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      Risk Factors of Delayed Surgical Intervention after Conservatively Treated Acute Traumatic Subdural Hematoma

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          Abstract

          Objective

          Acute subdural hematoma (ASDH) is generally considered a condition that should be managed surgically. However, some patients initially receive conservative treatment, a subset of whom require surgical intervention later. This study aimed to evaluate the predictors of delayed surgical intervention in ASDH patients who are initially managed conservatively.

          Methods

          From January 2007 to December 2015, 842 patients diagnosed with ASDH were treated at our institution. Among them, 158 patients with convexity ASDH were initially treated conservatively. Patients were divided into a delayed surgery group and a conservative group. Demographic characteristics, past medication and medical histories, and radiological and laboratory data were collected by retrospective chart review. Independent risk factors were identified with univariate and multivariate analyses.

          Results

          Twenty-eight patients (17.7%) underwent delayed surgical intervention. Their mean age was 69.0 years, and 82.1% were male. Hypertension, diabetes mellitus, and heart disease prevalence and use of anti-platelet agents did not significantly differ from the conservative group. However, age ( p=0.024), previous cerebral infarction history ( p=0.026), increased maximal hematoma thickness ( p<0.001), midline shifting ( p=0.001) and accompanying subarachnoid hemorrhage ( p=0.022) on initial brain computed tomography (CT) scan, low hemoglobin level ( p<0.001), high leukocyte count ( p=0.004), and low glucose level ( p=0.002) were significantly associated with delayed surgical intervention. In multivariate analysis, increased maximal hematoma thickness (odds ratio [OR]=1.279, 95% confidence interval [CI] 1.075–1.521; p=0.006), low hemoglobin level (OR=0.673, 95% CI 0.467–0.970; p=0.034), and high leukocyte count (OR=1.142, 95% CI 1.024–1.272; p=0.017) were independent risk factors for delayed surgical intervention.

          Conclusion

          Due to the high likelihood of delayed surgical intervention among minimal ASDH patients with a thicker hematoma on initial brain CT, lower hemoglobin level, and higher leukocyte count, these patients should receive more careful observation.

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          Most cited references29

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          Pathophysiology of chronic subdural haematoma: inflammation, angiogenesis and implications for pharmacotherapy

          Chronic subdural haematoma (CSDH) is an encapsulated collection of blood and fluid on the surface of the brain. Historically considered a result of head trauma, recent evidence suggests there are more complex processes involved. Trauma may be absent or very minor and does not explain the progressive, chronic course of the condition. This review focuses on several key processes involved in CSDH development: angiogenesis, fibrinolysis and inflammation. The characteristic membrane surrounding the CSDH has been identified as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within membrane walls, whilst fibrinolytic processes prevent clot formation resulting in continued haemorrhage. An abundance of inflammatory cells and markers have been identified within the membranes and subdural fluid and are likely to contribute to propagating an inflammatory response which stimulates ongoing membrane growth and fluid accumulation. Currently, the mainstay of treatment for CSDH is surgical drainage, which has associated risks of recurrence requiring repeat surgery. Understanding of the underlying pathophysiological processes has been applied to developing potential drug treatments. Ongoing research is needed to identify if these therapies are successful in controlling the inflammatory and angiogenic disease processes leading to control and resolution of CSDH.
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            Surgical management of acute subdural hematomas.

            An acute subdural hematoma (SDH) with a thickness greater than 10 mm or a midline shift greater than 5 mm on computed tomographic (CT) scan should be surgically evacuated, regardless of the patient's Glasgow Coma Scale (GCS) score. All patients with acute SDH in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring. A comatose patient (GCS score less than 9) with an SDH less than 10-mm thick and a midline shift less than 5 mm should undergo surgical evacuation of the lesion if the GCS score decreased between the time of injury and hospital admission by 2 or more points on the GCS and/or the patient presents with asymmetric or fixed and dilated pupils and/or the ICP exceeds 20 mm Hg. In patients with acute SDH and indications for surgery, surgical evacuation should be performed as soon as possible. If surgical evacuation of an acute SDH in a comatose patient (GCS < 9) is indicated, it should be performed using a craniotomy with or without bone flap removal and duraplasty.
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              Chronic subdural hematomas: a review.

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                Author and article information

                Journal
                J Korean Neurosurg Soc
                J Korean Neurosurg Soc
                jkns
                Journal of Korean Neurosurgical Society
                Korean Neurosurgical Society
                2005-3711
                1598-7876
                November 2017
                25 October 2017
                : 60
                : 6
                : 723-729
                Affiliations
                [1 ]Department of Neurosurgery, Hanyang University College of Medicine, Seoul, Korea
                [2 ]Department of Radiology, Hanyang University College of Medicine, Seoul, Korea
                [3 ]Department of Anesthesiology, Hanyang University College of Medicine, Seoul, Korea
                Author notes
                Address for reprints: Hyeong-Joong Yi, M.D., Ph.D., Department of Neurosurgery, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea, Tel: +82-2-2290-8499, Fax: +82-2-2281-0954, E-mail: hjyi8499@ 123456hanyang.ac.kr
                Article
                jkns-60-6-723
                10.3340/jkns.2017.0506.011
                5678053
                11c47889-2f9b-486d-955f-a2692af6b695
                Copyright © 2017 The Korean Neurosurgical Society

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 07 June 2017
                : 24 July 2017
                : 24 August 2017
                Categories
                Clinical Article

                Surgery
                hematoma,subdural,surgical procedure,operative,conservative treatment,risk factors,outcome
                Surgery
                hematoma, subdural, surgical procedure, operative, conservative treatment, risk factors, outcome

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