Development of the Subdural Hematoma in the Elderly (SHE) score to predict mortality

Alford, Elizabeth N; Rotman, Lauren E.; Erwood, Matthew S; Oster, Robert A.; Davis, Matthew C.; Pittman, H. Bruce C.; Zeiger, H E; Fisher, Winfield S.

doi:10.3171/2019.1.jns182895

Cited by 19 publications

(26 citation statements)

References 40 publications

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“…Careful selection of surgical candidates for cSDH evacuation incorporates a variety of factors including hemorrhage size, MLS, age, overall clinical history and exam, and the iGCS. In particular, the iGCS following cSDH is thought to be the factor with the highest prognostic utility [ 21 , 22 ]. In line with this, patients in our study who had an operation were younger, were more likely to have an isolated head injury, a better iGCS, larger cSDH thickness, and lower CCI and mFI-11 scores (Table 3 ).…”

Section: Discussionmentioning

confidence: 99%

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

McIntyre

Rawanduzy

Afridi

et al. 2020

Cureus

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Background Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty’s ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH. Methods Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints. Results Of the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis. Conclusion While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.

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Section: Discussionmentioning

confidence: 99%

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

McIntyre

Rawanduzy

Afridi

et al. 2020

Cureus

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“…Thus, the inclusion of this additional criterion into prognostication tools in CSDH appears warranted. Alford et al [6] suggest the SHE might be superior to other existing prediction models for SDH [37] thanks to the simplicity and readily availability of its components. The CFS is an easy-to-use scale, amply validated [10,38] in multiple settings, both in medicine and surgery, so that the authors believe that its incorporation into the SHE does not make it more cumbersome.…”

Section: Discussionmentioning

confidence: 99%

“…When deciding which patients should undergo further treatment of their CSDH, proper assessment of their prognosis is key. To aid clinicians in their decision-making and advising, the Subdural Hematoma in the Elderly (SHE) score was published in 2019 as a model to predict 30-day mortality from a subdural hematoma in the elderly population after minor or no trauma [ 6 ].…”

Section: Introductionmentioning

confidence: 99%

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score

2021

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The Subdural Hematoma in the Elderly (SHE) score was developed as a model to predict 30-day mortality from acute, chronic, and mixed subdural hematoma in the elderly population after minor or no trauma. Emerging evidence suggests frailty to be predictive of mortality and morbidity in the elderly. In this study, we aim to externally validate the SHE for chronic subdural hematoma (CSDH) alone, and we hypothesize that the incorporation of frailty into the SHE may increase its predictive power. A retrospective cohort of elderly patients with CSDH after minor or no trauma being treated at our institution was evaluated with the SHE. Thirty-day mortality and outcome were documented. Patients were assessed with the Clinical Frailty Scale (CFS), which was incorporated into a modified SHE (mSHE). Both the SHE and the mSHE were then assessed in their predictive powers through receiver operating characteristic statistics. We included 168 patients. Most (n = 124, 74%) had a favorable outcome at 30 days. Mortality was low at n = 7, 4%. The SHE failed to predict mortality (AUC = .564, p = .565). Contrarily, the mSHE performed well in both mortality (AUC = .749, p = .026) and outcome (AUC = .862, p < .001). A threshold of mSHE = 3 is predictive of mortality with a sensitivity of 50% and a specificity of 75% and of poor outcome with a sensitivity of 88% and a specificity of 64%. Frailty should be routinely evaluated in elderly individuals, as it can predict outcome and mortality, providing the possibility for medical, surgical, nutritional, cognitive, and physical exercise interventions.

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“…However, older age is generally accepted to be an important predictor of poor prognosis and mortality of SDH, which has a mortality rate ranging from 35% to 80%. [19][20][21][22] Furthermore, craniotomy under general anesthesia is often inappropriate in elderly patients due to their systemic comorbid burdens, such as cardiopulmonary failure, diabetes mellitus, and the use of antithrombotic drugs. Therefore, an endoscopic procedure under local anesthesia would be useful for patients with ASDH who cannot undergo craniotomy under general anesthesia.…”

Section: Elderly Patients With Asdhmentioning

confidence: 99%

Fifteen Cases of Endoscopic Treatment of Acute Subdural Hematoma with Small Craniotomy under Local Anesthesia: Endoscopic Hematoma Removal Reduces the Intraoperative Bleeding Amount and the Operative Time Compared with Craniotomy in Patients Aged 70 or Older

Katsuki

Kakizawa

Nishikawa

et al. 2020

Neurol. Med. Chir.(Tokyo)

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We report cases of acute subdural hematoma (ASDH) treated by endoscopic hematoma removal with a small craniotomy under local anesthesia. From 2015 to 2019, we retrospectively analyzed 15 ASDH patients who were 70 years or older and met our criteria for endoscopic treatment: (1) comorbidities indicated risks associated with a large craniotomy under general anesthesia; (2) decompressive craniectomy was unlikely; and (3) an enlarging hematoma was absent. We also performed a case-control study using the inverse probability weighting method to compare the 15 patients to 20 ASDH patients who were 70 years or older, met criteria (2) and (3), and were treated by craniotomy between 2012 and 2019. Among the 15 ASDH patients, the median age was 86 (range, 70-101) years, and fall was the common cause. The median Glasgow Coma Scale score on admission, operative time, stay time in the operation room, and bleeding amount were 8 (6-15), 91 (48-156) min, 120 (80-205) min, and 20 (5-400) mL, respectively. The extraction rates of all the hematomas exceeded 90%. No patients required conversion to craniotomy under general anesthesia. Three patients had favorable outcomes, and five died. The comparison with craniotomy revealed that the endoscopic procedure reduced the intraoperative bleeding amount, operative time, and stay time in the operation room (p <0.001, p = 0.02, and p <0.001, respectively). In summary, endoscopic hematoma removal for selected ASDH patients aged 70 years or older did not improve functional outcomes but reduced the bleeding amount and the operative time compared with craniotomy.

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Development of the Subdural Hematoma in the Elderly (SHE) score to predict mortality

Cited by 19 publications

References 40 publications

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis

A matter of frailty: the modified Subdural Hematoma in the Elderly (mSHE) score

Fifteen Cases of Endoscopic Treatment of Acute Subdural Hematoma with Small Craniotomy under Local Anesthesia: Endoscopic Hematoma Removal Reduces the Intraoperative Bleeding Amount and the Operative Time Compared with Craniotomy in Patients Aged 70 or Older

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