PDF
ePub
Citation
Print
Abstract
Objective
Acute subdural hematoma (ASDH) with good initial Glasgow Coma Scale (GCS) score 13–15 is generally regarded as a mild head injury. However, the risk increases when significant amount of hematoma with midline shift exists. This study is to evaluate the clinical outcomes of patients with good neurological scores in spite of significant amounts of ASDH, and to compare the outcomes according to the treatment modalities.
Methods
Sixty patients with initial GCS score 13–15 in spite of significant amounts of ASDH and midline shifts were enrolled. They were divided into groups according to age, sex, side of location, initial GCS score, midline shift, and hematoma thickness. According to the therapeutic modalities, early craniotomy and initially conserved groups were identified, and initially conserved group was further classified into persistently conserved and delayed operation groups. The outcomes were measured by Glasgow Outcome Scale.
Results
Initial GCS score was a significant factor that influenced the final outcome (p=0.001). The outcomes were good in both early craniotomy and initially conserved groups without significant differences (p=0.268). Fifteen of initially conserved 49 patients underwent delayed operations from neurological deteriorations, but the outcomes were good without significant differences from persistently conserved group (p=0.481).
Conclusion
Initial GCS score is an important factor that influences the clinical outcome. These patients can be conserved under close observations without early preventive craniotomies if no deteriorations are seen in the acute stage. Only those with delayed deteriorations may require simple operations such as burr hole trephinations which still guarantee good outcomes.
References
1. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of acute subdural hematomas. Neurosurgery 58 (3 Suppl):S16-S24; discussion Si-Siv. 2006.
2. Choi JH, Kim SM, Cho YJ, Kim CH, Shim YB, Park YK, et al. A clinical analysis of the patients who “talk and deteriorate” as a result of delayed traumatic intracerebral hematomas. J Korean Neurosurg Soc. 26:1204–1210. 1997.
3. Choi SW, Koh HS, Yeom JY, Kim SH, Song SH, Kim Y. Clinical analysis of the risk factors and prognostic factors of delayed deterioration following mild head injury. J Korean Neurosurg Soc. 28:1316–1323. 1999.
4. Dacey RG Jr, Alves WM, Rimel RW, Winn HR, Jane JA. Neurosurgical complications after apparently minor head injury. Assessment of risk in a series of 610 patients. J Neurosurg. 65:203–210. 1986.
5. Gómez PA, Lobato RD, Ortega JM, De La Cruz J. Mild head injury: differences in prognosis among patients with a Glasgow Coma Scale score of 13 to 15 and analysis of factors associated with abnormal CT findings. Br J Neurosurg. 10:453–460. 1996.
6. Hsiang JN, Yeung T, Yu AL, Poon WS. High-risk mild head injury. J Neurosurg. 87:234–238. 1997.
7. Jamjoom A, Nelson R, Stranjalis G, Wood S, Chissell H, Kane N, et al. Outcome following surgical evacuation of traumatic intracranial haematomas in the elderly. Br J Neurosurg. 6:27–32. 1992.
8. Kim KH. Predictors for functional recovery and mortality of surgically treated traumatic acute subdural hematomas in 256 patients. J Korean Neurosurg Soc. 45:143–150. 2009.
9. Kwon JT, Park K, Kim YB, Min BK, Hwang SN, Suk JS, et al. Clinical course and outcome following mild head injury. J Korean Neurosurg Soc. 21:1071–1079. 1992.
10. Lee DS, Park JT. Surgical outcome of traumatic brain injury in the elderly. J Korean Neurotraumatol Soc. 2:37–42. 2006.
11. Lee K, Lee KS, Bae HG, Yun IG, Lee IS. Characteristics of head injury in the aged. J Korean Neurosurg Soc. 19:1001–1008. 1990.
12. Lee MH, Lee YS, Lee JH, Ryu KY, Kang DG. Comparative study of surgical outcome and the features on old versus young aged traumatic brain injury patients. J Korean Neurotraumatol Soc. 6:125–131. 2010.
13. Lee YB, Kwon SJ. A more detailed classification of mild head injury in adults and treatment guidelines. J Korean Neurosurg Soc. 46:451–458. 2009.
14. Luerssen TG, Klauber MR, Marshall LF. Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury. J Neurosurg. 68:409–416. 1988.
15. Nagurney JT, Borczuk P, Thomas SH. Elder patients with closed head trauma: a comparison with nonelder patients. Acad Emerg Med. 5:678–684. 1998.
16. Osler T, Hales K, Baack B, Bear K, Hsi K, Pathak D, et al. Trauma in the elderly. Am J Surg. 156:537–543. 1988.
17. Park YK. Mild head injury, in Korean Neurotraumatology Society: Head Injury. Reston: Korea Medical, pp241–253;1996.
18. Park YS, Kim HJ, Whang K, Pyen JS, Hu C, Hong SK, et al. Clinical characteristics and prognosis of mild head injury in the elder-ly559. J Korean Neurosurg Soc. 31:564–568. 2002.
19. Pennings JL, Bachulis BL, Simons CT, Slazinski T. Survival after severe brain injury in the aged. Arch Surg. 128:787–793. ; discussion 793–794,. 1993.
20. Rimel RW, Giordani B, Barth JT, Boll TJ, Jane JA. Disability caused by minor head injury. Neurosurgery. 9:221–228. 1981.
21. Rockswold GL, Leonard PR, Nagib MG. Analysis of management in thirty-three closed head injury patients who “talked and deteriorated”. Neurosurgery. 21:51–55. 1987.
22. Ross AM, Pitts LH, Kobayashi S. Prognosticators of outcome after major head injury in the elderly. J Neurosci Nurs. 24:88–93. 1992.
23. Santora TA, Schinco MA, Trooskin SZ. Management of trauma in the elderly patient. Surg Clin North Am. 74:163–186. 1994.
24. Stein SC, Ross SE. The value of computed tomographic scans in patients with low-risk head injuries. Neurosurgery. 26:638–640. 1990.
25. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 2:81–84. 1974.
26. Williams DH, Levin HS, Eisenberg HM. Mild head injury classification. Neurosurgery. 27:422–428. 1990.
27. Yoon SM, Lee KS, Lee JH, Doh JW, Bae HG, Yun IG. Surgical outcome following evacuation of traumatic intracranial hematomas in the elderly. J Korean Neurosurg Soc. 33:477–482. 2003.
TABLE 1.
Clinical and radiological factors in relation to GOS (n=60
| No. of patient | Mean GOS score | p-value | |
|---|---|---|---|
| Age | |||
| ＜60 | 28 | 4.86 | 0.093 |
| ≥60 | 32 | 4.66 | |
| Sex | |||
| Male | 37 | 4.76 | 0.890 |
| Female | 23 | 4.74 | |
| Side of location | |||
| Left | 24 | 4.88 | 0.070 |
| Right | 36 | 4.67 | |
| Initial GCS score | |||
| 15 | 34 | 4.91 | 0.001∗ |
| 14 | 13 | 4.69 | |
| 13 | 13 | 4.38 | |
| Midline shift | |||
| ＜5 mm | 24 | 4.75 | 1.000 |
| ≥5 mm | 36 | 4.75 | |
| Hematoma thickness | |||
| ＜10 mm | 25 | 4.80 | 0.494 |
| ≥10 mm | 35 | 4.71 |
XML Download