Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals

Jessica C Eaton; R Michael Meyer; Do H Lim; Madeline E Greil; John R Williams; Christopher C Young; Jason K Barber; Nancy R Temkin; Robert H Bonow; Randall M Chesnut

doi:10.1016/j.wneu.2023.08.134

Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals

World Neurosurg. 2023 Nov:179:e523-e529. doi: 10.1016/j.wneu.2023.08.134. Epub 2023 Sep 6.

Affiliations

¹ Department of Neurological Surgery, University of Washington, Seattle, WA, USA.
² Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA.
³ Department of Neurological Surgery, University of Washington, Seattle, WA, USA; Harborview Injury Prevention Research Center, University of Washington, Seattle, WA, USA.
⁴ Department of Neurological Surgery, University of Washington, Seattle, WA, USA; School of Global Health, University of Washington, Seattle, WA, USA. Electronic address: chesnutr@uw.edu.

PMID: 37683917
DOI: 10.1016/j.wneu.2023.08.134

Abstract

Background: Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients.

Methods: We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury.

Results: Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted).

Conclusions: Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.

Keywords: 50 years and older; Acute subdural hematoma; Prognosis; Traumatic brain injury.

MeSH terms

Adrenal Cortex Hormones / therapeutic use
Craniocerebral Trauma*
Glasgow Coma Scale
Hematoma, Subdural / surgery
Hematoma, Subdural, Acute* / surgery
Humans
Prognosis
Retrospective Studies

Substances

Adrenal Cortex Hormones