Factors Associated with Early versus Delayed Expansion of Acute Subdural Hematomas Initially Managed Conservatively

Noninvasive Monitoring of Traumatic Intracranial Hematoma Progression Using the Infrascanner: Preliminary Experience

Objectives

Early detection of intracranial hematoma (ICH) expansion is critical to improving outcomes in patients with traumatic brain injuries (TBIs). The Infrascanner 2000 (InfraScan Inc) is a US Food and Drug Administration-cleared device capable of detecting ICHs. We report our preliminary experience of conducting a prospective evaluation of serial infrascans to evaluate the diagnostic performance of the device for monitoring changes in ICH size.

Methods

A single-center prospective observational study was conducted. We included patients with traumatic ICHs detected on admission computed tomography (CT) scanning, and conducted hourly infrascans until a second CT scan had been performed. We evaluated the practicability of enrollment, conducting hourly infrascans, and the diagnostic performance of the device.

Results

We approached 134 patients, or their legally authorized representatives, and enrolled 62 (46%). Most index hematomas were small (median, 2.5 mL, IQR, 0.6-7.0 mL), and 23 experienced enlargement. Hourly infrascan assessments were performed successfully in the majority of patients (300 of 340 scans, 88%). The most common reasons for scans not being performed, or not performed on time, were technical issues with the devices (17 scans, 40%), the presence of dressings and bandages (2 scans, 5%), and patients being taken for other investigations or treatment (12 scans, 31%). Given the sample size, the small size of enrolled patients' ICHs, and the low proportion that experienced enlargement, it was not possible to demonstrate the ability of the Infrascanner to detect expansion.

Conclusion

This preliminary study confirms the practicability of conducting a prospective evaluation of the Infrascanner for the purpose of serially monitoring the size of ICHs in trauma patients.

Quantitative evaluation of early antifibrinolytic therapy on 90-day mortality in elderly patients with acute traumatic subdural hematoma: insights from a prospective cohort study

BACKGROUND AND OBJECTIVES

Acute traumatic subdural hematomas (aTSDH) represent a frequent and critical neurosurgical emergency, associated with a significant risk of mortality. Elderly patients with symptomatic aTSDH may benefit from early antifibrinolytic therapy (EAFT). We aim to investigate whether EAFT can improve clinical outcomes in aTSDH patients and to explore the factors influencing mortality, using data from a nationwide, multicenter, prospective cohort study.

METHODS

Multicenter, prospective cohort study at 30 trauma centers from 2023 to 2024 enrolled 963 patients diagnosed aTSDH. After screening, 297 patients aged 60 years or older met inclusion criteria. The primary outcome was 90-day mortality. Secondary outcomes included vascular occlusion, brain rebleeding, sepsis, gastrointestinal bleeding, and renal failure.

RESULTS

A total of 297 aTSDH patients were identified, of whom 195 received EAFT, and 102 were in the control group. After propensity score matching (PSM), 80 patients in each group were compared. There were no significant differences in 90-day mortality (before PSM, P = 0.439; after PSM, P = 0.828). The difference between the two group in the incidence of brain rebleeding, sepsis, gastrointestinal bleeding, and renal failure were similar before and after PSM. The EAFT group had a significantly higher incidence of vascular occlusion compared to the control group (before PSM, P = 0.014; after PSM, P = 0.027). In multivariate logistic regression (odds ratio [95% confidence interval]), increased 90-day mortality was predicted by larger hematoma volume (2.329 [1.123-4.830], P = 0.023) and greater midline shift (2.251 [1.065-4.755], P = 0.034). Sensitivity analysis indicated that there was heterogeneity in the treatment effects between the two groups across different midline shift categories (before PSM, P = 0.012; after PSM, P = 0.043).

CONCLUSION

EAFT may not significantly reduce mortality in elderly aTSDH patients and could potentially increase the risk of vascular occlusion. Therefore, its use in this population should be approached with caution, carefully assessing the potential risks.

Nuance and profound impact: Evaluating the effects of the unmet full coma scale in patients with mild subdural hemorrhage

INTRODUCTION

Patients with subdural hemorrhage (SDH) and a Glasgow Coma Scale (GCS) score of 13-15 are typically categorized as having mild traumatic brain injury. We hypothesize that patients without a maximum GCS score - specifically, patients with GCS scores of 13 and 14 - may exhibit poorer neurological outcomes.

METHOD

Between January 1, 2019, and December 31, 2020, SDH patients with GCS scores ranging from 13 to 15 were retrospectively studied. We compared outcomes between patients with a maximum GCS score of 15 and those with scores of either 13 or 14. Independent factors associated with neurological deterioration among patients with a GCS score of 15 were evaluated using multivariate logistic regression (MLR) analysis.

RESULTS

During the study period, 470 patients with SDH and GCS scores between 13 and 15 were examined. Compared to patients with a maximum GCS score (N = 375), those in the GCS 13-14 group (N = 95) showed significantly higher rates of neurological deterioration (33.7% vs. 10.4%, p value <0.001) and neurosurgical interventions (26.3% vs. 16.3%, p value <0.024). Moreover, the GCS 13-14 group had a significantly poorer prognosis than patients with a GCS score of 15 [mortality rate: 7.4% vs. 2.4%, p value <0.017; rate of impaired consciousness at discharge: 21.1% vs. 4.0%, p value <0.001; and rate of neurological disability at discharge: 29.5% vs. 6.9%, p value <0.001]. The MLR analysis revealed that SDH thickness (odds ratio = 1.127, p value = 0.006) was an independent risk factor for neurological disability at discharge in patients with a GCS score of 15.

CONCLUSION

Among SDH patients with mild TBI, those with GCS scores of 13-14 exhibited poorer neurological outcomes than those with a maximum GCS score. The thickness of the SDH is positively associated with neurological disability in SDH patients with a maximum GCS score.

Does the Timing of the Surgery Have a Major Role in Influencing the Outcome in Elders with Acute Subdural Hematomas?

BACKGROUND

The incidence of traumatic acute subdural hematomas (ASDH) in the elderly is increasing. Despite surgical evacuation, these patients have poor survival and low rate of functional outcome, and surgical timing plays no clear role as a predictor. We investigated whether the timing of surgery had a major role in influencing the outcome in these patients.

METHODS

We retrospectively retrieved clinical and radiological data of all patients ≥70 years operated on for post-traumatic ASDH in a 3 year period in five Italian hospitals. Patients were divided into three surgical timing groups from hospital arrival: ultra-early (within 6 h); early (6-24 h); and delayed (after 24 h). Outcome was measured at discharge using two endpoints: survival (alive/dead) and functional outcome at the Glasgow Outcome Scale (GOS). Univariate and multivariate predictor models were constructed.

RESULTS

We included 136 patients. About 33% died as a result of the consequences of ASDH and among the survivors, only 24% were in good functional outcome at discharge. Surgical timing groups appeared different according to presenting the Glasgow Outcome Scale (GCS), which was on average lower in the ultra-early surgery group, and radiological findings, which appeared worse in the same group. Delayed surgery was more frequent in patients with subacute clinical deterioration. Surgical timing appeared to be neither associated with survival nor with functional outcome, also after stratification for preoperative GCS. Preoperative midline shift was the strongest outcome predictor.

CONCLUSIONS

An earlier surgery was offered to patients with worse clinical-radiological findings. Additionally, after stratification for GCS, it was not associated with better outcome. Among the radiological markers, preoperative midline shift was the strongest outcome predictor.

Recommended Primary Outcomes for Clinical Trials Evaluating Hemostatic Agents in Patients With Intracranial Hemorrhage: A Consensus Statement

IMPORTANCE

In patients with acute spontaneous or traumatic intracranial hemorrhage, early hemostasis is thought to be critical to minimize ongoing bleeding. However, research evaluating hemostatic therapies has been hampered by a lack of standardized clinical trial outcome measures.

OBJECTIVE

To identify appropriate primary outcomes for phase 2 and 3 clinical trials of therapies aimed at reducing acute intracranial bleeding.

EVIDENCE REVIEW

A comprehensive review of all previous clinical trials of hemostatic therapy for intracranial bleeding was performed, and studies measuring the frequency, risk factors, and association of intracranial bleeding with outcome of hemorrhage growth were included.

FINDINGS

A hierarchy of 3 outcome measures is recommended, with the first choice being a global patient-centered clinical outcome scale measured 30 to 180 days after the event; the second, a combined clinical and radiographic end point associating hemorrhage expansion with a poor patient-centered outcome at 24 hours or later; and the third, a radiographic measure of hemorrhage expansion at 24 hours alone. Additional recommendations stress the importance of separating various subtypes of bleeding when possible, early treatment within a standardized treatment window, and the routine use of computerized planimetry comparing continuous measures of absolute and relative hemorrhage growth as either a primary or secondary end point.

CONCLUSIONS AND RELEVANCE

Standardization of outcome measures in studies of intracranial bleeding and hemostatic therapy will support comparative effectiveness research and meta-analysis, with the goal of accelerating the translation of research into clinical practice. The 3 outcome measures proposed in this consensus statement could help this process.