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Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding
j o u r n a l o f s u r g i c a l r e s e a r c h m a y 2 0 2 0 ( 2 4 9 ) 9 9 e1 0 3
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ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding Benjamin N. Cragun, MD,* Matthew R. Noorbakhsh, MD, Frances Hite Philp, MS, Erin R. Suydam, MD, Michael F. Ditillo, DO, Allan S. Philp, MD, and Alan D. Murdock, MD Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
article info
abstract
Article history:
Background: Guidelines for management of intracranial hemorrhage do not account for
Received 18 January 2019
bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to
Received in revised form
convexity SDH, is a distinct clinical entity and these patients do not benefit from critical
19 May 2019
care monitoring or repeat imaging.
Accepted 6 December 2019
Methods: We identified patients presenting to a single level I trauma center with isolated
Available online xxx
head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH.
Keywords:
Results: Demographics, comorbidities, and use of antiplatelet and anticoagulant agents
ICH
were similar between the groups. As compared to patients with convexity SDH, patients
SDH
with parafalcine SDH had a significantly lower incidence of radiographic progression, and
Parafalcine
had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all
TBI
P < 0.005). Compared to patients admitted to the intensive care unit, patients with paraf-
Interhemispheric
alcine SDH admitted to the floor had a shorter length of stay (2.0 1.6 versus 3.8 2.9 d, P < 0.005) with no difference in outcomes. Conclusions: Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission. ª 2019 Elsevier Inc. All rights reserved.
Background Traumatic intracranial hemorrhage (ICH) represents a common cause of trauma admission. Patients with these injuries are frequently admitted to the trauma surgery team and placed in the intensive care unit (ICU) with close monitoring of neurological examination, repeat imaging, and neurosurgical consultation. Guidelines have been proposed to reduce unnecessary ICU admission and repeat imaging1 but have not been universally implemented. All traumatic ICHs are often treated as one homogenous disease despite evidence that
some types of bleeds are less likely to cause morbidity and mortality.2 Traumatic subarachnoid hemorrhage, for example, has been shown to have relatively benign outcomes, provided the patient presents without altered mental status.3 Parafalcine subdural hematoma (SDH) was first described in the 1940s as an “aberrant location” at a time when trephination was carried out for diagnostic purposes on obtunded patients after head trauma.4 As CT scanners have become ubiquitous, increasingly subtle bleeds have been noted, with unclear clinical significance.5 Although 9%-15% of all blunt ICHs are parafalcine in location,6-8 surgical management
* Corresponding author. Department of Surgery, Division of Trauma Surgery, Allegheny General Hospital, 320 E North Avenue, Pittsburgh, PA 15212. Tel.: þ916 390-7994; fax: þ412 359-3212. E-mail address: [email protected] (B.N. Cragun). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.12.019
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j o u r n a l o f s u r g i c a l r e s e a r c h m a y 2 0 2 0 ( 2 4 9 ) 9 9 e1 0 3
guidelines focus only on convexity SDHs.9 Several retrospective reviews have reported SDH by location, allowing some initial examination of the natural history of parafalcine bleeds. None of the patients with parafalcine SDH reported in these studies required surgery or resulted in mortality.6-8 Howard et al recently published a retrospective review of patients admitted with these types of ICHs to identify factors associated with worse outcomes.8 They suggest that patients may safely be admitted to the floor if they are young, present with Glasgow Coma Score10 (GCS) > 12, and have only an isolated head injury. Even still, there remains a relative paucity of evidence regarding the management of isolated traumatic parafalcine SDH. We hypothesize that traumatic parafalcine SDH represents a distinct clinical entity from convexity SDH and that these patients do not benefit from monitoring in the ICU or repeat imaging.
Materials and methods Trauma registry data were used to retrospectively identify adult patients presenting to a single level I trauma center with isolated ICH from February 2016 to August 2017. Isolated ICH was defined as maximum abbreviated injury score11 of 3 for head and <3 for any other body region. Patients were excluded if they had penetrating injuries or died before any imaging could be obtained. We identified isolated SDH by excluding patients with ICH in multiple locations or other types of ICH
(subarachnoid, intraparenchymal, epidural, or intraventricular hemorrhage). The study was approved under the institutional review board, and informed consent was waived in this retrospective study. Data collected from chart review included demographics, pre-existing medical conditions, and preinjury antiplatelet or anticoagulant use. We also reviewed the hospital course, including the admission location (ICU or floor), administration of reversal agents, neurosurgical interventions, imaging (measuring the widest dimension of bleed in transverse dimension), GCS on admission and discharge, and disposition at discharge. Primary outcomes were neurological deterioration, radiographic progression of the bleed (increase in volume or new bleeds, not simply redistribution or evolution of hemorrhage), neurosurgical procedures, and mortality. Secondary outcomes included admission location (floor versus ICU), hospital length of stay (LOS), and discharge destination. Data are presented as means with standard deviations or as frequencies, and comparisons were conducted using Fisher’s exact tests or Student’s t-tests as appropriate. A P 0.05 was considered statistically significant.
Results We identified 659 patients with isolated ICH over the 18month study period. After exclusion criteria were applied, 574 blunt traumatic ICH patients remained. We then excluded patients with other types of ICH and those with multiple
Table 1 e Baseline patient characteristics by location of subdural hematoma. Parafalcine (n ¼ 88)
Convexity (n ¼ 228)
P-value
Age, y SD
69.9 18.4
72.0 18.5
0.4
Gender, female; n (%)
48 (54.5%)
96 (42.1%)
0.06
Atrial fibrillation
19 (21.6%)
51 (22.4%)
1.0
Coronary artery disease
31 (35.2%)
104 (45.6%)
0.1
Congestive heart failure
19 (21.6%)
42 (18.4%)
0.5
5 (5.7%)
12 (5.3%)
1.0
COPD
22 (25.0%)
46 (20.2%)
0.4
Dementia
15 (17.0%)
59 (25.9%)
0.1
Diabetes mellitus
24 (27.3%)
54 (23.7%)
0.6
8 (9.1%)
12 (5.3%)
0.2
Outcome
Comorbid conditions, n (%)
Cirrhosis
DVT/PE Obstructive sleep apnea
32 (36.4%)
75 (32.9%)
0.6
Seizure disorder
10 (11.4%)
26 (11.4%)
1.0
Prior history of SDH
9 (10.2%)
42 (18.4%)
0.1
Parkinson’s Disease
1 (1.1%)
9 (3.9%)
0.3
13 (14.8%)
39 (17.1%)
0.7
50 (56.8%)
114 (50.0%)
0.3
Antiplatelet
30 (34.1%)
78 (34.2%)
1.0
Anticoagulant
20 (22.7%)
36 (15.8%)
0.2
CVA/TIA Antiplatelet or anticoagulant use
Presents data on age, sex, preinjury comorbid conditions, and preinjury use of antiplatelet or anticoagulant medications. There are no significant baseline differences between patients with parafalcine SDH and those with convexity SDH. COPD ¼ chronic obstructive pulmonary disease, CVA ¼ cerebral vascular accident; DVT/PE ¼ deep vein thrombosis or pulmonary embolism, TIA ¼ transient ischemic attack.
101
cragun et al traumatic parafalcine sdh
Table 2 e Admission characteristics of all subdural hematomas. Characteristic
Parafalcine
Convexity
P-value
88 (100%)
192 (84.2%)
<0.005
0 (0%)
36 (15.8%)
11.1 2.9
14.1 6.5
<0.005
3.1 0.3
3.5 0.8
<0.005
4.6 2.5
10.0 8.0
<0.005
1 (1.1%)
92 (40.4%)
<0.005
Admission GCS, n (%) 13-15 <13 Injury severity score Max AIS head Initial size of bleed (mm) Any midline shift, n (%)
Depicts data regarding the GCS, Injury Severity Score, initial size of the SDH in the transverse direction, and whether there is any midline shift for all patients presenting with isolated SDH. Parafalcine SDH appears less severe on presentation. AIS ¼ Abbreviated Injury Score.
intracranial pathologies, leaving 316 isolated SDH. We further classified those SDH by location, identifying 88 isolated parafalcine SDH and 228 isolated convexity SDH. Demographics data, comparing patients with isolated parafalcine SDH to patients with isolated convexity SDH, are presented in Table 1. There were no significant differences in demographics or preinjury comorbid conditions. Antiplatelet or anticoagulant use was equally prevalent in the two groups. All patients with isolated parafalcine SDH presented with GCS of 13-15, conventionally considered mild traumatic brain injury12 (TBI), in contrast to the convexity SDH group, which had 15.8% of patients present with moderate or severe TBI defined by GCS <13 (P < 0.005) (Table 2). Parafalcine bleeds were significantly smaller (P < 0.005) and were less likely to be associated with midline shift (P < 0.005). Mortality, hospital LOS, radiographic progression, neurological deterioration, and neurosurgical procedures performed are compared between the two groups as summarized in Table 3. Patients with parafalcine SDH had lower incidence of radiographic progression as compared to patients with convexity SDH, but no patients with parafalcine SDH experienced neurological deterioration or required surgical intervention. Patients with convexity SDH showed neurological deterioration in 21.5% (P < 0.005) and required surgery in 15.4% (P < 0.005). There was no mortality in the isolated parafalcine group, and mortality was 16.2% in the patients with isolated
convexity SDH (P < 0.005). Patients with parafalcine bleeds had a shorter average hospital LOS (P ¼ 0.01) and were more likely to be discharged to home (P ¼ 0.04). The Functional Independence Measure scores on discharge among survivors were higher for the parafalcine group (18.6 1.7 versus 17.4 2.9, P ¼ 0.04). Fifty-six (63.6%) of the parafalcine SDH patients were admitted to the ICU, with no difference in age (P ¼ 0.08), gender (P ¼ 0.7), or injury severity score (P ¼ 0.2). Patients admitted to the floor had a shorter hospital LOS (2.0 1.6 versus 3.8 2.9, P < 0.005) with no difference in outcomes. So as to not confound the comparison of parafalcine SDH and convexity bleeds by including the most severely injured and to see if the differences observed between parafalcine and convexity groups persisted when comparing only mild TBI, we repeated this analysis after excluding patients presenting with moderate or severe TBI (GCS <13). Doing so showed a similar pattern of lower incidence of all primary outcomes (Table 4). We classified patients according to the Brain Injury Guidelines1 and compared parafalcine and convexity SDH in the BIG3 category (Table 5). Doing so again showed lower incidence of all primary outcomes for patients with parafalcine SDH. Of the 88 patients presenting with isolated parafalcine bleeds, 56.8% were taking antiplatelet or anticoagulant medications. The initial size of the bleed was larger in the patients
Table 3 e Outcomes of parafalcine subdural hematomas compared with convexity subdural hematomas. Outcome
Nonsurvivable, n (%)
Parafalcine
Convexity
88
228
0 (0%)
16 (7.0%)
P-value
0.01
Radiographic progression, n (%)
6 (6.8%)
48 (21.1%)
<0.005
Neurologic deterioration, n (%)
0 (0%)
49 (21.5%)
<0.005
0 (0%)
35 (15.4%)
<0.005
Immediate (<24 h), n (%)
0 (0%)
26 (11.4%)
<0.005
Delayed (>24 h), n (%)
0 (0%)
11 (4.8%)
0.04
Mortality (or hospice), n (%)
0 (0%)
37 (16.2%)
<0.005
Hospital LOS (d), mean SD
3.1 2.6
4.5 4.7
0.01
Surgical procedure performed, n (%)
Depicts data regarding primary and secondary outcomes for patients presenting with parafalcine and convexity SDH. Nonsurvivable injury defined clinically by neurosurgery. Parafalcine SDH appears clinically benign as compared with convexity SDH.
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j o u r n a l o f s u r g i c a l r e s e a r c h m a y 2 0 2 0 ( 2 4 9 ) 9 9 e1 0 3
Table 4 e Comparison of parafalcine SDH to convexity SDH with mild traumatic brain injury (GCS, 13-15). Outcome Age, y SD
Parafalcine (n ¼ 88)
Mild convexity (n ¼ 192)
P-value
69.9 18.4
72.5 18.8
0.3
Size of bleed, mm SD
4.6 2.5
8.7 7.0
<0.005 <0.005
Midline shift, n (%)
1 (1.1%)
62 (32.3%)
Radiographic progression, n (%)
6 (6.8%)
39 (20.3%)
<0.005
Neurological deterioration, n (%)
0 (0%)
42 (21.9%)
<0.005
Surgical intervention performed, n (%)
0 (0%)
21 (10.9%)
<0.005
Immediate (<24 h), n (%)
0 (0%)
13 (6.8%)
0.01
Delayed (>24 h), n (%)
0 (0%)
9 (4.7%)
0.06
0 (0%)
14 (7.3%)
0.01
Mortality, n (%)
Depicts data regarding primary and secondary outcomes for only mild isolated SDH. Parafalcine SDH appears to be benign in comparison to mild convexity SDH.
on these medications (5.2 2.7 versus 3.8 1.9 mm, P ¼ 0.008), and radiographic progression was higher (12.0% versus 0%, P ¼ 0.03). Radiographic progression did not translate to neurologic deterioration, neurosurgical interventions, or mortality in the parafalcine group. The parafalcine and convexity SDH groups did not differ with respect to reversal of antiplatelet agents (with desmopressin and/or platelet transfusion) or reversal of anticoagulants (with fresh frozen plasma or prothrombin complex concentrate).
Discussion In this study, we demonstrate that isolated parafalcine SDH represent a distinct clinical entity from convexity SDH and that these patients do not benefit from ICU admission or repeat imaging. We report that 13.4% of patients with isolated ICH had an SDH in the parafalcine location, consistent with other published studies showing a range of 9%-15%.6-8 The parafalcine group had no mortality, no clinical worsening, and no need for neurosurgical intervention. Although 6.8% of our parafalcine SDH group did show radiographic progression, this did not translate to neurological deterioration or need for neurosurgical intervention. There is growing evidence that ICU admission for mild TBI is likely unnecessary.12 The patients with parafalcine bleeds who were admitted to the ICU had no significant baseline differences but stayed in the hospital 1 d longer on average
with no difference in outcomes. Decreasing unnecessary ICU admission can help reduce delirium,13 reduces costs to the patient and institution, and liberates resources for other critically injured patients. Protocols at many hospitals, including our own, call for repeat imaging of ICH even in the setting of mild TBI (GCS 13-15) despite growing evidence that this does not change management or outcomes.1,12,14 Repeat imaging did not change the management in any of our parafalcine SDH patients. We had some difficulty finding an appropriate comparison group for patients with parafalcine SDH. Comparing parafalcine to all convexity SDH clearly shows that parafalcine are relatively benign. But all parafalcine SDH patients in this study had GCS 13-15 on admission, indicating that they all suffered minor brain injuries. Excluding patients with GCS <13 on admission allows comparison of only mild traumatic brain injuries. This comparison (Table 4) still shows that parafalcine SDH is relatively benign as compared with mild convexity SDH. Although studies have shown that mild TBI patients are unlikely to benefit from repeat imaging or ICU admission, our data show that patients with parafalcine SDH are even less likely to benefit from those interventions. The Brain Injury Guidelines were designed to reduce unnecessary ICU admission, repeat imaging, and neurosurgery consultation.1 However, our data suggest that the guidelines could be amended to exclude parafalcine SDH completely as none of our parafalcine group showed any clinical worsening and no mortality.
Table 5 e Comparison of BIG3 (Brain Injury Guidelines) parafalcine SDH and convexity SDH. Outcome Nonsurvivable, n (%) Radiographic progression, n (%) Neurologic deterioration, n (%)
Parafalcine (n ¼ 53) 0 (0%) 6 (11.3%) 0 (0%)
Convexity (n ¼ 168)
P-value
16 (9.5%)
0.01
39 (23.2%)
0.05
44 (26.2%)
<0.005
0 (0%)
35 (20.8%)
<0.005
Immediate (<24 h), n (%)
0 (0%)
26 (15.5%)
<0.005
Delayed (>24 h), n (%)
0 (0%)
11 (6.5%)
0.07
0 (0%)
36 (21.4%)
<0.005
Surgical procedure performed, n (%)
Mortality (or hospice), n (%)
Depicts data regarding primary outcomes for all isolated SDH in BIG3. Parafalcine SDH appears to be benign as compared to BIG3 convexity SDH.
cragun et al traumatic parafalcine sdh
Our study has several limitations. Our data were retrospectively collected from a single level I trauma center; as such our data may not be generalizable to all centers. In addition, we excluded patients with systemic injury and with ICH in multiple locations. It remains unclear how parafalcine SDH interacts with systemic injury or how additional intracranial pathology affects outcomes.
Conclusions Our data showed no mortality, no clinical worsening, and no neurosurgical intervention in patients with isolated parafalcine SDH. These findings suggest that parafalcine bleeds represent a distinct and clinically benign entity as compared with convexity SDH. Although some patients with parafalcine bleeds show radiographic progression if they undergo repeat imaging, in our study, this progression did not translate to neurological deterioration, need for intervention, or mortality. Our data suggest that admission to an ICU and routine interval imaging provide no benefit for patients admitted with isolated parafalcine SDH.
Acknowledgment The authors would like to thank the Association for Academic Surgery, and the American College of Surgeons Committee on Trauma, Pennsylvania, and Region III chapters for the opportunity to present this research. Authors’ contributions: All authors participated in the conception and design of the study. Data collection was primarily performed by B.N.C., M.R.N., and F.H.P. The manuscript was primarily written by B.N.C., with critical edits and final approval from all authors.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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references
1. Joseph B, Friese RS, Sadoun M, et al. The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76:965e969. 2. Phelan HA, Eastman AL, Madden CJ, et al. TBI risk stratification at presentation: a prospective study of the incidence and timing of radiographic worsening in the Parkland Protocol. J Trauma Acute Care Surg. 2012;73(2 Suppl 1):S122eS127. 3. Phelan HA, Richter AA, Scott WW, et al. Does isolated traumatic subarachnoid hemorrhage merit a lower intensity level of observation than other traumatic brain injury? J Neurotrauma. 2014;31:1733e1736. 4. Aring C, Evans J. Aberrant location of subdural hematoma. Arch Neurol Psychiatry. 1940;44:1296e1306. 5. Rieth KG, Davis DO. Subdural hematomas: an unusual appearance on computed tomography. J Comput Assist Tomogr. 1979;3:331e334. 6. Bajsarowicz P, Prakash I, Lamoureux J, et al. Nonsurgical acute traumatic subdural hematoma: what is the risk? J Neurosurg. 2015;123:1176e1183. 7. Sweis RT, Ouyang B, Lopez GA, et al. Falcine and tentorial subdural hematomas may not routinely require transfer to a tertiary care center. J Emerg Med. 2015;49:679e685. 8. Howard BM, Rindler RS, Holland CM, et al. Management and outcomes of isolated tentorial and parafalcine "smear" subdural hematomas at a level-1 trauma center: necessity of high acuity care. J Neurotrauma. 2017;34:128e136. 9. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery. 2006;58(3 Suppl l):S16eS24. discussion Si-iv. 10. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81e84. 11. Copes WS, Champion HR, Sacco WJ, et al. The injury severity score revisited. J Trauma. 1988;28:69e77. 12. Washington CW, Grubb Jr RL. Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury? J Neurosurg. 2012;116:549e557. 13. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med. 2007;33:66e73. 14. AbdelFattah KR, Eastman AL, Aldy KN, et al. A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg. 2012;73:685e688.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding Benjamin N. Cragun, MD,* Matthew R. Noorbakhsh, MD, Frances Hite Philp, MS, Erin R. Suydam, MD, Michael F. Ditillo, DO, Allan S. Philp, MD, and Alan D. Murdock, MD Department of Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
article info
abstract
Article history:
Background: Guidelines for management of intracranial hemorrhage do not account for
Received 18 January 2019
bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to
Received in revised form
convexity SDH, is a distinct clinical entity and these patients do not benefit from critical
19 May 2019
care monitoring or repeat imaging.
Accepted 6 December 2019
Methods: We identified patients presenting to a single level I trauma center with isolated
Available online xxx
head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH.
Keywords:
Results: Demographics, comorbidities, and use of antiplatelet and anticoagulant agents
ICH
were similar between the groups. As compared to patients with convexity SDH, patients
SDH
with parafalcine SDH had a significantly lower incidence of radiographic progression, and
Parafalcine
had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all
TBI
P < 0.005). Compared to patients admitted to the intensive care unit, patients with paraf-
Interhemispheric
alcine SDH admitted to the floor had a shorter length of stay (2.0 1.6 versus 3.8 2.9 d, P < 0.005) with no difference in outcomes. Conclusions: Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission. ª 2019 Elsevier Inc. All rights reserved.
Background Traumatic intracranial hemorrhage (ICH) represents a common cause of trauma admission. Patients with these injuries are frequently admitted to the trauma surgery team and placed in the intensive care unit (ICU) with close monitoring of neurological examination, repeat imaging, and neurosurgical consultation. Guidelines have been proposed to reduce unnecessary ICU admission and repeat imaging1 but have not been universally implemented. All traumatic ICHs are often treated as one homogenous disease despite evidence that
some types of bleeds are less likely to cause morbidity and mortality.2 Traumatic subarachnoid hemorrhage, for example, has been shown to have relatively benign outcomes, provided the patient presents without altered mental status.3 Parafalcine subdural hematoma (SDH) was first described in the 1940s as an “aberrant location” at a time when trephination was carried out for diagnostic purposes on obtunded patients after head trauma.4 As CT scanners have become ubiquitous, increasingly subtle bleeds have been noted, with unclear clinical significance.5 Although 9%-15% of all blunt ICHs are parafalcine in location,6-8 surgical management
* Corresponding author. Department of Surgery, Division of Trauma Surgery, Allegheny General Hospital, 320 E North Avenue, Pittsburgh, PA 15212. Tel.: þ916 390-7994; fax: þ412 359-3212. E-mail address: [email protected] (B.N. Cragun). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.12.019
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j o u r n a l o f s u r g i c a l r e s e a r c h m a y 2 0 2 0 ( 2 4 9 ) 9 9 e1 0 3
guidelines focus only on convexity SDHs.9 Several retrospective reviews have reported SDH by location, allowing some initial examination of the natural history of parafalcine bleeds. None of the patients with parafalcine SDH reported in these studies required surgery or resulted in mortality.6-8 Howard et al recently published a retrospective review of patients admitted with these types of ICHs to identify factors associated with worse outcomes.8 They suggest that patients may safely be admitted to the floor if they are young, present with Glasgow Coma Score10 (GCS) > 12, and have only an isolated head injury. Even still, there remains a relative paucity of evidence regarding the management of isolated traumatic parafalcine SDH. We hypothesize that traumatic parafalcine SDH represents a distinct clinical entity from convexity SDH and that these patients do not benefit from monitoring in the ICU or repeat imaging.
Materials and methods Trauma registry data were used to retrospectively identify adult patients presenting to a single level I trauma center with isolated ICH from February 2016 to August 2017. Isolated ICH was defined as maximum abbreviated injury score11 of 3 for head and <3 for any other body region. Patients were excluded if they had penetrating injuries or died before any imaging could be obtained. We identified isolated SDH by excluding patients with ICH in multiple locations or other types of ICH
(subarachnoid, intraparenchymal, epidural, or intraventricular hemorrhage). The study was approved under the institutional review board, and informed consent was waived in this retrospective study. Data collected from chart review included demographics, pre-existing medical conditions, and preinjury antiplatelet or anticoagulant use. We also reviewed the hospital course, including the admission location (ICU or floor), administration of reversal agents, neurosurgical interventions, imaging (measuring the widest dimension of bleed in transverse dimension), GCS on admission and discharge, and disposition at discharge. Primary outcomes were neurological deterioration, radiographic progression of the bleed (increase in volume or new bleeds, not simply redistribution or evolution of hemorrhage), neurosurgical procedures, and mortality. Secondary outcomes included admission location (floor versus ICU), hospital length of stay (LOS), and discharge destination. Data are presented as means with standard deviations or as frequencies, and comparisons were conducted using Fisher’s exact tests or Student’s t-tests as appropriate. A P 0.05 was considered statistically significant.
Results We identified 659 patients with isolated ICH over the 18month study period. After exclusion criteria were applied, 574 blunt traumatic ICH patients remained. We then excluded patients with other types of ICH and those with multiple
Table 1 e Baseline patient characteristics by location of subdural hematoma. Parafalcine (n ¼ 88)
Convexity (n ¼ 228)
P-value
Age, y SD
69.9 18.4
72.0 18.5
0.4
Gender, female; n (%)
48 (54.5%)
96 (42.1%)
0.06
Atrial fibrillation
19 (21.6%)
51 (22.4%)
1.0
Coronary artery disease
31 (35.2%)
104 (45.6%)
0.1
Congestive heart failure
19 (21.6%)
42 (18.4%)
0.5
5 (5.7%)
12 (5.3%)
1.0
COPD
22 (25.0%)
46 (20.2%)
0.4
Dementia
15 (17.0%)
59 (25.9%)
0.1
Diabetes mellitus
24 (27.3%)
54 (23.7%)
0.6
8 (9.1%)
12 (5.3%)
0.2
Outcome
Comorbid conditions, n (%)
Cirrhosis
DVT/PE Obstructive sleep apnea
32 (36.4%)
75 (32.9%)
0.6
Seizure disorder
10 (11.4%)
26 (11.4%)
1.0
Prior history of SDH
9 (10.2%)
42 (18.4%)
0.1
Parkinson’s Disease
1 (1.1%)
9 (3.9%)
0.3
13 (14.8%)
39 (17.1%)
0.7
50 (56.8%)
114 (50.0%)
0.3
Antiplatelet
30 (34.1%)
78 (34.2%)
1.0
Anticoagulant
20 (22.7%)
36 (15.8%)
0.2
CVA/TIA Antiplatelet or anticoagulant use
Presents data on age, sex, preinjury comorbid conditions, and preinjury use of antiplatelet or anticoagulant medications. There are no significant baseline differences between patients with parafalcine SDH and those with convexity SDH. COPD ¼ chronic obstructive pulmonary disease, CVA ¼ cerebral vascular accident; DVT/PE ¼ deep vein thrombosis or pulmonary embolism, TIA ¼ transient ischemic attack.
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cragun et al traumatic parafalcine sdh
Table 2 e Admission characteristics of all subdural hematomas. Characteristic
Parafalcine
Convexity
P-value
88 (100%)
192 (84.2%)
<0.005
0 (0%)
36 (15.8%)
11.1 2.9
14.1 6.5
<0.005
3.1 0.3
3.5 0.8
<0.005
4.6 2.5
10.0 8.0
<0.005
1 (1.1%)
92 (40.4%)
<0.005
Admission GCS, n (%) 13-15 <13 Injury severity score Max AIS head Initial size of bleed (mm) Any midline shift, n (%)
Depicts data regarding the GCS, Injury Severity Score, initial size of the SDH in the transverse direction, and whether there is any midline shift for all patients presenting with isolated SDH. Parafalcine SDH appears less severe on presentation. AIS ¼ Abbreviated Injury Score.
intracranial pathologies, leaving 316 isolated SDH. We further classified those SDH by location, identifying 88 isolated parafalcine SDH and 228 isolated convexity SDH. Demographics data, comparing patients with isolated parafalcine SDH to patients with isolated convexity SDH, are presented in Table 1. There were no significant differences in demographics or preinjury comorbid conditions. Antiplatelet or anticoagulant use was equally prevalent in the two groups. All patients with isolated parafalcine SDH presented with GCS of 13-15, conventionally considered mild traumatic brain injury12 (TBI), in contrast to the convexity SDH group, which had 15.8% of patients present with moderate or severe TBI defined by GCS <13 (P < 0.005) (Table 2). Parafalcine bleeds were significantly smaller (P < 0.005) and were less likely to be associated with midline shift (P < 0.005). Mortality, hospital LOS, radiographic progression, neurological deterioration, and neurosurgical procedures performed are compared between the two groups as summarized in Table 3. Patients with parafalcine SDH had lower incidence of radiographic progression as compared to patients with convexity SDH, but no patients with parafalcine SDH experienced neurological deterioration or required surgical intervention. Patients with convexity SDH showed neurological deterioration in 21.5% (P < 0.005) and required surgery in 15.4% (P < 0.005). There was no mortality in the isolated parafalcine group, and mortality was 16.2% in the patients with isolated
convexity SDH (P < 0.005). Patients with parafalcine bleeds had a shorter average hospital LOS (P ¼ 0.01) and were more likely to be discharged to home (P ¼ 0.04). The Functional Independence Measure scores on discharge among survivors were higher for the parafalcine group (18.6 1.7 versus 17.4 2.9, P ¼ 0.04). Fifty-six (63.6%) of the parafalcine SDH patients were admitted to the ICU, with no difference in age (P ¼ 0.08), gender (P ¼ 0.7), or injury severity score (P ¼ 0.2). Patients admitted to the floor had a shorter hospital LOS (2.0 1.6 versus 3.8 2.9, P < 0.005) with no difference in outcomes. So as to not confound the comparison of parafalcine SDH and convexity bleeds by including the most severely injured and to see if the differences observed between parafalcine and convexity groups persisted when comparing only mild TBI, we repeated this analysis after excluding patients presenting with moderate or severe TBI (GCS <13). Doing so showed a similar pattern of lower incidence of all primary outcomes (Table 4). We classified patients according to the Brain Injury Guidelines1 and compared parafalcine and convexity SDH in the BIG3 category (Table 5). Doing so again showed lower incidence of all primary outcomes for patients with parafalcine SDH. Of the 88 patients presenting with isolated parafalcine bleeds, 56.8% were taking antiplatelet or anticoagulant medications. The initial size of the bleed was larger in the patients
Table 3 e Outcomes of parafalcine subdural hematomas compared with convexity subdural hematomas. Outcome
Nonsurvivable, n (%)
Parafalcine
Convexity
88
228
0 (0%)
16 (7.0%)
P-value
0.01
Radiographic progression, n (%)
6 (6.8%)
48 (21.1%)
<0.005
Neurologic deterioration, n (%)
0 (0%)
49 (21.5%)
<0.005
0 (0%)
35 (15.4%)
<0.005
Immediate (<24 h), n (%)
0 (0%)
26 (11.4%)
<0.005
Delayed (>24 h), n (%)
0 (0%)
11 (4.8%)
0.04
Mortality (or hospice), n (%)
0 (0%)
37 (16.2%)
<0.005
Hospital LOS (d), mean SD
3.1 2.6
4.5 4.7
0.01
Surgical procedure performed, n (%)
Depicts data regarding primary and secondary outcomes for patients presenting with parafalcine and convexity SDH. Nonsurvivable injury defined clinically by neurosurgery. Parafalcine SDH appears clinically benign as compared with convexity SDH.
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j o u r n a l o f s u r g i c a l r e s e a r c h m a y 2 0 2 0 ( 2 4 9 ) 9 9 e1 0 3
Table 4 e Comparison of parafalcine SDH to convexity SDH with mild traumatic brain injury (GCS, 13-15). Outcome Age, y SD
Parafalcine (n ¼ 88)
Mild convexity (n ¼ 192)
P-value
69.9 18.4
72.5 18.8
0.3
Size of bleed, mm SD
4.6 2.5
8.7 7.0
<0.005 <0.005
Midline shift, n (%)
1 (1.1%)
62 (32.3%)
Radiographic progression, n (%)
6 (6.8%)
39 (20.3%)
<0.005
Neurological deterioration, n (%)
0 (0%)
42 (21.9%)
<0.005
Surgical intervention performed, n (%)
0 (0%)
21 (10.9%)
<0.005
Immediate (<24 h), n (%)
0 (0%)
13 (6.8%)
0.01
Delayed (>24 h), n (%)
0 (0%)
9 (4.7%)
0.06
0 (0%)
14 (7.3%)
0.01
Mortality, n (%)
Depicts data regarding primary and secondary outcomes for only mild isolated SDH. Parafalcine SDH appears to be benign in comparison to mild convexity SDH.
on these medications (5.2 2.7 versus 3.8 1.9 mm, P ¼ 0.008), and radiographic progression was higher (12.0% versus 0%, P ¼ 0.03). Radiographic progression did not translate to neurologic deterioration, neurosurgical interventions, or mortality in the parafalcine group. The parafalcine and convexity SDH groups did not differ with respect to reversal of antiplatelet agents (with desmopressin and/or platelet transfusion) or reversal of anticoagulants (with fresh frozen plasma or prothrombin complex concentrate).
Discussion In this study, we demonstrate that isolated parafalcine SDH represent a distinct clinical entity from convexity SDH and that these patients do not benefit from ICU admission or repeat imaging. We report that 13.4% of patients with isolated ICH had an SDH in the parafalcine location, consistent with other published studies showing a range of 9%-15%.6-8 The parafalcine group had no mortality, no clinical worsening, and no need for neurosurgical intervention. Although 6.8% of our parafalcine SDH group did show radiographic progression, this did not translate to neurological deterioration or need for neurosurgical intervention. There is growing evidence that ICU admission for mild TBI is likely unnecessary.12 The patients with parafalcine bleeds who were admitted to the ICU had no significant baseline differences but stayed in the hospital 1 d longer on average
with no difference in outcomes. Decreasing unnecessary ICU admission can help reduce delirium,13 reduces costs to the patient and institution, and liberates resources for other critically injured patients. Protocols at many hospitals, including our own, call for repeat imaging of ICH even in the setting of mild TBI (GCS 13-15) despite growing evidence that this does not change management or outcomes.1,12,14 Repeat imaging did not change the management in any of our parafalcine SDH patients. We had some difficulty finding an appropriate comparison group for patients with parafalcine SDH. Comparing parafalcine to all convexity SDH clearly shows that parafalcine are relatively benign. But all parafalcine SDH patients in this study had GCS 13-15 on admission, indicating that they all suffered minor brain injuries. Excluding patients with GCS <13 on admission allows comparison of only mild traumatic brain injuries. This comparison (Table 4) still shows that parafalcine SDH is relatively benign as compared with mild convexity SDH. Although studies have shown that mild TBI patients are unlikely to benefit from repeat imaging or ICU admission, our data show that patients with parafalcine SDH are even less likely to benefit from those interventions. The Brain Injury Guidelines were designed to reduce unnecessary ICU admission, repeat imaging, and neurosurgery consultation.1 However, our data suggest that the guidelines could be amended to exclude parafalcine SDH completely as none of our parafalcine group showed any clinical worsening and no mortality.
Table 5 e Comparison of BIG3 (Brain Injury Guidelines) parafalcine SDH and convexity SDH. Outcome Nonsurvivable, n (%) Radiographic progression, n (%) Neurologic deterioration, n (%)
Parafalcine (n ¼ 53) 0 (0%) 6 (11.3%) 0 (0%)
Convexity (n ¼ 168)
P-value
16 (9.5%)
0.01
39 (23.2%)
0.05
44 (26.2%)
<0.005
0 (0%)
35 (20.8%)
<0.005
Immediate (<24 h), n (%)
0 (0%)
26 (15.5%)
<0.005
Delayed (>24 h), n (%)
0 (0%)
11 (6.5%)
0.07
0 (0%)
36 (21.4%)
<0.005
Surgical procedure performed, n (%)
Mortality (or hospice), n (%)
Depicts data regarding primary outcomes for all isolated SDH in BIG3. Parafalcine SDH appears to be benign as compared to BIG3 convexity SDH.
cragun et al traumatic parafalcine sdh
Our study has several limitations. Our data were retrospectively collected from a single level I trauma center; as such our data may not be generalizable to all centers. In addition, we excluded patients with systemic injury and with ICH in multiple locations. It remains unclear how parafalcine SDH interacts with systemic injury or how additional intracranial pathology affects outcomes.
Conclusions Our data showed no mortality, no clinical worsening, and no neurosurgical intervention in patients with isolated parafalcine SDH. These findings suggest that parafalcine bleeds represent a distinct and clinically benign entity as compared with convexity SDH. Although some patients with parafalcine bleeds show radiographic progression if they undergo repeat imaging, in our study, this progression did not translate to neurological deterioration, need for intervention, or mortality. Our data suggest that admission to an ICU and routine interval imaging provide no benefit for patients admitted with isolated parafalcine SDH.
Acknowledgment The authors would like to thank the Association for Academic Surgery, and the American College of Surgeons Committee on Trauma, Pennsylvania, and Region III chapters for the opportunity to present this research. Authors’ contributions: All authors participated in the conception and design of the study. Data collection was primarily performed by B.N.C., M.R.N., and F.H.P. The manuscript was primarily written by B.N.C., with critical edits and final approval from all authors.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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