Kliś, Kornelia

Krzyżewski, Roger

Kwinta, Borys

Moskała, Marek

English

Jagiellonian Univeristy Repository

FOLIA MEDICA CRACOVIENSIAVol. LVIII, 1, 2018: 53–56PL ISSN 0015-5616Prolonged international normalized ratio is independently associated with recurrence of acute subdural hematoma needing reoperationBorys Kwinta1, Roger M. Krzyżewski1, Kornelia Kliś2,3, Marek Moskała11Department of Neurosurgery and Neurotraumatology, Jagiellonian University Medical CollegeKraków, Poland2Jagiellonian University Medical College, Kraków, Poland3Faculty of Computer Science, Electronics and Telecommunications, AGH University of Science and TechnologyKraków, PolandCorresponding author: Borys Kwinta, MD, PhDDepartment of Neurosurgery and Neurotraumatology, Jagiellonian University Medical Collegeul. Botaniczna 3, 31-503 Kraków, PolandPhone: +48 12 424 86 62; E-mail: bmkwinta@gmail.comAbstract: I n t r o d u c t i o n: Acute subdural hematoma (aSDH) removal is one of the most common-ly performed procedure in neurosurgery. Complications of those surgeries which require reoperation are associated with higher risk of poor treatment outcome. Th erefore we decided to analyse poten-tial factors which might be associated with risk of early reoperation among patients who underwent aSDH surgery.M a t e r i a l s  a n d  m e t h o d s: We retrospectively analysed 328 patients treated due to aSDH. From their medical records we obtained detailed medical history. Early reoperation was defi ned as reoperation during the same hospital stay. To determine the potential predictors of early reoperation we used univari-ate and multivariate logistic regression analyses.R e s u l t s: A total of 20 (6.09%) patients required early reoperation. Th ose patients had signifi cantly higher International Normalized Ratio (INR) upon admission (1.96 ± 2.55 vs. 1.26 ± 0.50; p <0.01) and signifi cantly higher Prothrombin Time (PT) upon admission (21.84 ± 27.10 vs. 13.40 ± 3.45; p <0.01). In  multivariate logistic regression analysis aft er adjustment for all possible confounders higher INR (OR: 1.762; 95% CI: 1.017–22.840; p = 0.045) remained independently associated with higher risk of early reoperation among patients with aSDH.54 Borys Kwinta, Roger M. Krzyżewski, et al.C o n c l u s i o n s: Patients with higher INR and PT upon admission are at higher risk of early reoperation. Higher INR is independently associated with higher risk of early reoperation among patients with aSDH.Key words: acute subdural hematoma, reoperation, prothrombin time, traumatic brain injury.IntroductionTh ere are many studies presenting treatment results of Traumatic Brain Injury (TBI) caused by acute Subdural Hematoma (aSDH) and discussing infl uencing factors  [1]. Most of the authors emphasise the initial neurological status and the severity of the trauma as one of the most important prognostic factors [2, 3].Nevertheless the curse of surgical treatment has also significant impact on outcome after TBI [4]. Complication in term of recurrent hematoma leading to reoperation impair substantially the treatment results. In cranial neurosurgery the reoperation ratio due to haemorrhage varies between 0.77–6.9% [5]. In the studies concerning TBI treatment reoperations due to secondary clot reaccumulation ranged from 6.9 up to 9.1% [5, 6].In our study we decided to investigate factors infl uencing the early recurrence of the acute subdural hematoma which required another surgery during the same hospital stay.Patients and methodsWe retrospectively analyzed 328 patients hospitalized between January 2013 and December 2016 with CT-confi rmed aSDH who underwent surgical procedures. Upon admission patients were assessed using Glasgow Coma Scale (GCS). From their medical record we obtained detailed medical history which included previous diseases and current medications. We also obtained blood test results taken within 24  hours before the surgery together with details concerning operation such as its date, type and side and whether the doctor who performed the surgery and their assistant were specialists in neurosurgery. Coagulation paramteres such as Prothrombin Time (PT) also shown by International Normalized Ration (INR) and Activated Partial Th rombpolsatin Time (APTT) were taken into consideration. Type of craniotomy was defi ned by anatomical localization and surface area. Surface area was defi ned by number of convexity bones that were contained in craniotomy. Early reoperation was defi ned as reoperation that occurred during the same hospitalization due to a  primary neurosurgical condition. Study protocol was approved by local bioethical committee. Prolonged international normalized ratio is independently associated… 55We used χ2 test to test proportion. T-test and Mann-Whitney U test were used as appropriate for continuous variables. To determine the potential predictors of reoperation aft er aSDH surgery we used univariate and multivariate logistic regression analysis. P-values <0.05 were considered to be statistically signifi cant. Th reshold of p-value <0.1 was used to qualify data to multivariate logistic regression analysis. Forward logistic regression analysis was followed by backwards logistic regression analysis. To perform all statistical analysis we used STATISTICA v. 10 for Windows (Statsoft , Poland).ResultsOur study group consisted of 328 patients and 30% of them were females. Mean age of study group was 70.22 ± 15.61 years and mean GCS upon admission was 13.14 ± 3.62. A total of 20 (6.10%) patients manifested with recurrent SDH needing reoperation. Th ose patients had signifi cantyl longer PT (21.84 ± 27.10 s vs. 13.40 ± 3.45 s, p <0.01) and INR (1.96 ± 2.55 vs. 1.25 ± 0.50, p <0.01). Details concerning medical history, current medications and blood test results are presented in Table 1. Detalis concerning surgery are prested in Table 2. Aft er adjustment of all possible confounders, prolonged INR (OR: 1.76, 95% CI: 1.007–3.081, p = 0.045) remained independently associated with higher risk of early unplanned reoperation.DiscussionIn this retropspective study we established the frequency of recurrent aSDH requring reoperation at 6.09%. Moreover we found that prolonged INR is independantly associated with risk of aSDH recurrence. In our institution patients with INR >1.5 are receiving Fresh Frozen Plasma (FFP) prior to surgery. In case of neurological status worsening patients receiving FFP during emergency surgery.Problem of recurrent aSDH is rarely addressed in the literature. Th is is one of the very few studies focusing on prediction of aSDH recurrence. Due to the best of our knowledge there are no studies showing relation between coagulation markers and risk of recurrent aSDH requiring reoperation. Wafaisade et al. found that coagulopathy was present in 22.7% of patients with aSDH [7]. It was associated with a  number of clinical factors such as admitory Glasgow Coma Scale, Injury Severity Score and Abbreviated Injury Scale. Th is study has not examined relation of coagulopathy to recurrence of aSDH or treatment outcome [7]. Lemcke et al. found that prolonged INR is signifi cantly associated with risk of poor treatment outcome aft er aSDH [8]. Presence of coagulopathy have been described with increased risk of death in patients with aSDH [9]. Unfortunately most 56 Borys Kwinta, Roger M. Krzyżewski, et al.of the studies examining couagulopathy in aSDH are limited to patients admitted to Intensive Care Unit [7, 9].In conclusion abnormal INR carries high risk of recurrent aSDH requiring reoperation. Normalization of the INR prior to surgery is necessary to avoid recurrent aSDH.AcknowledgmentsNone.Confl icts of interest disclosureNo declared.References1. Matsushima K., Inaba K., Siboni S., et al.: Emergent operation for isolated severe traumatic brain injury: Does time matter? J Trauma Acute Care Surg. 2015; 79: 838–842.2. Leitgeb J., Mauritz W., Brazinova A., et al.: Outcome aft er severe brain trauma due to acute subdural hematoma. J Neurosurg. 2012; 117: 324–333.3. Al-Muft i F., Mayer S.A.: Neurocritical Care of Acute Subdural Hemorrhage. NeurosurgClin N Am. 2017; 28: 267–278.4. Chen S.H., Chen Y., Fang W.K., Huang D.W., Huang K.C., Tseng S.H.: Comparison of craniotomy and decompressive craniectomy in severely head-injured patients with acute subdural hematoma. J Trauma. 2011; 71: 1632–1636.5. Desai V.R., Grossman R., Sparrow H.: Incidence of Intracranial Hemorrhage After a  Cranial Operation. Cureus. 2016; 20, 8: e616.6. Bullock R., Hanemann C.O., Murray L., Teasdale G.M.: Recurrent hematomas following craniotomy for traumatic intracranial mass. J Neurosurg. 1990; 72: 9–14.7. Wafaisade A., Lefering R., Tjardes T., et al.: Trauma Registry of DGU. Acute coagulopathy in isolated blunt traumatic brain injury. Neurocrit Care. 2010; 12: 211–219.8. Lemcke J., Al-Zain F., von der Brelie C., Ebenau M., Meier U.: Th e infl uence of coagulopathy on outcome aft er traumatic subdural hematoma: a retrospective single-center analysis of 319 patients. Blood Coagul Fibrinolysis. 2014; 25: 353–359.9. Bershad E.M., Farhadi S., Suri M.F., et al.: Coagulopathy and inhospital deaths in patients with acute subdural hematoma. J Neurosurg. 2008; 109: 664–669.

Prolonged international normalized ratio is independently associated with recurrence of acute subdural hematoma needing reoperation

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Prolonged international normalized ratio is independently associated with recurrence of acute subdural hematoma needing reoperation

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