Predictors for Functional Recovery and Mortality of Surgically Treated Traumatic Acute Subdural Hematomas in 256 Patients

  • Kim, Kyu-Hong (Department of Neurosurgery, Masan Samsung Hospital, Sungkyunkwan University School of Medicine)
  • Published : 2009.03.28


Objective : The purpose of this study was to investigate the reliable factors influencing the surgical outcome of the patients with traumatic acute subdural hematoma (ASDH) and to improve the functional outcome of these patients. Methods : A total of 256 consecutive patients who underwent surgical intervention for traumatic ASDH between March 1998 and March 2008 were reviewed. We evaluated the influence of perioperative variables on functional recovery and mortality using multivariate logistic regression analysis. Results : Functional recovery was achieved in 42.2% of patients and the overall mortality was 39.8%. Age (OR=4.91, p=0.002), mechanism of injury (OR=3.66, p=0.003), pupillary abnormality (OR=3.73, p=0.003), GCS score on admission (OR=5.64, p=0.000), and intraoperative acute brain swelling (ABS) (OR=3.71, p=0.009) were independent predictors for functional recovery. And preoperative pupillary abnormality (OR=2.60, p=0.023), GCS score (OR=4.66, p=0.000), and intraoperative ABS (OR=4.16, p=0.001) were independent predictors for mortality. Midline shift, thickness and volume of hematoma, type of surgery, and time to surgery showed no independent association with functional recovery, although these variables were correlated with functional recovery in univariate analyses. Conclusion : Functional recovery was more likely to be achieved in patients who were under 40 years of age, victims of motor vehicle collision and having preoperative reactive pupils, higher GCS score and the absence of ABS during surgery. These results would be helpful for neurosurgeon to improve outcomes from traumatic acute subdural hematomas.


  1. Becker DP, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R : The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47 : 491-502, 1977
  2. Berger MS, Pitts LH, Lovely M, Edwards MS, Bartkowski HM : Outcome from severe head injury in children and adolescents. J Neurosurg 62 : 194-199, 1985
  3. Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care : Guidelines for the management of severe head injury. J Neurotrauma 13 : 641-734, 1996
  4. Cooper PR, Rovit RL, Ransohoff J : Hemicraniectomy in the treatment of acute subdural hematoma : a reappraisal. Surg Neurol 5 : 25-28, 1976
  5. Cruz J, Minoja G, Okuchi K : Improving clinical outcomes from acute subdural hematomas with the emergency preoperative administration of high doses mannitol : a randomized trial. Neurosurgery 49 : 864-871, 2001
  6. Czosnyka M, Pickard JD : Monitoring and interpretation of intracranial pressure. J Neurol Neurosurg Psychiatry 75 : 813-821, 2004
  7. D'Amato L, Piazza O, Alliata L, Sabia G, Zito G, Frassanito L, et al : Prognosis of isolated acute post-traumatic subdural hematoma. J Neurosurg Sci 51 : 107-111, 2007
  8. Dent DL, Croce MA, Menke PG, Young BH, Hinson MS, Kudsk KA, et al : Prognostic factors after acute subdural hematoma. J Trauma 39 : 36-42; discussion 42-43, 1995
  9. Fell DA, Fitzgerald S, Moiel RH, Caram P : Acute subdural hematomas. Review of 144 cases. J Neurosurg 42 : 37-42, 1975
  10. Haselsberger K, Pucher R, Auer LM : Prognosis after acute subdural or epidural hemorrhage. Acta Neurochir (Wien) 90 : 111-116, 1988
  11. Hatashita S, Koga N, Hosaka Y, Takagi S : Acute subdural hematoma : severity of injury, surgical intervention, and mortality. Neurol Med Chir (Tokyo) 33 : 13-18, 1993
  12. Hernesniemi J : Outcome following head injuries in the aged. Acta Neurochir (Wien) 49 : 67-69, 1979
  13. Howard MA 3rd, Gross AS, Dacey RG Jr, Winn HR : Acute subdural hematomas : an age-dependant clinical entity. J Neurosurg 71 : 858-863, 1989
  14. Jang HS, Lee YB, Chung C, Lee KC, Park YS, Mok JH : Acute subdural hematoma : an analysis of 244 operated cases. J Korean Neurosurg Soc 25 : 111-118, 1996
  15. Jennett B, Bond M : Assessment of outcome after severe brain damage. Lancet 1 : 480-484, 1975
  16. Klun B, Fettich M : Factors influencing the outcome in acute subdural hematoma. A review of 330 cases. Acta Neurochir (Wien) 71 : 171-178, 1984
  17. Koc RK, Akdemir H, Oktem IS, Meral M, Menkü A : Acute subdural hematoma : outcome and outcome prediction. Neurosurg Rev 20 : 239-244, 1997
  18. Kotwica Z, Brzezinski J : Acute subdural hematoma in adults : an analysis of outcome in comatose patients. Acta Neurochir (Wien) 121 : 95-99, 1993
  19. Lobato RD, Cordobes F, Rivas JJ, de la Feunte M, Montero A, Barcena A, et al : Outcome from severe head injury related to the type of intracranial lesion. A computerized tomography study. J Neurosurg 59 : 762-774, 1983
  20. Marmarou A, Fatouros PP, Barzo P, Portella G, Yoshihara M, Tsuji O, et al : Contribution of edema and cerebral blood volume to traumatic brain swelling in head-injured patients. J Neurosurg 93 : 183-193, 2000
  21. Marshall LF, Gautille T, Klauber MR : The outcome of severe closed head injury. J Neurosurg 75 : 528-536, 1991
  22. Marshall LF, Toole BM, Bowers SA : The National Traumatic Coma Data Bank, Part 2 : Patients who talk and deteriorate : implications for treatment. J Neurosurg 59 : 285-288, 1983
  23. Phuenpathom N, Choomuang M, Ratanalert S : Outcome and outcome prediction in acute subdural hematoma. Surg Neurol 40 : 22-25, 1993
  24. Piotrowski WP, M$\ddot{u}$hl BJ : [Results of surgery in acute subdural hematoma.] Unfauchirurg 98 : 432-436, 1995
  25. Ransohoff J, Benjamin MV, Gage EL Jr, Epstein F : Hemicraniectomy in the management of acute subdural hematoma. J Neurosurg 34 : 70-76, 1971
  26. Richards T, Hoff J : Factors affecting survival from acute subdural hematoma. Surgery 75 : 253-258, 1974
  27. Sakas DE, Bullock MR, Teasdale GM : One-year outcome following craniotomy for traumatic hematoma in patients with fixed dilated pupils. J Neurosurg 82 : 961-965, 1995
  28. Salvant JB Jr, Muizelaar JP : Changes in cerebral blood flow and metabolism related to the presence of subdural hematoma. Neurosurgery 33 : 387-393; discussion 393, 1993
  29. Seelig JM, Becker DP, Miller JD, Greenberg RP, Ward JD, Choi SC : Traumatic acute subdural hematoma : major mortality reduction in comatose patients treated within four hours. New Engl J Med 304 : 1511-1518, 1981
  30. Servadei F : Prognostic factors in severely head injured adult patients with acute subdural hematomas. Acta Neurochir (Wien) 139 : 279-285, 1997
  31. Shigemori M, Syojima K, Nakayama K, Kojima T, Ogata T, Watanabe M, et al : The outcome from acute subdural hematoma following decompressive hemicraniectomy. Acta Neurochir (Wien) 54 : 61-69, 1980
  32. Stening WA, Berry G, Dan NG, Kwok B, Mandryk JA, Ring I, et al : Experience with acute subdural hematomas in New South Wales. Aust N Z J Surg 56 : 549-556, 1986
  33. Stone JL, Rifai MH, Sugar O, Lang RG, Oldershaw JB, Moody RA : Subdural hematomas. I. Acute subdural hematoma : progress in definition, clinical pathology, and therapy. Surg Neurol 19 : 216-231, 1983
  34. Teasdale G, Jennett B : Assessment of coma and impaired consciousness. A practical scale. Lancet 2 : 81-84, 1974
  35. Tian HL, Chen SW, Xu T, Hu J, Rong BY, Wang G, et al : Risk factors related to hospital mortality in patients with isolated traumatic acute subdural hematoma: analysis of 308 patients undergone surgery. Chin Med J (Engl) 121 : 1080-1084, 2008
  36. Tokumi T, Shigemori M, Kikuchi N : Treatment of acute subdural hematoma in Nakamura N, Hashimoto T, Yasue M(eds) : Recent advance in neurotraumatology. Berlin/Heidelberg/New York/Tokyo Springer Verlag, 1992, pp367-370
  37. Wilberger JE Jr, Harris M, Diamond DL : Acute subdural hematoma : morbidity, mortality, and operative timing. J Neurosurg 74 : 212-218, 1991
  38. Wilberger JE Jr, Harris M, Diamond DL : Acute subdural hematoma : morbidity and mortality related to timing of operative intervention. J Trauma 30 : 733-736, 1990
  39. Wong CW : Criteria for conservative treatment of supratentorial acute subdural hematomas. Acta Neurochir (Wien) 135 : 38-43, 1995
  40. Yanaka K, Kamezaki T, Yamada T, Takano S, Meguro K, Nose T : Acute subdural hematoma : prediction of outcome with a linear discriminant function. Neurol Med Chir (Tokyo) 33 : 552-558, 1993