Objective

There is little evidence to guide patient selection for subdural hemorrhage (SDH) evacuation. This study was designed to assess the benefit of surgical evacuation of SDH, identify predictors of functional outcome, and create a bedside score to guide the clinical management of SDH.

Methods

A cohort of 331 patients presenting to a single center from 2010 to 2014 with a principal diagnosis of subdural hemorrhage was identified. Clinical and radiographic information were extracted from the medical record. Outcomes of interest were (1) the occurrence of surgical evacuation of SDH, and (2) an unfavorable 90-day functional status represented by a modified Rankin score (mRS) ≥ 3. Propensity score matching and adjustment techniques were employed to assess the benefit of surgery accounting for confounding by indication. Multivariable logistic regression models predicting follow-up functional outcome were generated and bootstrapped separately among those with acute SDH and those with either subacute or chronic SDH. Clinical scores were created using model coefficients.

Results

In this cohort [65% male, mean age 67 years], 47% underwent surgery. Age, focal neurologic deficit, SDH thickness > 10 mm, midline shift > 5mm, and SDH acuity predicted undergoing surgery. Propensity score matching analysis demonstrated that operated patients overall were less likely to have unfavorable 90-day mRS outcome (OR 0.35, 95% C.I. 0.15-0.82). Among patients with acute SDH, age, female sex, pre-admission mRS, focal neurologic deficit, and neuropsychiatric symptoms predicted 90-day functional outcome (c-statistic 0.89, optimism-corrected c-statistic 0.87) and were incorporated into an acute SDH score (range 1–10). Patients with SDH score > 4 were significantly more likely to have an unfavorable outcome if treated medically versus surgically; there was no difference in 90-day functional status by treatment strategy among patients with SDH score ≤ 4. No difference in outcome was seen by surgical status across the spectrum of chronic SDH scores.

Conclusions

Surgical evacuation of subdural hematomas overall is associated with favorable outcome. Patient selection for evacuation is enhanced by the application of the acute SDH score. Future studies are necessary to validate the SDH score in an external cohort.

中文翻译：

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硬膜下血肿：预后的预测因素和指导手术决策的评分

客观的

几乎没有证据可以指导硬膜下出血 (SDH) 清除术的患者选择。本研究旨在评估 SDH 手术清除的益处，确定功能结果的预测因素，并创建床边评分以指导 SDH 的临床管理。

方法

确定了 2010 年至 2014 年在单一中心就诊的 331 名主要诊断为硬膜下出血的患者队列。从病历中提取临床和影像学信息。感兴趣的结果是 (1) SDH 手术清除的发生，和 (2) 90 天不利的功能状态，由改良的 Rankin 评分 (mRS) ≥ 3 表示。采用倾向评分匹配和调整技术来评估益处手术考虑了适应症的混杂因素。预测随访功能结果的多变量逻辑回归模型分别在急性 SDH 和亚急性或慢性 SDH 患者中生成和引导。使用模型系数创建临床评分。

结果

在该队列中 [65% 男性，平均年龄 67 岁]，47% 接受了手术。年龄、局灶性神经功能缺损、SDH 厚度 > 10 毫米、中线偏移 > 5 毫米和 SDH 敏锐度预测接受手术。倾向评分匹配分析表明，手术患者总体上不太可能出现不利的 90 天 mRS 结果（OR 0.35，95% CI 0.15-0.82）。在急性 SDH 患者中，年龄、女性、入院前 mRS、局灶性神经功能缺损和神经精神症状可预测 90 天的功能结果（c 统计量为 0.89，乐观校正 c 统计量为 0.87）并被纳入急性 SDH分数（范围 1-10）。如果药物治疗与手术治疗相比，SDH 评分 > 4 的患者出现不良结果的可能性明显更高；

结论

手术清除硬膜下血肿总体上与良好的结果相关。急性 SDH 评分的应用增强了患者对疏散的选择。未来的研究需要在外部队列中验证 SDH 评分。