INTRODUCTION :
Death in neurotrauma practice, though inevitable, is an
undesirable outcome. Again, a death after a surgical intervention
which is intended for the betterment of the patient is truly
agonising for a neurosurgeon.
Acute subdural hematoma is the most common type of traumatic
intra cranial hematoma accounting for 24% cases of severe head
injuries and caries highest mortality. The mortality rates are seen to
be ranging from 30% to 90%.
INCIDENCE :
Acute subdural hematomas accounts for 24% of severe head
injury patients and the incidence of severe head injury is 21 per
100000 people.
PATHOPHYSIOLOGY :
Acute subdural hematoma occurs in of 3 mechanisms.
1. Damage to surface cortical vessel.
2. Bleeding from underlying parenchyma injury.
3. Tearing of bridging veins from cortex to dural venous sinuses.
Arbitrarily divided into 3 stages. i.e. Acute SDH-1 to 3 days from
injury; Sub acute SDH- 4 to 21 days of injury; Chronic SDH -after 3
weeks of injury.
Associated brain injury :
The chief factor that makes an acute subdural hematoma a serious
condition is the frequency with which associated brain damage
occurs. Such brain damage varies from simple sub pial
haemorrhage to extensive laceration of brain. Cerebral edema and
brain stem distortion often complicates the picture.
Site of hematoma
The common sites for the acute subdural hematoma are the
inferior frontal, the anterior temporal and the parietal regions.
Fronto polar and sub frontal hematomas, hematomas in the
middle cranial fossa, over the occipital pole and hematomas of
posterior fossa and in the inter hemispheric regions have all been
encountered.
Clinical picture :
Alteration in conscious level, gradual worsening in the level of
consciousness is the classical presentation. A fluctuation level of
consciousness may also be seen. Increasing restlessness is an
important sign. Some evidence of localization is present in about
70% of cases. In the rest the localizing signs do not occur either
because of associated lesions or rapid development of brainstem
signs. The onset of pupillary changes and hemiparesis points to the
side of the lesion. With the introduction and wide availability of
cranial CT, early diagnosis and timely surgical intervention for SDH
is an attainable gold standard.
Aim and Objective :
A retrospective analysis was carried out on the death of 38 patients
with post traumatic acute subdural hematoma, who underwent
decompressive craniotomy under a uniform protocol at our
institution, between July 2017 and March 2018, in order to study
the various parameters which led to the undesired outcome.
MATERIALS AND METHODS :
This retrospective study is based on the collected experience of 38
patients who died after being managed for acute subdural
hematoma with surgical decompression at Thanjavur Medical
college Hospital, which caters neurotrauma care for nearly six
districts in its vincity.
Data collected from our neurotrauma registry (july 2017-march
2018) has been used for the analysis. In this study period, 74
patients with post traumatic acute SDH underwent decompressive
craniectomy. All the 38 patients who died in the post operative
period has been taken into account without any exclusion criteria.
Once patients presenting to our emergency department have had
their cardiopulmonary status stabilized, they have a rapid and
directed neurologic examination and appropriate imaging. In our
facility, patients with acute subdural hematoma with more than 5
mm of shift proceed to the operating room, irrespective of the
GCS, unless brain-dead. Trauma registry data are prospectively
recorded by the treating doctors during routine clinical care.
Trained clinical data specialists abstract additional data from the
medical record for review and reporting purposes. Data are
composed of demographic information, medical history, and
detailed information on presentation to the hospital and the
course of treatment
1. Data collected includes
2. the age of the patient,
3. nature of injury,
4. interval between the time of trauma and time of admission to
the hospital,
5. neurological and hemodynamic status at the time of
admission,
6. necessity for pre operative blood transfusion
7. other associated injuries,
8. respiratory efforts,
9. imaging results,
10, intra operative findings, blood loss and the need for intra-op
transfusion,
11. Necessity for post-operative ventilator support and post-op
care.
Observations AGE :
Most patient who suffered acute sub dural hematoma were
young<35yrs (n=21) and middle aged 36-59(n=11) rather than old
>60yrs(n=6) .
SEX :
Regarding the sex, men (n=25) are more in number compared to
women.(n=13)
1. 26 patients had been under the influence of alcohol at the time
of trauma.
MODE OF INJURY :
Road traffic accidents were the most common mode of injury
(n=35), of which motorcyclists-32, pedestrians- 3.
TIME OF PRESENTATION FROM TRAUMA :
Most patients (n=23) presented atleast 12 hours after the time of
trauma, out of which 2 patients have presented after 24 hours.
GLASGOW COMA SCALE AT PRESENTATION:
All the patients on evaluation at our emergency department at the
time of admission had gcs score
score
ASSOCIATED INJURIES :
Two patients had associated long bone injuries. Three patients had
severe chest injury which mandated intercostal drainage
Three patients had been hemodynamically unstable at the time of
admission, which resuscitation, pre op blood transfusion and
inotropic support before surgical decompression
COMORBIDITIES:
Known Comorbid illness were present in 11 patients, 4 patients
were diabetic and hypertensive,2 were diabetic, 2 were
hypertensive and CAD patient, 2 were bronchial asthma patients,
one patient a known case of CVA and type 2 DM
1. All the patients had undergone emergency ET intubation at
the time of admission (in view of poor GCS). 18 patients had
poor spontaneous respiratory efforts
2. 6 patients had primary brainstem contusion in the initial
imaging, one patient had ipsilateral PCA territory ischemic
changes, one patient had associated contralateral temporal
ICH, 8 patients had ipsilateral FTP SAH.
INTRA OP FINDINGS
During surgery brain has been severely contused in 22 patients, of
whom burst temporal lobe had been found in 13 patients. Brain
had been tense and not pulsating in 6 patients. One patient had an
intra-op hemodynamic instability and was on inotropic support in
the post operative period
All the patients were given elective post op ventilator support
OUTCOME :
4 patients died on the day of surgery itself, 16 patients died
between post op day 1 to 3, 15 died between post op day 3 to 7,
th and 3 patients after 7 POD
RESULTS AND INTERPRETATIONS :
1. This data cannot be extrapolated as that the survival is worse in
young age. It is the reflection of increased incidence of trauma
in the younger age group. And out of the 74 patients who had
undergone in the study period, 66 belong to young and middle
aged, i.e., 6 out of 8 elderly people died after surgery.
2. 25 out of 52 men (48%), 13 out of 22 (59%) women had died
after Decompression.
3. 18 out of 23 patients who presented after 12 hrs of trauma
died before POD 3
4. All the four patients who died on the day of surgery had GCS 3
(n=1) or 4 (n=3),one among which had intra operative
hemodynamic instability
5. All those four patients had been found to severely contused,
tense, non pulsating brain during surgery. Rest of the two
patients with similar finding died on POD-1
6. All the patients who died before POD 3 had GCS score 5 or less
7. All patients with associated injuries (chest and long bone
injuries) died before POD 3
8. All patients with associated findings in brain imaging died
before POD 3
9. one patient of the study group developed DKA died between
POD 4 and 7
10. Two patients developed AKI, one needed RRT for the same,
and both the patients died between POD 4-7
11. Electrolyte imbalance noticed in most patients died between
POD 4-7 (most patients had hypokalemia) despite the efforts
to correct the same
12. Out of the 18 patients who crossed POD 3, 15 patients could
not be weaned from ventillator at any point in the post op period
13. One patient had severe UGI bleed on POD 5, blood
transfusions, antisecretory drugs, fluid resuscitation could not
help the patient and he died on that same night
14. One patient had been successfully weaned from ventillator on
6th POD, and showed signs of neurological improvement.
Tracheostomy closed. Patients had aspirated feeds on POD 11,
Tracheostomy re established, but he failed to improve and died
th on 12 POD
15. Another one had a tracheostomy tube block and got
desaturated,after being shifted to general ward. patient
shifted back to neuro-icu for ventillator support, but he could
not be saved.
16. All the 20 deaths on/before POD 3, are directly attributed to
the impact of trauma (poor GCS, polytrauma, imaging results,
intra op findings)
17. Out of the 15 deaths b/w POD 4 and 7
18. 9 patients had documented metabolic complications
19. One with uncontrolled DKA
20. Two had AKI
21. 7 had electrolyte imbalance
22. One patient had UGI bleed
23. Five patients, gradually deteriorated since the day of surgery,
became ventilator dependent, and died (no cause other than
head injury is reported in autopsy)
th
24. Deaths after 7 POD
25. One due to aspiration of feeds
26. One due tracheostomy obstruction
27. One patient,had CSF otorrhea post operatively, had high
temperature and died on 14th POD despite our attempts with
higher antibitiotics
CONCLUSIONS :
Pre operative GCS score and the time interval between the trauma
and presentation at the trauma-care had the major impact on the
outcome. Being the tertiary care centre covering six rural districts,
the initial admission at district head quarters hospital and delayed
referral have been the primary factors which need to be addressed.
Patients who survive beyond POD 3, attention to the metabolic
parameters would have a sound edge in decreasing the mortality.
In the hospital which serves the poor and illiterate people, more
focus should be laid upon educating the relatives, in taking care of
the patients recovering from coma, in terms of feeding and
tracheostomy care. Pitfalls in rehabilitation and education result in
avoidable undesired outcome.