Intraoperative Prognostic Factors in Patients with Traumatic Acute Subdural Haematoma Undergoing Decompressive CraniectomyA Pilot Study

Abstract

Introduction: Traumatic Acute Subdural Haematoma (TASH) remains one of the most lethal of all head injuries with high mortality and morbidity. The admission Glasgow Coma Score (GCS), age, pupillary response and size, hypoxia, hyperthermia, and raised Intra Cranial Pressure (ICP) are the conventional prognostic indicator markers for TASH. However, these markers do not represent secondary brain injury. Aim: To identify the intraoperative prognostic markers and devise a scoring system based on these factors to aid in defining prognosis of patients with TASH undergoing Decompressive Craniectomy (DC). Materials and Methods: This pilot study was conducted in the Department of Neurosurgery, Government Medical College Thrissur, Kerala, India, over a period of one year from July 2018 to August 2019. Total 100 patients who presented with TASH and underwent DC were included in the present study. Intraoperative factors such as hypotension, saturation fall, brain bulge, brain pulsations, clot volume and Sub Arachnoid Haemorrhage (SAH) size were recorded. The primary outcome on the 30th day as alive or dead and functional outcome by Modified Rankin scale on 60th day was recorded. Based on these factors a scoring system was devised. Parameters were assessed using Chi-square test. Results: Among the 100 patients, 95 were males and five females with maximum cases (56) clustered between 36 to 50 years. Intraoperative fall in Blood Pressure (BP) lasting >5 minutes, fall in saturation of O2 , presence of brain bulge (moderate to severe), clot volume >30 mL, poor brain pulsation, presence of co-existant SAH and presence of brain contusion indicated unfavourable prognosis. Poor GCS score was associated with poor functional outcome of Modified Rankin Scale (MRS) 6. Based on intraoperative prognostic scoring, patients belonging to Grade A category had favourable prognosis (no death). Patents belonging to Grade C had poor prognosis (43 death). Conclusion: Intraoperative factors should serve as vital prognostic tools, hand in hand with the conventional admission GCS and Computed Tomography (CT) while managing a patient with TASH undergoing DC. Such an approach would mirror the maximum damage suffered by brain due to injury which is inclusive of primary brain injury and secondary insults as well, suffered up to and until the time of a durotomy.

Keywords

• head injury
• intracranial pressure
• primary brain injury
• prognostic indicators