Investigation of chronic subdural hematoma with impending brain herniation on admission

Abstract

  Chronic subdural hematoma (CSDH) with brain herniation signs is rarely seen in emergency departments, and there are few cumulative data to analyze such cases. Here we evaluated the clinical features, risk factors, and rates of completion of CSDH patients with impending brain herniation on arrival in a cohort study. The cases of 492 consecutive patients with CSDH between January 2010 and October 2015 were retrospectively evaluated. We first analyzed the clinical factors and compared them between the patients with and without brain herniation signs on admission. Among the patients who had brain herniation signs on arrival, we then compared clinical factors between the patients with and without completion of brain herniation post-surgery. Eleven (2.2%) patients showed brain herniation signs on arrival, and six patients (1.2%) progressed to complete brain herniation. The patients with brain herniation signs on arrival were significantly older (p=0.03) and more frequently hospitalized with a concomitant illness (p=0.004). A multivariate logistic regression analysis showed that admission to another hospital was the only independent risk factor for having had brain herniation signs on arrival. Having a history of head injury (p=0.02) and disappearance of the ambient cistern (p=0.0009) were significantly associated with the completion of brain herniation. The prognosis was generally poor when the patient presented with brain herniation signs on admission. Our results demonstrate that the diagnosis of CSDH is often made late, despite patients’ hospitalization for a concomitant illness. When an elderly patient shows mild disturbance of consciousness, non-neurosurgeon physicians should consider the possibility of CSDH regardless of a recent history of head injury.