Introduction: Acute subdural hematoma (SDH) is an uncommon presentation of aneurysmal hemorrhage that has been identified as a poor prognostic sign. Current series are small, have short follow-up and/or were collected over a long period during which treatment has evolved. We present a large modern series of aneurysmal SDH with long-term follow-up, and evaluate prognostic factors for good outcome.
Methods: A prospectively maintained database was queried for all patients presenting with aneurysmal SDH from 2000-present. Thirty patients met criteria and were analyzed. Statistical analysis was performed with unpaired t-test or Fisher’s exact test when appropriate.
Results: Average age was 61. Average Hunt-Hess (HH) was 3.8. Average initial SDH thickness was 6.7mm; average midline shift was 5.9mm. 21 SDHs were on the right, 26 presented with subarachnoid hemorrhage and 19 harbored intraparenchymal hematoma. 18 underwent open surgical treatment, 8 received endosaccular coiling, one underwent both, and three were not treated due to poor status.
Good (Glascow Outcome Scale, GOS 4-5) discharge condition occurred in 20% of patients and increased to 40% at 6-12 months. Good clinical presentation (HH 1-2) had a good outcome in 75%. Poor clinical presentation (HH 4-5) had a good outcome in 30%.
Good outcome correlated with younger age (p=0.04), smaller aneurysm size (p=0.04) and HH at intervention (p=0.04); it did not correlate with gender, race, admission HH, subarachnoid or intraparenchymal hemorrhage, size or laterality of hemorrhage, midline shift or treatment modality (p>0.15).
Conclusions: Aneurysmal SDH presents with poor clinical grade; however, even poor grade presentation can ultimately result in good outcome in nearly a third of cases, suggesting that clinical presentation may be exaggerated by the hematoma. Clinical grade and age were predictors of outcome; laterality, size of hematoma, and midline shift were not, suggesting that clinical status is more important than radiographic findings.
Patient Care: This study will affect the initial evaluation and management decisions for this patient population, especially regarding long-term outcome of aggressive treatment.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Recognize the uncommon presentation of acute SDH as a manifestation of aneurysmal hemorrhage, 2) Understand the clinical presentation, general treatment options and outcomes for aneurysmal SDH, 3) Describe prognostic factors for outcome in aneurysmal SDH.