Risk Factors for Reoperation after Traumatic Intracranial Hemorrhage

Sang-Mi Yang; Sukh Que Park; Sung-Jin Cho; Jae-Chil Chang; Hyung-Ki Park; Ra-Sun Kim

doi:10.13004/kjnt.2013.9.2.114

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Yang, Park, Cho, Chang, Park, and Kim: Risk Factors for Reoperation after Traumatic Intracranial Hemorrhage

Clinical Article

Korean J Nutr 2013;9(2):114-119.

Published online: 20 October 2013

DOI: https://doi.org/10.13004/kjnt.2013.9.2.114

Risk Factors for Reoperation after Traumatic Intracranial Hemorrhage

Sang-Mi Yang, MD, Sukh Que Park, MD, Sung-Jin Cho, MD, Jae-Chil Chang, MD, Hyung-Ki Park, MD, Ra-Sun Kim, MD

Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, Korea

Address for correspondence: Sukh Que Park, MD Department of Neurosurgery, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea Tel: +82-2-709-9268, Fax: +82-2-792-5976 E-mail: drcolor@schmc.ac.kr

Received 18 August 2013 Revised 9 October 2013 Accepted 9 October 2013

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

Progression after operation in traumatic brain injury (TBI) is often correlated with morbidity and poor outcome. We have investigated to characterize the natural course of traumatic intracranial hemorrhage and to identify the risk factors for postoperative progression in TBI.

Methods

36 patients requiring reoperation due to hemorrhagic progression following surgery for traumatic intracranial hemorrhage were identified in a retrospective review of 335 patients treated at our hospital between 2001 and 2010. We reviewed the age, sex, Glasgow Coma Scale, the amount of hemorrhage, the type of hemorrhage, rebleeding site, coagulation profiles, and so on. Univariate statistics were used to examine the relationship between the risk factors and reoperation.

Results

Acute subdural hematoma was the most common initial lesion requiring reoperation. Most patients had a reoperation within 24–48 hours after operation. Peri-lesional edema (p=0.002), and initial volume of hematoma (p=0.013) were the possible factors of hemorrhagic progression requiring reoperation. But preoperative coagulopathy was not risk factor of hemorrhagic progression requiring reoperation.

Conclusion

Peri-lesional edema and initial volume of hematoma were the statistical significant factors requiring reoperation. Close observation with prompt management is needed to improve the outcome even in patient without coagulopathy.

Keywords: Traumatic brain injury, Rebleeding, Progression, Risk factor, Reoperation

References

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TABLE 1.

Demographics and statistical analysis of total 302 patients having decompressive craniectomy and hematoma removal operation after traumatic brain injury and 36 patients with postoperative hemorrhagic progression

Patient demographics	Progression group (n, %)	Non-progression group (n, %)	Total (n, %)	p-value
No. of patients	36	266	302
Mean age (years)	57.0	55.9	55.2	0.306^∗∗
Sex				0.125^∗
Male	23 (63.9)	222 (83.5)	245 (81.1)
Female	13 (36.1)	44 (16.5)	57 (18.9)
Mechanism of injury				0.819^∗
Fall down	4 (11.1)	25 (9.4)	29 (9.6)
Slip down	12 (33.3)	96 (36.1)	108 (35.8)
Roll down	7 (19.5)	43 (16.2)	50 (16.6)
In-car accident	6 (16.7)	39 (14.7)	45 (14.9)
Pedestrian accident	4 (11.1)	34 (12.8)	38 (12.6)
Motorcycle accident	3 (8.3)	27 (10.2)	30 (9.9)
Etc.	0 (0)	2 (0.8)	2 (0.7)
GCS				0.984^∗
Severe (5–8)	9 (25)	71 (26.7)	80 (26.5)
Moderate (9–12)	16 (44.4)	151 (56.8)	167 (55.3)
Mild (13–15)	11 (30.6)	44 (16.5)	55 (18.2)
Radiographic findings
SDH	21 (58.3)	144 (54.1)	165 (54.6)	0.394^∗
EDH	8 (22.2)	78 (29.3)	86 (28.5)	0.416^∗
ICH	7 (19.5)	44 (16.5)	51 (16.9)	0.275^∗
Skull fracture	14 (38.9)	126 (47.4)	140 (46.4)	0.258^∗
Peri-lesional edema	25 (69.4)	100 (37.6)	125 (41.4)	0.002^∗
Sulcal effacement	26 (72.2)	204 (76.7)	230 (76.2)	0.784^∗
Preoperative coagulopathy	11 (30.6)	71 (26.7)	82 (27.1)	0.342^∗

^∗ statistical significance was evaluated by chi-square test

^∗∗ student's t-test. Etc.: other causes including penetrating injury, GCS: Glasgow Coma Scale, SDH: subdural hematoma, EDH: epidural hematoma, ICH: intracerebral hemorrhage

TABLE 2.

The initial volume of the hematoma on CT scan of patients after TBI

Volume (cm³)	Non-progression group (n=266)(%)	Progression group (n=36)(%)	p-value^∗
<30	60 (22.6%)	5 (13.9%)
≥30	206 (77.4%)	31 (86.1%)
Mean volume	49.2	52.6	0.013

^∗ student's t-test. The volume was calculated using the following formula: (ABC)/2 (cm³), A: maximum diameter (cm), B: the diameter at 90° to the maximum diameter (cm), C: the total number of 10 mm axial slices, CT: computed tomography, TBI: traumatic brain injury

TABLE 3.

Comparison of the lesions requiring reoperation with the initial location of hemorrhage on the CT scan

Location Types of hemorrhage		n=36 (%)	Total (%)
Initial site	EDH	6 (16.7)	28 (77.8)
	SDH	17 (47.2)
	ICH	5 (13.9)
Other site	EDH	2 (5.5)	8 (22.2)
	SDH	4 (11.2)
	ICH	2 (5.5)

EDH: epidural hematoma, SDH: subdural hematoma, ICH: intracerebral hemorrhage, CT: computed tomography

TABLE 4.

Comparison of the pre and postoperative coagulation profiles of 302 patients after TBI

Variables	Non-progression group (mean±SD)	Progression group (mean±SD)	p-value^∗
PT (INR)
Preoperative	1.15±0.45	0.98±0.08	0.296
Postoperative	2.17±4.19	1.30±0.12	0.469
aPTT (sec)
Preoperative	32.31±7.51	30.29±7.21	0.415
Postoperative	59.45±81.33	33.66±5.57	0.560
PLT count (×10³/μL)
Preoperative	248.92±86.43	223.00±69.26	0.375
Postoperative	169.37±71.38	140.88±58.32	0.279

^∗ p-value was analyzed between non-progression and progression groups. PT: prothrombin time, INR: International Normalized Ratio, aPTT: activated partial thromboplastin time, PLT: platelet, SD: standard deviation, TBI: traumatic brain injury

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