Lalith Premachandra, MD
CHRISTUS Mother Frances Hospital Tyler
Tyler, Texas
Disclosure information not submitted.
Title: Early versus Late Surgery for Acute Subdural Hematoma
Introduction: Subdural hematoma (SDH) represents one type of intracranial mass lesion, and national guidelines define the subset of patients who would benefit from surgical evacuation. The objective of this study is to compare patients with indications for surgical evacuation of SDH who underwent early surgical intervention (within 12 hours of meeting surgical indication: E group) to those who underwent late surgical intervention ( > 12 hours of meeting surgical indication: L group).
Methods: We performed a retrospective chart review of patients admitted with SDH to our hospital between 1/2012 and 03/2021. The following data were collected from the electronic health record: Age in years, Glasgow coma score (GCS) on admission, APACHE IV score (acute physiologic and chronic health evaluation), traumatic vs spontaneous, antiplatelet therapy (APT), anticoagulant therapy (AC), and indication for surgery (a thickness greater than 10 mm [OR1] or a midline shift (MLS) greater than 5 mm on CT [OR2], GCS < 9 and SDH less than 10-mm thick and a MLS < 5 if GCS drops by more than 2 points between time of injury and hospital admission [OR3], or asymmetric or fixed and dilated pupil [OR4]). Outcome was evaluated at hospital discharge on the modified Rankin scale (range, 0 [normal] to 6 [death]) with 0 – 3 considered as good functional outcome).
Results: We identified a total of 176 patients (68 in the E group and 108 in the L group). Compared to the E group, the L group had similar age (73 +/- 13 vs 70 +/- 13, p = 0.2), higher GCS (14.6 +/- 0.8 vs 12.2 +/- 3.8, p < 0.01), lower APACHE IV scores ( 44 +/- 14 vs 52 +/- 25, p = 0.6), similar % with traumatic SDH (38% vs 43%, p = 0.5), similar % on APT (41 % vs 43 %, p = 0.8) and AC (21% vs 16 %, p = 0.4), similar % with OR1 (94% vs 94 %, p = 1.0) , OR2 (65 % vs 75 %, p = 0.2), OR3 (0 % vs 1.5, p = 0.3) and lower % with OR4 indications (0 % vs 7 %, p < 0.01). L group had better functional outcome compared to E group (mRS 0-3, 85% vs 68%, p = 0.01).
Conclusion: Patients with SDH who underwent early surgical intervention had lower GCS, higher APACHE score and more percentage with asymmetric or fixed and dilated pupils, and worse outcomes compared to those who underwent late surgical interventions. These findings should be further investigated in large multicenter prospective studies.