Densitometric analysis of brain computed tomography as a new prognostic factor in patients with acute subdural hematoma

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  • Department of Neurosurgery, University Hospital 12 de Octubre, Madrid, Spain
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OBJECTIVE

Acute subdural hematoma (ASDH) is a major cause of mortality and morbidity after traumatic brain injury (TBI). Surgical evacuation is the mainstay of treatment in patients with altered neurological status or significant mass effect. Nevertheless, concerns regarding surgical indication still persist. Given that clinicians often make therapeutic decisions on the basis of their prognosis assessment, to accurately evaluate the prognosis is of great significance. Unfortunately, there is a lack of specific and reliable prognostic models. In addition, the interdependence of certain well-known predictive variables usually employed to guide surgical decision-making in ASDH has been proven. Because gray matter and white matter are highly susceptible to secondary insults during the early phase after TBI, the authors aimed to assess the extent of these secondary insults with a brain parenchyma densitometric quantitative CT analysis and to evaluate its prognostic capacity.

METHODS

The authors performed a retrospective analysis among their prospectively collected cohort of patients with moderate to severe TBI. Patients with surgically evacuated, isolated, unilateral ASDH admitted between 2010 and 2017 were selected. Thirty-nine patients were included. For each patient, brain parenchyma density in Hounsfield units (HUs) was measured in 10 selected slices from the supratentorial region. In each slice, different regions of interest (ROIs), including and excluding the cortical parenchyma, were defined. The injured hemisphere, the contralateral hemisphere, and the absolute differences between them were analyzed. The outcome was evaluated using the Glasgow Outcome Scale–Extended at 1 year after TBI.

RESULTS

Fifteen patients (38.5%) had a favorable outcome. Collected demographic, clinical, and radiographic data did not show significant differences between favorable and unfavorable outcomes. In contrast, the densitometric analysis demonstrated that greater absolute differences between both hemispheres were associated with poor outcome. These differences were detected along the supratentorial region, but were greater at the high convexity level. Moreover, these HU differences were far more marked at the cortical parenchyma. It was also detected that these differences were more prone to ischemic and/or edematous insults than to hyperemic changes. Age was significantly correlated with the side-to-side HU differences in patients with unfavorable outcome.

CONCLUSIONS

The densitometric analysis is a promising prognostic tool in patients diagnosed with ASDH. The supplementary prognostic information provided by the densitometric analysis should be evaluated in future studies.

ABBREVIATIONS

ASDH = acute subdural hematoma; AUC = area under the ROC curve; CRASH = Corticosteroid Randomization After Significant Head Injury; GCS = Glasgow Coma Scale; GM = gray matter; GOSE = Glasgow Outcome Scale–Extended; GWR = gray-white matter ratio; HU = Hounsfield unit; iASDH = isolated ASDH; IMPACT = International Mission for Prognosis and Analysis of Clinical Trials in TBI; IQR = interquartile range; LV = lateral ventricle; MIPAV = Medical Image Processing, Analysis, and Visualization; ROC = receiver operating characteristic; ROI = region of interest; TBI = traumatic brain injury; WM = white matter.

Supplementary Materials

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Illustration from Gogos et al. (pp 1728–1737). Copyright Kenneth X. Probst. Published with permission.

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Contributor Notes

Correspondence Daniel García-Pérez: University Hospital 12 de Octubre, Madrid, Spain. dgp.neurosurgery@gmail.com.

INCLUDE WHEN CITING Published online July 31, 2020; DOI: 10.3171/2020.4.JNS193445.

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

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