treated with antithrombotic drugs (3.3%) compared to the non-antithrombotic group (0.9%). Patients on an antithrombotic drug pre-operatively were at higher risk of thromboembolic events with no excess risk of bleed recurrence or worse functional outcome after CSDH drainage. The data did not support delaying surgery in patients on antithrombotic therapy. In the absence of a randomized controlled trial, early surgery and early antithrombotic recommencement should be considered in those at high risk of thromboembolic events.