A Decision Instrument to Identify Isolated Traumatic Subdural Hematomas at Low Risk of Neurological Deterioration, Surgical Intervention or Radiographic Worsening

Abstract

Background and Objectives

Subdural hematoma (SDH) is the most common form of traumatic intracranial hemorrhage. Severity of disease in patients with SDH varies widely. It was hypothesized that a decision rule could identify patients with SDH who are at very low-risk for neurological decline, neurosurgical intervention or radiographic worsening.

Methods

Retrospective chart review of consecutive patients age ≥ 16 with Glasgow Coma Score (GCS) ≥ 13 and CT-documented isolated SDH presenting to a university affiliated, urban, 100,000-annual-visit ED from 2009-2015. Demographic, historical and physical exam variables were collected. Primary outcome was a composite of neurosurgical intervention, worsening repeat CT and neurological decline. Univariate analysis was performed and statistically important variables were utilized to create a logistic regression model.

Results

644 patients with isolated SDH were reviewed, 340 in the derivation group and 304 in the validation set. Mortality was 2.2%. 15.5% of patients required neurosurgery. A decision instrument was created: patients were low risk if they had none of the following factors: SDH thickness ≥ 5mm, warfarin use, clopidogrel use, GCS < 14 and presence of midline shift. This model had a sensitivity of 98.6% for the composite endpoint, specificity of 37.1% and a negative likelihood ratio of 0.037. In the validation cohort, sensitivity was 96.3%, specificity was 31.5% and negative likelihood ratio was 0.127.

Conclusion

Subdural hematomas are amenable to risk stratification analysis. With prospective validation, this decision instrument may aid in triaging these patients, including reducing the need for transfer to tertiary centers.

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