Ulus Travma Acil Cerrahi Derg. 2019; 25(2): 147-153 | DOI: 10.5505/tjtes.2018.48079

Akut subdural hematomda mortaliteye etki eden faktörler: Dekompresif kraniyektomi faydalý mýdýr?

Ýlhan Yýlmaz¹, Devrimsel Harika Ertem², Mustafa Kýlýç¹, Kadir Altaþ¹, Muyassar Mirhasilova¹, Burak Ozdemir¹, Osman Tanriverdi³, Adem Yilmaz^1
1Sisli Hamidiye Etfal Eðitim Ve Araþtýrma Hastanesi, Saðlýk Bilimleri Üniversitesi, Nöroþirurji Kliniði, Ýstanbul, Türkiye.
²Sisli Hamidiye Etfal Eðitim Ve Araþtýrma Hastanesi, Saðlýk Bilimleri Üniversitesi, Nöroloji Kliniði, Ýstanbul, Türkiye.
³Bakýrköy Ruh Ve Sinir Hastalýklarý Hastanesi, Saðlýk Bilimleri Üniversitesi, Nöroþirurji Kliniði, Ýstanbul, Türkiye.

AMAÇ: Hýzlý taný ve agresif nöroþirürjik müdahalelere raðmen, akut subdural hematom (ASH), yüksek morbidite ve mortalite oranlarýna neden olmaktadýr. Kraniyotomi ve dekompresif kraniyektomi (DK) gibi cerrahi prosedürler etkili görünmemelerine raðmen, ASH’nin tedavisinde tercih edilen yaklaþým halen tartýþmalýdýr. Bu yazýda, DK uygulanan ASH hastalarýnda mortalite ile iliþkili faktörlerin deðerlendirilmesi amaçlanmýþtýr.
GEREÇ VE YÖNTEM: 2012’den 2017’ye kadar 60 aylýk bir dönemde ASH tanýlý 93 olgunun mortalite, Glasgow Koma Skoru (GKS), demografik özellikleri, klinik ve radyolojik özellikleri deðerlendirildi. Mortaliteyi öngörmede lojistik regresyon modelleri kullanýldý.
BULGULAR: Yaþ ortalamasý 59.82±19.49 (daðýlým, 16–88) olan 65 erkek ve 28 kadýn olgu alýndý. On altý hasta (%17.2) ameliyatý takiben hayatýný kaybetti. Ýleri yaþ (p=0.007) ve düþük GKS skorlarý (p=0.022) mortalite oranlarý üzerinde anlamlý bulundu. Ortalama hematom kalýnlýðý 15.46±5.73 mm, orta hat kaymasýnýn ortalamasý 9.90±4.84 mm idi. ADSH hastalarýnda mortalite oraný aþýrý orta hat kaymasý (p=0.011, r=0.262) ve yaþ (p=0.022, r=0.237) ile pozitif korelasyon gösterdi. Orta hat kaymasý ≥10 mm olan ve hematom kalýnlýðý ≥15 mm olan hastalarda mortalite oraný ile anlamlý bir iliþki vardý (p=0.014, p=0.039). Ayrýca travma, subaraknoid, epidural ve intrakranial hemoraji komorbiditeleri, kompresyon kýrýklarý ve kontüzyonun etiyolojisi anlamlý olarak korelasyon göstermedi.
TARTIÞMA: Bulgularýmýz, DK’nin 65 yaþ üzeri hastalarda ve GKS skoru <6 olanlarda daha yüksek mortalite oranlarý ile iliþkili olduðunu göstermektedir. Orta hat kaymasýnýn ≥10 mm ve hematom kalýnlýðýnýn ≥15 mm ve üzerinde olmasý mortalite ile anlamlý derecede iliþkilidir. Çalýþmamýz DK’nin ileri orta hat kaymasýný önlemede yardýmcý olabileceði ve kraniotomi ile kýyaslandýðýnda daha düþük bir mortaliteyle birlikte olduðu sonucunu desteklemektedir.

Anahtar Kelimeler: Akut subdural hematom, dekompresif kraniektomi; mortalite; sonuç.

---

Factors associated with mortality in acute subdural hematoma: Is decompressive craniectomy effective?

Ýlhan Yýlmaz¹, Devrimsel Harika Ertem², Mustafa Kýlýç¹, Kadir Altaþ¹, Muyassar Mirhasilova¹, Burak Ozdemir¹, Osman Tanriverdi³, Adem Yilmaz^1
1Department of Neurosurgery, University of Health Sciences, Þiþli Hamidiye Etfal Training and Research Hospital, Ýstanbul-Turkey
²Department of Neurology, University of Health Sciences, Þiþli Hamidiye Etfal Training and Research Hospital, Ýstanbul-Turkey
³Department of Neurosurgery, University of Health Sciences, Bakýrköy Training and Research Hospital For Neurology, Neurosurgery and Psychiatry, Ýstanbul-Turkey

BACKGROUND: Despite rapid diagnosis and aggressive neurosurgical intervention, acute subdural hematoma (ASDH) is a severe type of head injury that can result in high morbidity and mortality. Although surgical procedures, such as craniotomy and decompressive craniectomy (DC), can be effective, the preferred approach for treating an ASDH remains controversial. The aim of this report was to evaluate factors associated with mortality in patients with ASDH and determinants of outcome in those with ASDH who underwent DC.
METHODS: The demographic details and clinical and radiological characteristics of a total of 93 patients with ASDH who underwent DC during a 60-month period from 2012 to 2017 were evaluated to determine the effect on mortality and any association with the Glasgow Coma Scale (GCS) score recorded on arrival.
RESULTS: Sixty-five male and 28 female subjects with a mean age of 59.82±19.49 years (range: 16–88 years) were included in the study. Sixteen patients (17.2%) died following the surgery. Older age (p=0.007) and lower GCS scores (p=0.022) were statistically significantly associated with the mortality rate. The mean hematoma thickness was 15.46±5.73 mm, and the mean midline shift was 9.90±4.84 mm. The mortality rate was positively correlated with an excessive midline shift (p=0.011; r=0.262) and age (p=0.022; r=0.237) in patients with ADSH. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm was significantly associated with mortality (p=0.014; p=0.039). The etiology of the trauma; comorbidities of subarachnoid, epidural, or intracranial hemorrhage; compression fractures; or contusions were not significantly correlated.
CONCLUSION: The results indicated that there was a higher mortality rate among older patients and those with a GCS score of <6 on arrival. A midline shift of ≥10 mm and a hematoma thickness of ≥15 mm were significantly related to mortality. Our study supports the conclusion that DC may help prevent further midline shift and be associated with a lower mortality rate compared with a craniotomy.

Keywords: Acute subdural hematoma, decompressive craniectomy; mortality; outcome.

---

ATIF KOPYALA