Acta Neurochirurgica

, Volume 159, Issue 8, pp 1553–1559

Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study

  • Arturo Chieregato
  • Alessandra Venditto
  • Emanuele Russo
  • Costanza Martino
  • Giovanni Bini
Original Article - Brain Injury
  • 122 Downloads

Abstract

Background

The outcome of patients with severe traumatic brain injury (TBI) and acute traumatic subdural hematoma (aSDH) admitted to the emergency room with bilaterally dilated, unreactive pupils (bilateral mydriasis) is notoriously poor.

Methods

Of 2074 TBI patients consecutively admitted to our facility between 1997 and 2012, 115 had a first CT scan with aSDH, unreactive bilateral mydriasis, and a Glasgow Coma Score of 3 or 4. Sixty-two patients were unoperated and died within hours or a few days. The remaining 53 patients (2.5% of the 2074 consecutive patients) were scheduled for emergent evacuation of the aSDH. We compared three different dosages of mannitol to landmark different comprehensive levels of treatment: (1) a “basic” level of treatment characterized by a single conventional dose (18 to 36 g), (2) “reinforced” treatment landmarked by a single high dose (54 to 72 g), and (3) “aggressive” treatment landmarked by a single high dose (90 to 106 g). Doses above 36 g were administered intravenously over a period of 5 min.

Results

Of the 53 selected patients, 7 were aggressively managed (13.2%) and 24 (45.3%) received reinforced treatment. Rates of hyperventilation and barbiturate bolus administration were appropriately associated with increasing doses of mannitol. After adjustment for age, aggressive management was significantly associated with a lower risk of death and persistent vegetative state [adjusted OR 0.016 (95% 0.001–0.405)]. Patients surviving after aggressive management suffered more severe disability at 1 year.

Conclusion

The study shows an association between reduced mortality and persistent vegetative state, albeit at the cost of increased long-term severe disability in survivors, and aggressive medical preoperative management of mydriatic patients with aSDH following TBI.

Keywords

Brain injuries Mannitol Mydriasis Outcome Subdural hematoma Transtentorial herniation 

Copyright information

© Springer-Verlag Wien 2017

Authors and Affiliations

  • Arturo Chieregato
    • 1
  • Alessandra Venditto
    • 2
  • Emanuele Russo
    • 2
  • Costanza Martino
    • 2
  • Giovanni Bini
    • 2
  1. 1.NeurorianimazioneASST Grande Ospedale Metropolitano NiguardaMilanItaly
  2. 2.Ospedale “M Bufalini”, Anestesia e RianimazioneCesenaItaly

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