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Modified Puerto Rico Recurrence Scale for chronic subdural hematomas: augmenting the grading scale with postoperative pneumocephalus volume

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Abstract

Background

Chronic subdural hematomas (CSDHs) are common in the elderly, with a relatively high rate of recurrence after initial surgical intervention. Our research team previously created a predictive grading system, the Puerto Rico Recurrence Scale (PRRS), to identify patients at high risk of CSDH recurrence. In this study, we introduce a modification of the (mPRRS) that includes pneumocephalus volume, which has been independently associated with recurrence.

Methods

A single-center Puerto Rican population-based retrospective study was performed to analyze data for patients treated for CSDH at 1 institution between July 1, 2017, and December 31, 2019. Univariate and multivariate analyses were used to create a grading scale predictive of recurrence. Retrospective validation was conducted for the cohort.

Results

Of 108 patients included in the study, 42 had recurrence, and 66 had nonrecurrence. Postoperative subdural space, postoperative midline shift, and pneumocephalus volume were all higher with recurrence (P = 0.002, P = 0.009, and P < 0.001, respectively). Multivariate analysis was used to create a 6-point grading scale comprising 3 variables (pneumocephalus volume [< 10, 10–20, 21–30, and > 30 cm3], postoperative midline shift [< 0.4, 0.41–1.0, and > 1.0 cm], and laterality [unilateral and bilateral]). Recurrence rates progressively increased in low-risk to high-risk groups (2/18 [11%] vs 21/34 [62%]; P < 0.003).

Conclusion

The mPRRS incorporating pneumocephalus measurement improves CSDH recurrence prediction. The mPRRS indicated that patients with higher scores have a greater risk of recurrence and emphasized the importance of measuring postoperative variables for prediction. The mPRRS grading scale for CSDHs may be applicable not only to the Puerto Rican population but also to the general population.

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Data Availability

Data is available upon appropriate request.

Abbreviations

AUC:

Area under the curve

CAVA:

Computer-assisted volumetric analysis

CI:

Confidence interval

CSDH:

Chronic subdural hematoma

CT:

Computed tomography

CTI:

Centro de Tecnologia da Informaçāo

DSM-V :

Diagnostic and Statistical Manual of Mental Disorders, 5th edition

HU:

Hounsfield unit

IQR:

Interquartile range

mPRRS:

Modified Puerto Rico Recurrence Scale

MRI:

Magnetic resonance imaging

OR:

Odds ratio

PACS:

Picture archiving and communication system

PRMC:

Puerto Rico Medical Center

PRRS:

Puerto Rico Recurrence Scale

ROC:

Receiver operating characteristic

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Acknowledgements

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

Funding

This study was funded in part by the Newsome Chair in Neurosurgery Research held by Dr. Preul and the Barrow Neurological Foundation.

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Authors and Affiliations

  1. Neurosurgery Section, Department of Surgery, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico

    Giancarlo Mignucci-Jiménez, Alejandro J. Matos-Cruz & Caleb E. Feliciano-Valls

  2. The Loyal and Edith Davis Neurosurgical Research Laboratory, C/O Neuroscience Publications, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ, 85013, USA

    Giancarlo Mignucci-Jiménez, Grant Koskay, Sahin Hanalioglu, Nicolas I. Gonzalez-Romo, Yuan Xu, Melissa S. Kovacs & Mark C. Preul

  3. Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA

    Alejandro J. Matos-Cruz

Authors
  1. Giancarlo Mignucci-Jiménez
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Contributions

Giancarlo Mignucci-Jiménez, Alejandro J. Matos-Cruz, and Caleb E. Feliciano-Valls contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Giancarlo Mignucci-Jiménez, Alejandro J. Matos-Cruz, and Melissa S. Kovacs. The first draft of the manuscript was written by Giancarlo Mignucci-Jiménez, Grant Koskay, and Mark C. Preul, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mark C. Preul.

Ethics declarations

Ethical approval

This is a retrospective study. Electronic medical records of patients were analyzed retrospectively after approval by the University of Puerto Rico Medical Sciences Campus Institutional Review Board (A0230120).

Consent to participate

No patient consent was required due to the study’s retrospective nature and lack of identifiable health information.

Conflict of interest

The authors declare no competing interests.

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Mignucci-Jiménez, G., Matos-Cruz, A.J., Koskay, G. et al. Modified Puerto Rico Recurrence Scale for chronic subdural hematomas: augmenting the grading scale with postoperative pneumocephalus volume. Acta Neurochir 165, 3229–3238 (2023). https://doi.org/10.1007/s00701-023-05737-w

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