Accepted Manuscript Title: Age determination of subdural hematomas with CT and MRI: a systematic review Author: Tessa Sieswerda-Hoogendoorn Floor A.M. Postema Dagmar Verbaan Charles B. Majoie Rick R. van Rijn PII: DOI: Reference:
S0720-048X(14)00153-3 http://dx.doi.org/doi:10.1016/j.ejrad.2014.03.015 EURR 6717
To appear in:
European Journal of Radiology
Received date: Accepted date:
17-1-2014 11-3-2014
Please cite this article as: Sieswerda-Hoogendoorn T, Postema FAM, Verbaan D, Majoie CB, van Rijn RR, Age determination of subdural hematomas with CT and MRI: a systematic review, European Journal of Radiology (2014), http://dx.doi.org/10.1016/j.ejrad.2014.03.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Age determination of subdural hematomas with CT and MRI: a systematic review
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Tessa Sieswerda‐Hoogendoorn, MD, MSc 1,2 Floor A.M. Postema, MSc 3 Dagmar Verbaan, MSc, PhD4 Charles B. Majoie, MD, PhD 2 Rick R. van Rijn, MD, PhD 1,2
Affiliations
Corresponding author
d
M
an
1 Section of Forensic Pediatrics, Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands 2 Department of Radiology, Academic Medical Center/Emma Children’s Hospital, Amsterdam, The Netherlands 3 Faculty of Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands 4 Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
Ac ce p
te
Tessa Sieswerda‐Hoogendoorn, MD, MSc. Section of Forensic Pediatrics, Department of Forensic Medicine Netherlands Forensic Institute PO Box 24044 2490 AA The Hague The Netherlands E‐mail: [email protected] Phone: +31‐20‐5669111, pager 58896 Floor Postema AMC, Faculty of Medicine, University of Amsterdam Meibergdreef 9 1105 AZ Amsterdam The Netherlands Email: [email protected] Phone: +31‐20‐5669111 Dagmar Verbaan AMC, Department of Neurosurgery Meibergdreef 9 1105 AZ Amsterdam The Netherlands
Page 1 of 37
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Acknowledgements
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Email: [email protected] Phone: +31‐20‐5669111 Charles Majoie AMC, Department of Radiology Meibergdreef 9 1105 AZ Amsterdam The Netherlands Email: [email protected] Phone: +31‐20‐5669111 Rick van Rijn AMC, Department of Radiology, Meibergdreef 9 1105 AZ Amsterdam The Netherlands Email: [email protected] Phone: +31‐20‐5669111, pager 62690
Ac ce p
te
d
We would like to thank all authors who replied to our request for additional information on their studies. Furthermore, we would like to thank the following people for their help with the translations: Mr. J. I.L.M. Verbeke, MD (French), Mr. T. Laméris (Japanese), Ms. W.M. Sieswerda‐Mesman, MD (German), Mr O. Olsen, MD (Norwegian), Prof. A. Rossi (Italian), Ms. L.P. Lin (Chinese), Ms S.G. Postema, BSc (Spanish), Mr. M. Kuzak, MSc (Polish).
Page 2 of 37
Abstract Objectives To systematically review the literature on dating subdural hematomas (SDHs) on CT and MRI
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scans.
cr
Methods
We performed a systematic review in MEDLINE, EMBASE and Cochrane to search for articles
us
that described the appearance of SDHs on CT or MRI in relation to time between trauma and scanning. Two researchers independently screened the articles, assessed methodological quality and performed data extraction. Medians with interquartile ranges were calculated.
an
Differences were tested with a Mann‐Whitney U or Kruskal Wallis H test.
M
Results
We included 22 studies describing 973 SDHs on CT and 4 studies describing 83 SDHs on MRI. Data from 17 studies (413 SDHs) could be pooled. There were significant differences
d
between time intervals for the different densities on CT (p 40 days was analyzed as 40 days).
ip t
Statistical analysis For the studies providing individual patient data, we performed a pooled analysis. We
cr
recorded density or intensity of the SDHs in combination with the time in days between the onset of the SDH and scanning in IBM SPSS Statistics 19. Normality was assessed using the
us
Kolmogorov‐Smirnov test. Medians with interquartile ranges (IQR) were calculated for all time intervals, as data were non‐normally distributed. Differences between different subgroups were tested with a Mann‐Whitney U test for two groups and a Kruskal Wallis H
an
test for more than two groups. For the studies not providing individual patient data, we extracted the time interval for each density/ intensity for the whole group. These data were
Ac ce p
te
d
M
presented in the measure they were presented in the original article.
Page 8 of 37
Results Study identification We included 23 studies describing densities of SDHs on CT (1070 cases) 9‐11,15‐17,20‐36 and 5
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studies describing intensities of SDHs on MRI in 126 cases 17,22,36‐38. Three studies described both CT and MRI data, meaning that in total 25 studies were included. The flow chart of
cr
study selection is illustrated in Figure 1. Study characteristics of the studies included are described in table 1.
us
Study quality
All studies included in this review were retrospective or prospective observational cohort
an
studies. None of the studies defined a control group. The mean score of the studies was 4 out of 6 points on the adapted NOS, see table 2. The most common methodological problem
M
was, as expected, that none of the included studies could demonstrate that the outcome of interest (SDH) was not already present before the trauma.
te
All studies
d
Densities and time intervals between trauma and scanning on CT
Data of 17 studies describing 413 SDHs did provide information at individual level and could
Ac ce p
be pooled 9,15,17,20,22‐24,26‐35. There were significant differences between the median time intervals (IQR) for the different densities (p 22 days - 2 SDHs hypodense after 7-22 days - 16 SDHs hypodense after > 22 days
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Author Bradford, 201336
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individual patient data suitable for pooling
Haar, 197721
Ac
Scotti, 197711
ce pt
Reed, 198610
ed
M
Lee, 199725
an
us
Dias, 199816
SDH = subdural hematoma SD = standard deviation
Page 33 of 37
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Table 5
Group
N
Hyperdense
Children Adults
50 37
Time interval in days, median (IQR) 2 (1-3) 3 (1-30)*
Isodense
Children Adults
4 18
2 (0-5) 46 (26-90)#
Hypodense
Children Adults
63 118
2 (0-9) 16 (8-33)
Mixed density
Children Adults
11 365
M
P$ Children vs adults 0.046
0 7
6 122
0.000
d
Max
0 0
0 1
122 177
0.000
2 (1-3) 0 (0-11)*
0 0
11 243
0.332
ep te
$
31 18
Min
an
Density
us
Table 5. Pooled analysis of time intervals for each density on CT for children and adults separately.
MWU test was used to test the differences between children and adults for each density.
#
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* Significant difference with isodensity (p= 0.000) and hypodensity (p= 0.000) Significant difference with hypodensity (p=0.001)
N= number IQR = interquartile range Min= minimum Max= maximum
Page 34 of 37
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Table 6
Density
Group
N
Time interval
an
Table 6. Pooled analysis of time intervals for each density on CT for AHT and non-AHT pediatric cases separately
Min
Max
AHT vs
median (IQR)
Hypodense
Mixed density
0
-
Non-AHT
49
2 (1-4 )*
0
AHT
-
-
-
Non-AHT
4
AHT
1
Non-AHT
7
AHT
17
Non-AHT
14
#
2 (0-5 )
0
-
non-AHT 0.08
11
6
10
0.75
36 (7-61)
2
120
2 (1-4)
0
5
1 (1-3)†
0
11
0.54
MWU test was used to test the differences between AHT and non-AHT cases for each density.
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$
1
d
Isodense
AHT
ep te
Hyperdense
M
in days,
p$
* Significant difference with hypodensity (p=0.000) #
Significant difference with hypodensity (p=0.024)
† Significant difference with hypodensity (p=0.001) AHT= abusive head trauma N= number IQR = interquartile range Min= minimum Max= maximum
Page 35 of 37
Table 7
Table 7. Pooled analysis of time intervals for each intensity on MRI for T1 and T2 sequences
Sequence Intensity
N
Time interval in
Min
Max
days, median
9 (5-13)
3
35
Isointense
5
4 (2-33)
2
49
Hypointense
5
90 (19-105)
us
Hyperintense
14
11 (5-39)
Isointense
4
7 (4-20)
Hypointense
10
Mixed
4
an
2
cr
14
120
90
3
23
6 (2-9)
2
35
14 (10-49)
9
120
M
1
ed
T2
Hyperintense
ce pt
T1
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(IQR)
intensity
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N= number IQR = interquartile range Min= minimum Max= maximum
Page 36 of 37
Table 8
Table 8. Time intervals of SDHs of different intensities on MRI in studies that did not
Results - 6 SDHs hyperintense on T1 and hypointense on T2/ Flair after 0-5 days - 6 SDHs hyperintense on T1 and hyperintense in T2/ Flair after 2-30 days - 16 SDHs with equal volumes of mixed hyper- and hypointense on T1 and mixed hyper- and hypointense on T2/ Flair after 0-30 days - 14 SDHs with unequal volumes, mostly hypointense on T1 and hyperintense on T2/ Flair, smaller component hyperintense on T1 and hypointense on T2/ Flair after 0-30 days - 11 SDHs hypo or isointense on T1 and hypointense on T2 after average 5 days, SD 4.1 - 5 SDHs hyperintense on T1 and hyperintense on T2 after average 27.8 days, SD 20 - 1 SDH hypointense on T1 and hyperintense on T2 after 37 days - 5 SDHs mixed intensity on T1 and mixed intensity on T2 after average 17.8 days, SD 12.2
an
Ac
ce pt
SDH= subdural hematoma
ed
M
Kaminogo, 199938
us
cr
Author Bradford, 201336
ip t
provide individual patient data suitable for pooling
Page 37 of 37
S0720-048X(14)00153-3 http://dx.doi.org/doi:10.1016/j.ejrad.2014.03.015 EURR 6717
To appear in:
European Journal of Radiology
Received date: Accepted date:
17-1-2014 11-3-2014
Please cite this article as: Sieswerda-Hoogendoorn T, Postema FAM, Verbaan D, Majoie CB, van Rijn RR, Age determination of subdural hematomas with CT and MRI: a systematic review, European Journal of Radiology (2014), http://dx.doi.org/10.1016/j.ejrad.2014.03.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ip t
Age determination of subdural hematomas with CT and MRI: a systematic review
us
cr
Tessa Sieswerda‐Hoogendoorn, MD, MSc 1,2 Floor A.M. Postema, MSc 3 Dagmar Verbaan, MSc, PhD4 Charles B. Majoie, MD, PhD 2 Rick R. van Rijn, MD, PhD 1,2
Affiliations
Corresponding author
d
M
an
1 Section of Forensic Pediatrics, Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, The Netherlands 2 Department of Radiology, Academic Medical Center/Emma Children’s Hospital, Amsterdam, The Netherlands 3 Faculty of Medicine, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands 4 Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
Ac ce p
te
Tessa Sieswerda‐Hoogendoorn, MD, MSc. Section of Forensic Pediatrics, Department of Forensic Medicine Netherlands Forensic Institute PO Box 24044 2490 AA The Hague The Netherlands E‐mail: [email protected] Phone: +31‐20‐5669111, pager 58896 Floor Postema AMC, Faculty of Medicine, University of Amsterdam Meibergdreef 9 1105 AZ Amsterdam The Netherlands Email: [email protected] Phone: +31‐20‐5669111 Dagmar Verbaan AMC, Department of Neurosurgery Meibergdreef 9 1105 AZ Amsterdam The Netherlands
Page 1 of 37
cr us an M
Acknowledgements
ip t
Email: [email protected] Phone: +31‐20‐5669111 Charles Majoie AMC, Department of Radiology Meibergdreef 9 1105 AZ Amsterdam The Netherlands Email: [email protected] Phone: +31‐20‐5669111 Rick van Rijn AMC, Department of Radiology, Meibergdreef 9 1105 AZ Amsterdam The Netherlands Email: [email protected] Phone: +31‐20‐5669111, pager 62690
Ac ce p
te
d
We would like to thank all authors who replied to our request for additional information on their studies. Furthermore, we would like to thank the following people for their help with the translations: Mr. J. I.L.M. Verbeke, MD (French), Mr. T. Laméris (Japanese), Ms. W.M. Sieswerda‐Mesman, MD (German), Mr O. Olsen, MD (Norwegian), Prof. A. Rossi (Italian), Ms. L.P. Lin (Chinese), Ms S.G. Postema, BSc (Spanish), Mr. M. Kuzak, MSc (Polish).
Page 2 of 37
Abstract Objectives To systematically review the literature on dating subdural hematomas (SDHs) on CT and MRI
ip t
scans.
cr
Methods
We performed a systematic review in MEDLINE, EMBASE and Cochrane to search for articles
us
that described the appearance of SDHs on CT or MRI in relation to time between trauma and scanning. Two researchers independently screened the articles, assessed methodological quality and performed data extraction. Medians with interquartile ranges were calculated.
an
Differences were tested with a Mann‐Whitney U or Kruskal Wallis H test.
M
Results
We included 22 studies describing 973 SDHs on CT and 4 studies describing 83 SDHs on MRI. Data from 17 studies (413 SDHs) could be pooled. There were significant differences
d
between time intervals for the different densities on CT (p 40 days was analyzed as 40 days).
ip t
Statistical analysis For the studies providing individual patient data, we performed a pooled analysis. We
cr
recorded density or intensity of the SDHs in combination with the time in days between the onset of the SDH and scanning in IBM SPSS Statistics 19. Normality was assessed using the
us
Kolmogorov‐Smirnov test. Medians with interquartile ranges (IQR) were calculated for all time intervals, as data were non‐normally distributed. Differences between different subgroups were tested with a Mann‐Whitney U test for two groups and a Kruskal Wallis H
an
test for more than two groups. For the studies not providing individual patient data, we extracted the time interval for each density/ intensity for the whole group. These data were
Ac ce p
te
d
M
presented in the measure they were presented in the original article.
Page 8 of 37
Results Study identification We included 23 studies describing densities of SDHs on CT (1070 cases) 9‐11,15‐17,20‐36 and 5
ip t
studies describing intensities of SDHs on MRI in 126 cases 17,22,36‐38. Three studies described both CT and MRI data, meaning that in total 25 studies were included. The flow chart of
cr
study selection is illustrated in Figure 1. Study characteristics of the studies included are described in table 1.
us
Study quality
All studies included in this review were retrospective or prospective observational cohort
an
studies. None of the studies defined a control group. The mean score of the studies was 4 out of 6 points on the adapted NOS, see table 2. The most common methodological problem
M
was, as expected, that none of the included studies could demonstrate that the outcome of interest (SDH) was not already present before the trauma.
te
All studies
d
Densities and time intervals between trauma and scanning on CT
Data of 17 studies describing 413 SDHs did provide information at individual level and could
Ac ce p
be pooled 9,15,17,20,22‐24,26‐35. There were significant differences between the median time intervals (IQR) for the different densities (p 22 days - 2 SDHs hypodense after 7-22 days - 16 SDHs hypodense after > 22 days
cr
Author Bradford, 201336
ip t
individual patient data suitable for pooling
Haar, 197721
Ac
Scotti, 197711
ce pt
Reed, 198610
ed
M
Lee, 199725
an
us
Dias, 199816
SDH = subdural hematoma SD = standard deviation
Page 33 of 37
cr
ip t
Table 5
Group
N
Hyperdense
Children Adults
50 37
Time interval in days, median (IQR) 2 (1-3) 3 (1-30)*
Isodense
Children Adults
4 18
2 (0-5) 46 (26-90)#
Hypodense
Children Adults
63 118
2 (0-9) 16 (8-33)
Mixed density
Children Adults
11 365
M
P$ Children vs adults 0.046
0 7
6 122
0.000
d
Max
0 0
0 1
122 177
0.000
2 (1-3) 0 (0-11)*
0 0
11 243
0.332
ep te
$
31 18
Min
an
Density
us
Table 5. Pooled analysis of time intervals for each density on CT for children and adults separately.
MWU test was used to test the differences between children and adults for each density.
#
Ac c
* Significant difference with isodensity (p= 0.000) and hypodensity (p= 0.000) Significant difference with hypodensity (p=0.001)
N= number IQR = interquartile range Min= minimum Max= maximum
Page 34 of 37
us
cr
ip t
Table 6
Density
Group
N
Time interval
an
Table 6. Pooled analysis of time intervals for each density on CT for AHT and non-AHT pediatric cases separately
Min
Max
AHT vs
median (IQR)
Hypodense
Mixed density
0
-
Non-AHT
49
2 (1-4 )*
0
AHT
-
-
-
Non-AHT
4
AHT
1
Non-AHT
7
AHT
17
Non-AHT
14
#
2 (0-5 )
0
-
non-AHT 0.08
11
6
10
0.75
36 (7-61)
2
120
2 (1-4)
0
5
1 (1-3)†
0
11
0.54
MWU test was used to test the differences between AHT and non-AHT cases for each density.
Ac c
$
1
d
Isodense
AHT
ep te
Hyperdense
M
in days,
p$
* Significant difference with hypodensity (p=0.000) #
Significant difference with hypodensity (p=0.024)
† Significant difference with hypodensity (p=0.001) AHT= abusive head trauma N= number IQR = interquartile range Min= minimum Max= maximum
Page 35 of 37
Table 7
Table 7. Pooled analysis of time intervals for each intensity on MRI for T1 and T2 sequences
Sequence Intensity
N
Time interval in
Min
Max
days, median
9 (5-13)
3
35
Isointense
5
4 (2-33)
2
49
Hypointense
5
90 (19-105)
us
Hyperintense
14
11 (5-39)
Isointense
4
7 (4-20)
Hypointense
10
Mixed
4
an
2
cr
14
120
90
3
23
6 (2-9)
2
35
14 (10-49)
9
120
M
1
ed
T2
Hyperintense
ce pt
T1
ip t
(IQR)
intensity
Ac
N= number IQR = interquartile range Min= minimum Max= maximum
Page 36 of 37
Table 8
Table 8. Time intervals of SDHs of different intensities on MRI in studies that did not
Results - 6 SDHs hyperintense on T1 and hypointense on T2/ Flair after 0-5 days - 6 SDHs hyperintense on T1 and hyperintense in T2/ Flair after 2-30 days - 16 SDHs with equal volumes of mixed hyper- and hypointense on T1 and mixed hyper- and hypointense on T2/ Flair after 0-30 days - 14 SDHs with unequal volumes, mostly hypointense on T1 and hyperintense on T2/ Flair, smaller component hyperintense on T1 and hypointense on T2/ Flair after 0-30 days - 11 SDHs hypo or isointense on T1 and hypointense on T2 after average 5 days, SD 4.1 - 5 SDHs hyperintense on T1 and hyperintense on T2 after average 27.8 days, SD 20 - 1 SDH hypointense on T1 and hyperintense on T2 after 37 days - 5 SDHs mixed intensity on T1 and mixed intensity on T2 after average 17.8 days, SD 12.2
an
Ac
ce pt
SDH= subdural hematoma
ed
M
Kaminogo, 199938
us
cr
Author Bradford, 201336
ip t
provide individual patient data suitable for pooling
Page 37 of 37
