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Mismatch Between Midline Shift and Hematoma Thickness As A Open access Original research Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2021-000707 on 21 May 2021. Downloaded from Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma Matheus Rodrigues de Souza,1 Caroline Ferreira Fagundes,1 Davi Jorge Fontoura Solla,2,3 Gustavo Carlos Lucena da Silva,1 Rafaela Borin Barreto,1 Manoel Jacobsen Teixeira,2 Robson Luis Oliveira de Amorim,2 Angelos G Kolias,4 Daniel Godoy,5 Wellingson Silva Paiva2,3 ► Additional supplemental ABSTRACT brain injury (TBI). The acceleration–deceleration material is published online Background Acute subdural hematoma (ASDH) resulting from trauma results in the rupture of the only. To view, please visit the journal online (http:// dx. doi. is a traumatic lesion commonly found secondary to bridged veins, which causes the formation of hema- org/ 10. 1136/ tsaco- 2021- traumatic brain injury. Radiological findings on CT, such toma.1–3 Damage to brain tissue cannot be attributed 000707). as hematoma thickness (HT) and structures midline shift only to ASDH, as this hematoma is commonly asso- (MLS), have an important prognostic role in this disease. ciated with cerebral edema, brain concussions, and 1 Department of Medicine, Mato The relationship between HT and MLS has been rarely Grosso State University, Caceres, diffuse axonal lesions, which can worsen patient 4 5 Mato Grosso, Brazil studied in the literature. Thus, this study aimed to assess prognosis. Despite advances in prehospital and 2Department of Neurology, the prognostic accuracy of the difference between MLS hospital support, this entity still has high mortality University of São Paulo, São and HT for acute outcomes in patients with ASDH in a rates.6–8 The mortality rate in the literature ranges Paulo, Brazil low- income to middle- income country. from 40% to 70%.6 9 10 3Department of Neurology, University of Cambridge, Methods This was a post- hoc analysis of a prospective Several factors are associated with the prognosis Cambridge, UK cohort study conducted in a university- associated of these patients, such as the Glasgow Coma Scale 4Department of Clinical tertiary- level hospital in Brazil. The TRIPOD (Transparent (GCS) score at admission, age, pupillary response, Neuroscience - Division of 11 12 Reporting of a multivariable prediction model for and associated traumatic injuries. Radiolog- copyright. Neurosurgery, Addenbrooke’s Individual Prognosis or Diagnosis) statement guidelines Hospital, Cambridge, UK ical findings on CT, such as hematoma thickness 5Intensive Care Unit, San Juan were followed. The difference values between MLS (HT) and structures midline shift (MLS), have an Bautista Hospital, San Fernando and HT (Zumkeller index, ZI) were divided into three important prognostic role and can be a determining del Valle de Catamarca, categories (<0.00, 0.01–3, and >3). Logistic regression factor for surgical management.13–17 Argentina analyses were performed to reveal the OR of categorized MLS is caused by the hematoma itself and ZI in predicting primary outcome measures. A Cox concomitant brain swelling.18 The effect of brain Correspondence to regression was also performed and the results were Professor Wellingson Silva swelling can be shown on the initial head CT scan by Paiva, Department of Neurology presented through HR. The discriminative ability of three the relationship of the MLS and the HT. Dispropor- – Division of Neurosurgery, multivariate models including clinical and radiological tionately increased MLS compared with HT would University of São Paulo, São variables (ZI, Rotterdam score, and Helsinki score) was raise concerns of brain tissue injury and edema, http://tsaco.bmj.com/ Paulo, São Paulo, Brazil; demonstrated. wellingsonpaiva@ yahoo. com. br and hence a higher intracranial pressure (ICP) and Results A total of 114 patients were included. Logistic a worse prognosis could be anticipated. HT, MLS, regression demonstrated an OR value equal to 8.12 for Received 8 February 2021 ICP, and other factors including the severity of brain Revised 5 April 2021 the ZI >3 category (OR 8.12, 95% CI 1.16 to 40.01; atrophy are interrelated.18–20 Accepted 11 April 2021 p=0.01), which proved to be an independent predictor of The concept of brain swelling is not new. mortality in the adjusted model for surgical intervention, However, complex scoring systems that assess age, and Glasgow Coma Scale (GCS) score. Cox radiological findings as prognostic factors for regression analysis demonstrated that this category was on September 28, 2021 by guest. Protected TBI include MLS and hematoma data in isolation associated with 14- day survival (HR 2.92, 95% CI 1.38 and not associated, such as the Rotterdam21 and to 6.16; p=0.005). A multivariate analysis performed for 22 three models including age and GCS with categorized ZI Helsinki scores. or Helsinki or Rotterdam score demonstrated area under The relationship between HT and MLS has been 18 19 19 the receiver operating characteristic curve values of little studied in the literature. Zumkeller et al 0.745, 0.767, and 0.808, respectively. were the first to evaluate the difference between them as prognostic factors for survival in a cohort Conclusions The present study highlights the potential © Author(s) (or their 9 usefulness of the difference between MLS and HT as a of patients. Recently, Bartels et al, in a retrospec- employer(s)) 2021. Re- use tive cohort of 59 patients, determined that a differ- permitted under CC BY-NC . No prognostic variable in patients with ASDH. commercial re-use . See rights Level of evidence Level III, epidemiological study. ence between MLS and HT greater than 3 mm was and permissions. Published associated with fatality. However, this parameter by BMJ. was not evaluated in a large sample and in low- To cite: de Souza MR, income or middle-income countries (LMICs), a Fagundes CF, Solla DJF, et al. BACKGROUND context of scarcity of resources that can benefit Trauma Surg Acute Care Open Acute subdural hematoma (ASDH) is a traumatic from simplified predictive models, thus requiring 2021;6:e000707. lesion commonly found secondary to traumatic additional studies for external validation of its real de Souza MR, et al. Trauma Surg Acute Care Open 2021;6:e000707. doi:10.1136/tsaco-2021-000707 1 Open access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2021-000707 on 21 May 2021. Downloaded from predictive value. Thus, this study aimed to assess the prognostic value of the difference between MLS and HT for acute outcomes in patients with ASDH in an LMIC. METHODS Study design This was a post- hoc analysis of a previously conducted prospec- tive cohort study. The study adhered to the principles of the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD), the TRIPOD state- ment.23 All participants provided written informed consent to participate, and none of them were identified in this study. Patients and population The study was conducted at the Clinics Hospital of São Paulo, a tertiary- level hospital located in the largest city of Brazil, serving a population of more than 12 million people. Data were collected from a prospective data bank registry of patients with TBI admitted to the emergency department between January 2012 and December 2015. Inclusion criteria were defined as age greater than or equal to 18 years and traumatic ASDH confirmed by CT. Exclusion criteria were spontaneous or subacute ASHD, bilateral ASDH, epidural hematoma and patients with poly- trauma. In our institution, any patient with intracranial abnor- malities is eligible to be transferred to intensive care unit, which Figure 1 The thickness of the acute subdural hematoma (red arrow) is subject to availability of bed. Therapeutic planning followed was measured on a CT scan as the largest distance between the cortex the recommendations provided by the Advanced Trauma Life and the internal table: midline, orange line; midline shift, orange arrow. Support and the guidelines provided by the Brain Trauma Foun- HT, hematoma thickness; MLS, midline shift. dation. Patients with non-operative management were submitted to a strict control of ICP, so when surgical evacuation is neces- copyright. sary it is immediately performed. ASDH. The HT was subtracted from the MLS to obtain the value described by Zumkeller et al19—the Zumkeller index Outcome and variables of interest (ZI=MLS−HT). Clinical variables To assess its relationship with the outcome, a categorical vari- Epidemiological data such as sex and age were assessed. Trauma able with three cut- off points was created, categorized as ZI, mechanisms were analyzed and classified as road traffic injury, using the authors’ original work as a guide or key parameter.19 fall, violence, and others. The GCS postresuscitation care for The first category included patients whose MLS was lower than hospital admission and pupillary response were also included. HT. The second category included patients whose calculation was between 0.01 mm and 3 mm. The third category included Radiological variables patients who had a difference of MLS−HT greater than 3 mm. http://tsaco.bmj.com/ The diagnosis of ASDH was made based on the admission CT This categorization takes into account the principle that there is evaluation performed using a multidetector 64- channel CT an underlying brain swelling when MLS is greater than HT. scanner (Philips Medical Systems World Headquarters, Best, Patients were followed up during their hospital stay. The The Netherlands) by a neurosurgeon and confirmed by an predictive value of the ZI and other variables was assessed for experienced radiologist. The Rotterdam and Helsinki scores the primary outcome of 14- day mortality, based on reports in the were calculated according to the original article that describes literature for assessing acute outcomes of TBI.26 27 21 22 them. These scores were chosen because they are complex on September 28, 2021 by guest.
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