Aggressive medical management of acute traumatic subdural hematomas before emergency craniotomy in patients presenting with bilateral unreactive pupils. A cohort study
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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.
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.
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.
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.
KeywordsBrain injuries Mannitol Mydriasis Outcome Subdural hematoma Transtentorial herniation
We are grateful to Maurizio Ravaldini (RN) (Unità Operativa Anestesia e Rianimazione, Rianimazione per la Traumatologia e le Neuroscienze, Ospedale Bufalini, AUSL Romagna, Cesena, Italy) for daily assistance and development of our local TBI patient database.
We also are grateful to Laila Portolani (Head Nurse), Giulia Paci (RN), Wilma Benedettini (RN), Diletta Castagnoli (RN), Silvia Chiesa (RN), Veruska Pransani (RN), and Sara Salvigni (RN) (Unità Operativa Anestesia e Rianimazione, Rianimazione per la Traumatologia e le Neuroscienze, Ospedale Bufalini, AUSL Romagna, Cesena, Italy) for collecting patient outcomes at 1 year.
We are also grateful to Erika Cordella (MD), Silvia Olivieri (MD), and Giuseppe Sabia (MD) (Unità Operativa Anestesia e Rianimazione, Rianimazione per la Traumatologia e le Neuroscienze, Ospedale Bufalini, AUSL Romagna, Cesena, Italy) who participated in prospective data collection for the local trauma registry.
Compliance with ethical standards
No funding was received for this research.
Conflicts of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent licensing arrangements), or nonfinancial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
For this type of study formal consent is not required.
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