Coagulopathy and inhospital deaths in patients with acute subdural hematoma

Clinical article

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Object

Acute subdural hematoma (SDH) is one of the most lethal forms of intracranial injury; several risk factors predictive of a worse outcome have been identified. Emerging research suggests that patients with coagulopathy and intracerebral hemorrhage have a worse outcome than patients without coagulopathy but with intracerebral hemorrhage. The authors sought to determine if such a relationship exists for patients with acute SDH.

Methods

The authors conducted a retrospective analysis of consecutive patients admitted to a neurosciences intensive care unit with acute SDH over a 4-year period (January 1997–December 2001). Demographic data, laboratory values, admission source, prior functional status, medical comorbidities, treatments received, and discharge disposition were recorded, as were scores on the Acute Physiology, Age, and Chronic Health Evaluation III (APACHE III). Coagulopathy was defined as an internal normalized ratio > 1.2 or a prothrombin time ≥12.7 seconds. Univariate and multivariate analyses were performed on 244 patients to determine factors associated with worse short-term outcomes.

Results

The authors identified 248 patients with acute SDH admitted to the neurointensive care unit during the study period, of which 244 had complete data. Most were male (61%), and the mean age of the study population was 71.3 ± 15 years (range 20–95 years). Fifty-three patients (22%) had coagulopathy. The median APACHE III score was 43 (range 11–119). Twenty-nine patients (12%) died in the hospital. Independent predictors of inhospital death included APACHE III score (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.4–13.4, p = 0.011) and coagulopathy (OR 2.7, 95% CI 1.1–7.1, p = 0.037). Surgical evacuation of acute SDH was associated with reduced inhospital deaths (OR 0.2, 95% CI 0.1–0.6, p = 0.003).

Conclusions

Coagulopathy is independently associated with inhospital death in patients with acute SDH. Time to treatment to correct coagulopathy using fresh frozen plasma and/or vitamin K was prolonged.

Abbreviations used in this paper: APACHE III = Acute Physiology, Age, and Chronic Health Evaluation III; CI = confidence interval; FFP = fresh frozen plasma; GCS = Glasgow Coma Scale; ICH = intracerebral hemorrhage; ICU = intensive care unit; INR = international normalized ratio; LOS = length of stay; NICU = neurosciences ICU; OAT = oral anticoagulation therapy; OR = odds ratio; PCC = prothrombin complex concentrate; PT = prothrombin time; rFVIIa = recombinant activated factor VIIa; SD = standard deviation; SDH = subdural hematoma.

Article Information

Address correspondence to: Jose I Suarez, M.D., Department of Neurology, Baylor College of Medicine, One Baylor Plaza, NB 302, Houston, Texas 77030. email: jisuarez@bcm.tmc.edu.

© AANS, except where prohibited by US copyright law.

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