Time to surgery following chronic subdural hematoma: post hoc analysis of a prospective cohort study

Abstract

BackgroundChronic subdural hematoma (CSDH) is a common neurological condition; surgical evacuation is the mainstay of treatment for symptomatic patients. No clear evidence exists regarding the impact of timing of surgery on outcomes. We investigated factors influencing time to surgery and its impact on outcomes of interest.MethodsPatients with CSDH who underwent burr-hole craniostomy were included. This is a subset of data from a prospective observational study conducted in the UK. Logistic mixed modelling was performed to examine the factors influencing time to surgery. The impact of time to surgery on discharge modified Rankin Scale (mRS), complications, recurrence, length of stay and survival was investigated with multivariable logistic regression analysis.Results656 patients were included. Time to surgery ranged from 0 to 44 days (median 1, IQR 1–3). Older age, more favorable mRS on admission, high preoperative Glasgow Coma Scale score, use of antiplatelet medications, comorbidities and bilateral hematomas were associated with increased time to surgery. Time to surgery showed a significant positive association with length of stay; it was not associated with outcome, complication rate, reoperation rate, or survival on multivariable analysis. There was a trend for patients with time to surgery of ≥7 days to have lower odds of favorable outcome at discharge (p=0.061).ConclusionsThis study provides evidence that time to surgery does not substantially impact on outcomes following CSDH. However, increasing time to surgery is associated with increasing length of stay. These results should not encourage delaying operations for patients when they are clinically indicated.

Surgical management of chronic subdural haematoma: looking beyond anaesthetic technique

“…The procedure is often performed out of hours and managed by junior neurosurgeons and anaesthetists. In this study, the median (IQR [range]) time from admission to surgery was similar in both groups but with a wide range: general anaesthesia 3 (3-3 [2-10]) days vs. regional anaesthesia 3 (2-5 [2][3][4][5][6][7][8][9][10][11][12][13][14][15]) days. Delays to definitive treatment may impact the incidence of complications and have been shown to affect the length of stay in a retrospective cohort study [13].…”

Controversies in the Surgical Treatment of Chronic Subdural Hematoma: A Systematic Scoping Review

“…While surgical time frames have been extensively studied in acute subdural hematomas, these do not pertain to cSDH [ 23 ]. Therefore, clinical practice is mostly based on the reasonable consensus that cSDHs should be ideally treated as soon as possible, especially in patients with neurological deficits.…”

“…While most papers highlight the fact that cSDH should be treated “timely”, only a few studies have studied this variable in chronic subdural hematoma treatment. Venturini et al in their 2019 observational cohort study examining 656 patients with cSDH concluded that the time of surgery is associated positively with the length of hospitalization, but not with the outcome, complications, recurrence, reoperation and survival [ 23 ]. Additionally, they showed that a time of surgery later than 7 days after symptoms begin decreases the chance of a favorable outcome at discharge.…”

“…Additionally, they showed that a time of surgery later than 7 days after symptoms begin decreases the chance of a favorable outcome at discharge. Most patients underwent surgery on the first day, which illustrates the timely manner in which they were treated [ 23 ]. On the other hand, Zolfaghari et al were not able to identify any significant negative effect upon outcome correlated to time from diagnostic CT scan until surgery.…”

“…Based on the new European Heart Rhythm Association (EHRA) guidelines and the British Society of Haematology guidelines, a 24-h delay of surgery is advised in patients systematically treated with new oral anticoagulants (NOACs), counting from the last dose taken. The delay may be extended to 48 h when renal impairment or direct thrombin inhibitor are part of a patient’s medical history [ 17 , 23 , 25 ]. If urgent surgery is required, guidelines propose prothrombin complex concentrate (PCC) for reversing the effects of NOACs [ 25 ].…”