Abstract:Purpose
Chronic subdural hematoma (CSDH) is a common neurological disease often affecting the elderly. Long-term excess mortality for patients after CSDH has been suggested but causes of death are unknown. We hypothesize that excess mortality of CSDH patients is related to frailty. In this article, we describe mortality rates and causes of death of CSDH patients compared with the general population and assess the association of frailty with mortality.
Methods
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“…Consequently, the merging of these blood ages as a single category avoided redundancy as it pertained to general disease course for those being surgically treated. This coincides and supports articles in the literature that have categorized both subacute and chronic SDHs together as “chronic” [ 27 , 42 , 43 ].…”
A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.
“…Consequently, the merging of these blood ages as a single category avoided redundancy as it pertained to general disease course for those being surgically treated. This coincides and supports articles in the literature that have categorized both subacute and chronic SDHs together as “chronic” [ 27 , 42 , 43 ].…”
A major challenge within the academic literature on SDHs has been inconsistent outcomes reported across studies. Historically, patients have been categorized by the blood-product age identified on imaging (i.e., acute, subacute, or chronic). However, this schematic has likely played a central role in producing the heterogeneity encountered in the literature. In this investigation, a total of 494 patients that underwent SDH evacuation at a tertiary medical center between November 2013-December 2021 were retrospectively identified. Mechanism of injury was reviewed by the authors and categorized as either positive or negative for a high-velocity impact (HVI) injury. Any head strike injury leading to the formation of a SDH while traveling at a velocity beyond that of normal locomotion or daily activities was categorized as an HVI. Patients were subsequently stratified by those with an acute SDHs after a high-velocity impact (aSDHHVI), those with an acute SDH without a high-velocity impact injury (aSDHWO), and those with any combination of subacute or chronic blood products (mixed-SDH [mSDH]). Nine percent (n = 44) of patients experienced an aSDHHVI, 23% (n = 113) aSDHWO, and 68% (n = 337) mSDH. Between these groups, highly distinct patient populations were identified using several metrics for comparison. Most notably, aSDHHVI had a significantly worse neurological status at discharge (50% vs. 23% aSDHWO vs. 8% mSDH; p < 0.001) and mortality (25% vs. 8% aSDHWO vs. 4% mSDH; p < 0.001). Controlling for gender, midline shift (mm), and anticoagulation use in the acute SDH population, multivariable logistic regression revealed a 6.85x odds ratio (p < 0.001) for poor outcomes in those with a positive history for a high-velocity impact injury. As such, the distribution of patients that suffer an HVI related acute SDH versus those that do not can significantly affect the outcomes reported. Adoption of this stratification system will help address the heterogeneity of SDH reporting in the literature while still closely aligning with conventional reporting.
“…1 ). 18 , 19 , 20 , 21 , 22 , 23 Table 1 depicts key findings of the studies assessing impact of frailty on outcomes in cSDH patients. Fig.…”
Section: Resultsmentioning
confidence: 99%
“… Retrospective cohort NSQIP database study from 2005 to 2018. n = 1647 Follow-up for 30-days mFI-5 Pre-operative frailty was correlated with increased occurrence of postoperative complications, discharge to destination other than home, and 30-day mortality. Blaauw et al, 2022 23 Evaluation of frailty as an index for mortality rate in patients with cSDH. Retrospective cohort n = 1307 median follow up 56 months CCI Within the cohort of CSDH patients, all six frailty indicators were associated with death Among CSDH patients frequent falling, inability to live independently, inability to perform daily self-care, and number of medications used were independently associated with mortality.…”
Section: Resultsmentioning
confidence: 99%
“…Three were single-center studies 18 , 19 , 20 and three were multicenter studies, 21 , 22 one of which was performed using patient data extracted from on the National Surgical Quality Improvement Program (NSQIP) database 22 and the other one was performed using the Dutch CBS database. 23 Two studies used clinical frailty scale (CFS) alone as a measure of frailty, 18 , 21 one study employed modified frailty index-5 (mFI-5) alone, 22 one study used both mFI-5 and modified frailty index-11 (mFI-11), 20 and another study used mFI-11 and CFS as frailty measures. 19 One study 23 employed Charlson Comorbidity Index (CCI) alone while two studies employed it in addition to other frailty scales/indices.…”
Section: Resultsmentioning
confidence: 99%
“… 23 Two studies used clinical frailty scale (CFS) alone as a measure of frailty, 18 , 21 one study employed modified frailty index-5 (mFI-5) alone, 22 one study used both mFI-5 and modified frailty index-11 (mFI-11), 20 and another study used mFI-11 and CFS as frailty measures. 19 One study 23 employed Charlson Comorbidity Index (CCI) alone while two studies employed it in addition to other frailty scales/indices. 18 , 20 The duration of outcomes assessment varied widely between studies including, 6 months, 21 3 months, 18 and 30 days 22 ; two studies used disposition i.e., discharge from hospital or in-hospital mortality as outcomes measurement time point.…”
BackgroundChronic subdural haematoma (CSDH) drainage is a common neurosurgical procedure. CSDHs cause excess mortality, which is exacerbated by frailty. Sarcopenia contributes to frailty – its key component, low muscle mass, can be assessed using cross‐sectional imaging. We aimed to examine the prognostic role of temporal muscle thickness (TMT) measured from preoperative computed tomography head scans among patients undergoing surgical CSDH drainage.MethodsWe retrospectively identified all patients who underwent CSDH drainage within 1 year of February 2019. We measured their mean TMT from preoperative computed tomography scans, tested the reliability of these measurements, and evaluated their prognostic value for postoperative survival.ResultsOne hundred and eighty‐eight (122, 65% males) patients (median age 78 years, IQR 70–85 years) were included. Thirty‐four (18%) patients died within 2 years, and 51 (27%) died at a median follow‐up of 39 months (IQR 34–42 months). Intra‐ and inter‐observer reliability of TMT measurements was good‐to‐excellent (ICC 0.85–0.97, P < 0.05). TMT decreased with age (Pearson's r = −0.38, P < 0.001). Females had lower TMT than males (P < 0.001). The optimal TMT cut‐off values for predicting two‐year survival were 4.475 mm for males and 3.125 mm for females. TMT below these cut‐offs was associated with shorter survival in both univariate (HR 3.24, 95% CI 1.85–5.67) and multivariate (HR 1.86, 95% CI 1.02–3.36) analyses adjusted for age, ASA grade and bleed size. The effect of TMT on mortality was not mediated by age.ConclusionsIn patients with CSDH, TMT measurements from preoperative imaging were reliable and contained prognostic information supplemental to previously known predictors of poor outcomes.
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