Development of the Subdural Hematoma in the Elderly (SHE) score to predict mortality

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The purpose of this study was to describe the development of a novel prognostic score, the Subdural Hematoma in the Elderly (SHE) score. The SHE score is intended to predict 30-day mortality in elderly patients (those > 65 years of age) with an acute, chronic, or mixed-density subdural hematoma (SDH) after minor, or no, prior trauma.


The authors used the Prognosis Research Strategy group methods to develop the clinical prediction model. The training data set included patients with acute, chronic, and mixed-density SDH. Based on multivariate analyses from a large data set, in addition to review of the extant literature, 3 components to the score were selected: age, admission Glasgow Coma Scale (GCS) score, and SDH volume. Patients are given 1 point if they are over 80 years old, 1 point for an admission GCS score of 5–12, 2 points for an admission GCS score of 3–4, and 1 point for SDH volume > 50 ml. The sum of points across all categories determines the SHE score.


The 30-day mortality rate steadily increased as the SHE score increased for all SDH acuities. For patients with an acute SDH, the 30-day mortality rate was 3.2% for SHE score of 0, and the rate increased to 13.1%, 32.7%, 95.7%, and 100% for SHE scores of 1, 2, 3, and 4, respectively. The model was most accurate for acute SDH (area under the curve [AUC] = 0.94), although it still performed well for chronic (AUC = 0.80) and mixed-density (AUC = 0.87) SDH.


The SHE score is a simple clinical grading scale that accurately stratifies patients’ risk of mortality based on age, admission GCS score, and SDH volume. Use of the SHE score could improve counseling of patients and their families, allow for standardization of clinical treatment protocols, and facilitate clinical research studies in SDH.

ABBREVIATIONS AUC = area under the curve; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; NN = neural network; PROGRESS = Prognosis Research Strategy; SDH = subdural hematoma; SHE = Subdural Hematoma in the Elderly.

Article Information

Correspondence Elizabeth N. Alford: University of Alabama at Birmingham, AL.

INCLUDE WHEN CITING Published online April 12, 2019; DOI: 10.3171/2019.1.JNS182895.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.



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    ROC curve for the SHE score demonstrating excellent predictive capacity in patients with acute SDH, with an AUC of 0.941. Figure is available in color online only.

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    Functional outcomes of acute SDH significantly worsen with increasing SHE score (p < 0.00001). The rate of good outcomes decreases from 77.7% for SHE score of 0 to 54.5%, 32.7%, 4.3%, and 0% for SHE scores of 1, 2, 3, and 4, respectively. Figure is available in color online only.

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    Using the Kaplan-Meier method, survival of patients with acute SDH varies significantly by SHE score (p < 0.00001). Figure is available in color online only.

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    ROC curve for the SHE score demonstrating significant predictive capacity in patients with chronic SDH, with an AUC of 0.80. Figure is available in color online only.

  • View in gallery

    ROC curve for the SHE score demonstrating significant predictive capacity in mixed-density patients with SDH, with an AUC of 0.874. Figure is available in color online only.


  • 1

    Abouzari MRashidi AZandi-Toghani MBehzadi MAsadollahi M: Chronic subdural hematoma outcome prediction using logistic regression and an artificial neural network. Neurosurg Rev 32:4794842009

  • 2

    Balser DFarooq SMehmood TReyes MSamadani U: Actual and projected incidence rates for chronic subdural hematomas in United States Veterans Administration and civilian populations. J Neurosurg 123:120912152015

  • 3

    Benedetto NGambacciani CMontemurro NMorganti RPerrini P: Surgical management of acute subdural haematomas in elderly: report of a single center experience. Br J Neurosurg 31:2442482017

  • 4

    Brennan PMKolias AGJoannides AJShapey JMarcus HJGregson BA: The management and outcome for patients with chronic subdural hematoma: a prospective, multicenter, observational cohort study in the United Kingdom. J Neurosurg 127:7327392017

  • 5

    De Bonis PTrevisi Gde Waure CSferrazza AVolpe MPompucci A: Antiplatelet/anticoagulant agents and chronic subdural hematoma in the elderly. PLoS One 8:e687322013

  • 6

    Defernez MKemsley EK: Avoiding overfitting in the analysis of high-dimensional data with artificial neural networks (ANNs). Analyst (Lond) 124:167516811999

  • 7

    Evans LRJones JLee HQGantner DJaison AMathew J: Prognosis of acute subdural haematoma in the elderly: a systematic review. J Neurotrauma [epub ahead of print]2018

  • 8

    Gaist DGarcía Rodríguez LAHellfritzsch MPoulsen FRHalle BHallas J: Association of antithrombotic drug use with subdural hematoma risk. JAMA 317:8368462017

  • 9

    Gulati SSolheim OCarlsen SMØie LRJensberg HGulati AM: Risk of intracranial hemorrhage (RICH) in users of oral antithrombotic drugs: Nationwide pharmacoepidemiological study. PLoS One 13:e02025752018

  • 10

    Gurer BKertmen HYilmaz ERDolgun HHasturk AESekerci Z: The surgical outcome of traumatic extraaxial hematomas causing brain herniation. Turk Neurosurg 27:37522017

  • 11

    Hanif SAbodunde OAli ZPidgeon C: Age related outcome in acute subdural haematoma following traumatic head injury. Ir Med J 102:2552572009

  • 12

    Hemphill JC IIIBonovich DCBesmertis LManley GTJohnston SC: The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32:8918972001

  • 13

    Hunt WEHess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14201968

  • 14

    Kitya DPunchak MAbdelgadir JObiga OHarborne DHaglund MM: Causes, clinical presentation, management, and outcomes of chronic subdural hematoma at Mbarara Regional Referral Hospital. Neurosurg Focus 45(4):E72018

  • 15

    Kuhn ENErwood MSOster RADavis MCZeiger HEPittman BC: Outcomes of subdural hematoma in the elderly (SHE) with a history of minor or no prior trauma. World Neurosurg 119:e374e3822018

  • 16

    Kwon CSAl-Awar ORichards OIzu ALengvenis G: Predicting prognosis of patients with chronic subdural hematoma: a new scoring system. World Neurosurg 109:e707e7142018

  • 17

    Lavrador JPTeixeira JCOliveira ESimão DSantos MMSimas N: Acute subdural hematoma evacuation: predictive factors of outcome. Asian J Neurosurg 13:5655712018

  • 18

    Ledić DGirotto DPal SKolbah B: Risk factors for subdural bleeding in elderly population. Coll Antropol 38:119511982014

  • 19

    Manickam AMarshman LAGJohnston RThomas PAW: Mathematical formulae to estimate chronic subdural haematoma volume. Flawed assumption regarding ellipsoid morphology. J Clin Neurosci 40:39432017

  • 20

    McGinity MJMichalek JERodriguez JSFloyd JR: Surgical evacuation of acute subdural hematoma in octogenarians: a ten-year experience from a single trauma center. Br J Neurosurg 31:7147172017

  • 21

    McNett MAmato SGianakis AGrimm DPhilippbar SABelle J: The FOUR score and GCS as predictors of outcome after traumatic brain injury. Neurocrit Care 21:52572014

  • 22

    Miranda LBBraxton EHobbs JQuigley MR: Chronic subdural hematoma in the elderly: not a benign disease. J Neurosurg 114:72762011

  • 23

    Motoie RKarashima SOtsuji RRen NNagaoka SMaeda K: Recurrence in 787 patients with chronic subdural hematoma: retrospective cohort investigation of associated factors including direct oral anticoagulant use. World Neurosurg 118:e87e912018

  • 24

    Moussa WMMKhedr WMElwany AH: Prognostic significance of hematoma thickness to midline shift ratio in patients with acute intracranial subdural hematoma: a retrospective study. Neurosurg Rev 41:4834882018

  • 25

    Ntaios GFaouzi MFerrari JLang WVemmos KMichel P: An integer-based score to predict functional outcome in acute ischemic stroke: the ASTRAL score. Neurology 78:191619222012

  • 26

    Okano AOya SFujisawa NTsuchiya TIndo MNakamura T: Analysis of risk factors for chronic subdural haematoma recurrence after burr hole surgery: optimal management of patients on antiplatelet therapy. Br J Neurosurg 28:2042082014

  • 27

    Orlando ALevy ASRubin BATanner ACarrick MMLieser M: Isolated subdural hematomas in mild traumatic brain injury. Part 1: the association between radiographic characteristics and neurosurgical intervention. J Neurosurg [epub ahead of print June 15 2018; DOI: 10.3171/2018.1.JNS171884]

  • 28

    Oshiro EMWalter KAPiantadosi SWitham TFTamargo RJ: A new subarachnoid hemorrhage grading system based on the Glasgow Coma Scale: a comparison with the Hunt and Hess and World Federation of Neurological Surgeons Scales in a clinical series. Neurosurgery 41:1401481997

  • 29

    Powers AYPinto MBAldridge AMTang OYChen JSBerube RL: Factors associated with the progression of conservatively managed acute traumatic subdural hemorrhage. J Crit Care 48:2432502018

  • 30

    Prasad GLAnmol NMenon GR: Outcome of traumatic brain injury in the elderly population: a tertiary center experience in a developing country. World Neurosurg 111:e228e2342018

  • 31

    Raj RMikkonen EDKivisaari RSkrifvars MBKorja MSiironen J: Mortality in elderly patients operated for an acute subdural hematoma: a surgical case series. World Neurosurg 88:5925972016

  • 32

    Sadaka FPatel DLakshmanan R: The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care 16:951012012

  • 33

    Sano HSatoh AMurayama YKato YOrigasa HInamasu J: Modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading system. World Neurosurg 83:8018072015

  • 34

    Saposnik GKapral MKLiu YHall RO’Donnell MRaptis S: Iscore: a risk score to predict death early after hospitalization for an acute ischemic stroke. Circulation 123:7397492011

  • 35

    Steyerberg EWMoons KGMvan der Windt DAHayden JAPerel PSchroter S: Prognosis Research Strategy (PROGRESS) 3: prognostic model research. PLoS Med 10:e10013812013

  • 36

    Stippler MRamirez PBerti AMacindoe CVillalobos NMurray-Krezan C: Chronic subdural hematoma patients aged 90 years and older. Neurol Res 35:2432462013

  • 37

    Sucu HKGokmen MGelal F: The value of XYZ/2 technique compared with computer-assisted volumetric analysis to estimate the volume of chronic subdural hematoma. Stroke 36:99810002005

  • 38

    Szczygielski JGund SMSchwerdtfeger KSteudel WIOertel J: Factors affecting outcome in treatment of chronic subdural hematoma in ICU patients: impact of anticoagulation. World Neurosurg 92:4264332016

  • 39

    Teasdale GMaas ALecky FManley GStocchetti NMurray G: The Glasgow Coma Scale at 40 years: standing the test of time. Lancet Neurol 13:8448542014

  • 40

    Thombre A: Comparing logistic regression, neural networks, c5.0 and M5ʹ classification techniques in Perner P (ed): Proceedings of the 8th International Conference on Machine Learning and Data Mining in Pattern Recognition. Berlin: Springer2012 Vol 7376 pp 132140

  • 41

    United Nations Population Fund: Ageing in the Twenty-First Century: A Celebration and a Challenge. New York: UNFPA2012 ( [Accessed January 31 2019]

  • 42

    Weimer JMGordon EFrontera JA: Predictors of functional outcome after subdural hematoma: a prospective study. Neurocrit Care 26:70792017

  • 43

    Whitehouse KJJeyaretna DSEnki DGWhitfield PC: Head injury in the elderly: what are the outcomes of neurosurgical care? World Neurosurg 94:4935002016

  • 44

    Won SYZagorcic ADubinski DQuick-Weller JHerrmann ESeifert V: Excellent accuracy of ABC/2 volume formula compared to computer-assisted volumetric analysis of subdural hematomas. PLoS One 13:e01998092018

  • 45

    Won YDNa MKRyu JICheong JHKim JMKim CH: Radiologic factors predicting deterioration of mental status in patients with acute traumatic subdural hematoma. World Neurosurg 111:e120e1342018

  • 46

    Yan CYang MFHuang YW: A reliable nomogram model to predict the recurrence of chronic subdural hematoma after burr hole surgery. World Neurosurg 118:e356e3662018




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