Accepted Manuscript Title: Predictors of rapid spontaneous resolution of acute subdural hematoma Authors: Kenji Fujimoto Tadahiro Otsuka Kimio Yoshizato Jun-ichi Kuratsu PII: DOI: Reference:
S0303-8467(13)00493-9 http://dx.doi.org/doi:10.1016/j.clineuro.2013.11.030 CLINEU 3555
To appear in:
Clinical Neurology and Neurosurgery
Received date: Revised date: Accepted date:
3-9-2013 8-11-2013 29-11-2013
Please cite this article as: Fujimoto K, Otsuka T, Yoshizato K, Kuratsu J-i, Predictors of rapid spontaneous resolution of acute subdural hematoma, Clinical Neurology and Neurosurgery (2013), http://dx.doi.org/10.1016/j.clineuro.2013.11.030 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.
Predictors of rapid spontaneous resolution of acute
ip t
subdural hematoma
cr
Kenji Fujimoto, M.D.1,2 , Tadahiro Otsuka, M.D., Ph.D.1, Kimio Yoshizato, M.D., Ph.D.1, Jun-ichi
us
Kuratsu, M.D.,Ph.D.2
1: Department of Neurosurgery, National Hospital Organization Kumamoto Medical Center
an
1-5, Ninomaru, Chuo-ku, Kumamoto 860-0008, Japan Phone: +81-96-353-6501
M
Fax: +81-96-325-2519
2: Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University School of Medicine
Ac ce p
Fax: +81-96-371-8064
te
Phone: +81-96-373-5219
d
1-1-1, Honjo, Kumamoto, Kumamoto 861-8556, Japan
Corresponding author: Kenji Fujimoto, M.D. Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University School of Medicine 1-1-1, Honjo, Kumamoto, Kumamoto 861-8556, Japan Phone: +81-96-373-5219 Fax: +81-96-371-8064
Email: [email protected]
pg. 1 Page 1 of 18
Abstract
ip t
Objective
Acute subdural hematoma (ASDH) usually requires emergency surgical decompression, but rare
cr
cases exhibit rapid spontaneous resolution. The aim of this retrospective study was to identify factors
us
predictive of spontaneous ASDH resolution.
an
Methods
A total of 366 consecutive patients with ASDH treated between January 2006 and September 2012
M
were identified in our hospital database. Patients with ASDH clot thickness >10 mm in the
d
frontoparietotemporal region and showing a midline shift >10 mm on the initial computed
te
tomography (CT) scan were divided into two groups according to subsequent spontaneous
Ac ce p
resolution. Univariate and multivariate logistic regression analyses were used to identify factors
predictive of rapid spontaneous ASDH resolution.
Results
Fifty-six ASDH patients met study criteria and 18 demonstrated rapid spontaneous resolution
(32%). Majority of these patients were not operated because of poor prognosis/condition and in
accordance to family wishes. Univariate analysis revealed significant differences in use of
antiplatelet agents before head injury and in the incidence of a low-density band between the
hematoma and inner wall of the skull bone on the initial CT. Use of antiplatelet agents before head
pg. 2 Page 2 of 18
injury (OR 19.6, 95%CI 1.5–260.1, p = 0.02) and the low-density band on CT images (OR 40.3,
ip t
95% CI 3.1–520.2, p = 0.005) were identified as independent predictive factors by multivariate
analysis.
cr
Conclusions
us
Our analysis suggested that use of antiplatelet agents before head injury and a low-density band
an
between the hematoma and inner skull bone on CT images (indicative of cerebrospinal fluid infusion
M
into the subdural space) increase the probability of rapid spontaneous resolution.
d
Key Words: acute subdural hematoma, antiplatelet agents, cerebrospinal fluid, frontoparietotemporal
Ac ce p
te
region, low-density band, redistribution of hematoma, spontaneous resolution
pg. 3 Page 3 of 18
ip t
Introduction Acute subdural hematoma (ASDH) is associated with high mortality, and immediate surgical
cr
intervention is indicated except for those cases deemed inoperable due to poor general condition or
us
irreversible brainstem injury.[1] Rapid spontaneous resolution of acute subdural hematoma (ASDH)
an
has rarely been reported.[2-20] Moreover, the true incidence of rapid spontaneous resolution of
ASDH is underestimated due to the routine use of emergency decompression. Two possible
M
mechanisms for spontaneous resolution of ASDH have been proposed: dilution and wash out of
d
hematoma by infusion of the cerebrospinal fluid (CSF) into the subdural space due to a tear in the
te
arachnoid membrane[12, 13] and redistribution of hematoma by acute cerebral swelling.[8, 10, 14]
Ac ce p
To the best of our knowledge, no previous report has analyzed clinical factors associated with
spontaneous ASDH resolution. Thus, our aim was to identify the factors for predicting the rapid
resolution of ASDH.
Materials and methods
From the 366 consecutive patients with ASDH treated by our hospital from January 2006 to
September 2012 and included in an institutional database, we selected patients who met the
following criteria that are important indications for emergency surgery: (1) a clot thickness >10 mm
pg. 4 Page 4 of 18
in the frontoparietotemporal region and (2) a midline shift >10 mm on the initial computed
ip t
tomography (CT). In the present analysis, we defined rapid spontaneous resolution of ASDH as (1)
neurological improvement within 24 h of presentation and (2) reduction of clot thickness by >5 mm
cr
within 96 h of initial CT (Fig. 1). To clarify the relationship between resolution of ASDH and
us
neurological improvement, we excluded patients (1) who underwent emergency surgeries, (2)
an
with primary fatal brainstem hemorrhage, or (3) with >20 cc of hemorrhagic contusion volume on
the initial CT.
M
Patient data collected include age, sex, initial Glasgow Coma Scale (GCS), bilateral pupillary
d
dilatation on presentation, peripheral blood hemoglobin (Hb) and platelet count (Plt), international
te
normalized ratio of prothrombin time (PT-INR), time from injury to initial CT, use of anticoagulants
Ac ce p
before head injury, use of antiplatelet agents before head injury, deterioration in liver function, clot
thickness, presence and size of a midline shift, presence of a low-density band between the
hematoma and inner wall of the skull bone on initial CT scan, skull fracture on the side of the
hematoma, and use of osmotherapy after hospital arrival.
Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS,
version 19). Data are presented as mean ± standard deviation. Clinical variables were compared
between ASDH patients demonstrating rapid spontaneous resolution and patients not demonstrating
rapid spontaneous resolution by chi-square or t-tests. Univariate analysis was performed to identify
pg. 5 Page 5 of 18
candidate clinical factors related to spontaneous resolution of ASDH. All candidate predictors with p
ip t
< 0.2 were included in a stepwise multiple logistic regression model. Factors with p < 0.05 by
multivariate analysis were considered independent predictive factors. Model validity was assessed
cr
using the Hosmer and Lemeshow goodness-of-fit test (p > 0.05 indicating adequate model fit of
an
us
data).
Results
M
Of the 366 ASDH patients treated between January 2006 and September 2012, 56 met our inclusion
d
criteria (clot thickness in the frontoparietotemporal region and midline shift >10 mm). Rapid
te
spontaneous resolution of ASDH occurred in 18 patients (32%). We did not perform emergency
Ac ce p
surgeries to evacuate the hematoma considering patients’ advanced age, poor general condition, and
family wishes in 15 (83%) patients in the resolution group and 35 (92%) patients in the no-resolution
group. Conservative therapy under close observation was initiated because there were no ominous
neurologic symptoms in 3 (17%) patients in the resolution group and 3 (8%) patients in the no-
resolution group. In the resolution group, time from injury to initial CT was 6 h in 3 patients (17%), and undocumented in 1 patient (6%). In
the no-resolution group, time from injury to initial CT was 6 h in 4 patients (11%), and undocumented in 7 patients (18%). Although there
pg. 6 Page 6 of 18
were some missing values, the time from injury to initial CT was
S0303-8467(13)00493-9 http://dx.doi.org/doi:10.1016/j.clineuro.2013.11.030 CLINEU 3555
To appear in:
Clinical Neurology and Neurosurgery
Received date: Revised date: Accepted date:
3-9-2013 8-11-2013 29-11-2013
Please cite this article as: Fujimoto K, Otsuka T, Yoshizato K, Kuratsu J-i, Predictors of rapid spontaneous resolution of acute subdural hematoma, Clinical Neurology and Neurosurgery (2013), http://dx.doi.org/10.1016/j.clineuro.2013.11.030 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.
Predictors of rapid spontaneous resolution of acute
ip t
subdural hematoma
cr
Kenji Fujimoto, M.D.1,2 , Tadahiro Otsuka, M.D., Ph.D.1, Kimio Yoshizato, M.D., Ph.D.1, Jun-ichi
us
Kuratsu, M.D.,Ph.D.2
1: Department of Neurosurgery, National Hospital Organization Kumamoto Medical Center
an
1-5, Ninomaru, Chuo-ku, Kumamoto 860-0008, Japan Phone: +81-96-353-6501
M
Fax: +81-96-325-2519
2: Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University School of Medicine
Ac ce p
Fax: +81-96-371-8064
te
Phone: +81-96-373-5219
d
1-1-1, Honjo, Kumamoto, Kumamoto 861-8556, Japan
Corresponding author: Kenji Fujimoto, M.D. Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University School of Medicine 1-1-1, Honjo, Kumamoto, Kumamoto 861-8556, Japan Phone: +81-96-373-5219 Fax: +81-96-371-8064
Email: [email protected]
pg. 1 Page 1 of 18
Abstract
ip t
Objective
Acute subdural hematoma (ASDH) usually requires emergency surgical decompression, but rare
cr
cases exhibit rapid spontaneous resolution. The aim of this retrospective study was to identify factors
us
predictive of spontaneous ASDH resolution.
an
Methods
A total of 366 consecutive patients with ASDH treated between January 2006 and September 2012
M
were identified in our hospital database. Patients with ASDH clot thickness >10 mm in the
d
frontoparietotemporal region and showing a midline shift >10 mm on the initial computed
te
tomography (CT) scan were divided into two groups according to subsequent spontaneous
Ac ce p
resolution. Univariate and multivariate logistic regression analyses were used to identify factors
predictive of rapid spontaneous ASDH resolution.
Results
Fifty-six ASDH patients met study criteria and 18 demonstrated rapid spontaneous resolution
(32%). Majority of these patients were not operated because of poor prognosis/condition and in
accordance to family wishes. Univariate analysis revealed significant differences in use of
antiplatelet agents before head injury and in the incidence of a low-density band between the
hematoma and inner wall of the skull bone on the initial CT. Use of antiplatelet agents before head
pg. 2 Page 2 of 18
injury (OR 19.6, 95%CI 1.5–260.1, p = 0.02) and the low-density band on CT images (OR 40.3,
ip t
95% CI 3.1–520.2, p = 0.005) were identified as independent predictive factors by multivariate
analysis.
cr
Conclusions
us
Our analysis suggested that use of antiplatelet agents before head injury and a low-density band
an
between the hematoma and inner skull bone on CT images (indicative of cerebrospinal fluid infusion
M
into the subdural space) increase the probability of rapid spontaneous resolution.
d
Key Words: acute subdural hematoma, antiplatelet agents, cerebrospinal fluid, frontoparietotemporal
Ac ce p
te
region, low-density band, redistribution of hematoma, spontaneous resolution
pg. 3 Page 3 of 18
ip t
Introduction Acute subdural hematoma (ASDH) is associated with high mortality, and immediate surgical
cr
intervention is indicated except for those cases deemed inoperable due to poor general condition or
us
irreversible brainstem injury.[1] Rapid spontaneous resolution of acute subdural hematoma (ASDH)
an
has rarely been reported.[2-20] Moreover, the true incidence of rapid spontaneous resolution of
ASDH is underestimated due to the routine use of emergency decompression. Two possible
M
mechanisms for spontaneous resolution of ASDH have been proposed: dilution and wash out of
d
hematoma by infusion of the cerebrospinal fluid (CSF) into the subdural space due to a tear in the
te
arachnoid membrane[12, 13] and redistribution of hematoma by acute cerebral swelling.[8, 10, 14]
Ac ce p
To the best of our knowledge, no previous report has analyzed clinical factors associated with
spontaneous ASDH resolution. Thus, our aim was to identify the factors for predicting the rapid
resolution of ASDH.
Materials and methods
From the 366 consecutive patients with ASDH treated by our hospital from January 2006 to
September 2012 and included in an institutional database, we selected patients who met the
following criteria that are important indications for emergency surgery: (1) a clot thickness >10 mm
pg. 4 Page 4 of 18
in the frontoparietotemporal region and (2) a midline shift >10 mm on the initial computed
ip t
tomography (CT). In the present analysis, we defined rapid spontaneous resolution of ASDH as (1)
neurological improvement within 24 h of presentation and (2) reduction of clot thickness by >5 mm
cr
within 96 h of initial CT (Fig. 1). To clarify the relationship between resolution of ASDH and
us
neurological improvement, we excluded patients (1) who underwent emergency surgeries, (2)
an
with primary fatal brainstem hemorrhage, or (3) with >20 cc of hemorrhagic contusion volume on
the initial CT.
M
Patient data collected include age, sex, initial Glasgow Coma Scale (GCS), bilateral pupillary
d
dilatation on presentation, peripheral blood hemoglobin (Hb) and platelet count (Plt), international
te
normalized ratio of prothrombin time (PT-INR), time from injury to initial CT, use of anticoagulants
Ac ce p
before head injury, use of antiplatelet agents before head injury, deterioration in liver function, clot
thickness, presence and size of a midline shift, presence of a low-density band between the
hematoma and inner wall of the skull bone on initial CT scan, skull fracture on the side of the
hematoma, and use of osmotherapy after hospital arrival.
Statistical analyses were performed with the Statistical Package for the Social Sciences (SPSS,
version 19). Data are presented as mean ± standard deviation. Clinical variables were compared
between ASDH patients demonstrating rapid spontaneous resolution and patients not demonstrating
rapid spontaneous resolution by chi-square or t-tests. Univariate analysis was performed to identify
pg. 5 Page 5 of 18
candidate clinical factors related to spontaneous resolution of ASDH. All candidate predictors with p
ip t
< 0.2 were included in a stepwise multiple logistic regression model. Factors with p < 0.05 by
multivariate analysis were considered independent predictive factors. Model validity was assessed
cr
using the Hosmer and Lemeshow goodness-of-fit test (p > 0.05 indicating adequate model fit of
an
us
data).
Results
M
Of the 366 ASDH patients treated between January 2006 and September 2012, 56 met our inclusion
d
criteria (clot thickness in the frontoparietotemporal region and midline shift >10 mm). Rapid
te
spontaneous resolution of ASDH occurred in 18 patients (32%). We did not perform emergency
Ac ce p
surgeries to evacuate the hematoma considering patients’ advanced age, poor general condition, and
family wishes in 15 (83%) patients in the resolution group and 35 (92%) patients in the no-resolution
group. Conservative therapy under close observation was initiated because there were no ominous
neurologic symptoms in 3 (17%) patients in the resolution group and 3 (8%) patients in the no-
resolution group. In the resolution group, time from injury to initial CT was 6 h in 3 patients (17%), and undocumented in 1 patient (6%). In
the no-resolution group, time from injury to initial CT was 6 h in 4 patients (11%), and undocumented in 7 patients (18%). Although there
pg. 6 Page 6 of 18
were some missing values, the time from injury to initial CT was
