Clinical study
The profile of blunt traumatic supratentorial cranial bleed types

https://doi.org/10.1016/j.jocn.2018.10.149Get rights and content

Highlights

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    There are clinically significant differences in distributions, clinical courses and outcomes of different subtypes of traumatic infratentorial bleeds.

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    Subdural hemorrhage is the most common traumatic supratentorial bleed.

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    The most common mechanism of injury was from falls.

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    The majority of traumatic infratentorial bleeds present as mild severity traumatic brain injury and are managed non-operatively.

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    Subdural and intraventricular supratentorial hemorrhages carry the highest risk of mortality.

Abstract

The characteristics of blunt traumatic supratentorial cranial bleed (STCB) types have not been directly compared. The National Trauma Data Bank (NTDB) 2014 was queried for adults with an isolated single STCB n = 57,278. Patients were grouped by STCB categories: subdural (SDH), subarachnoid (SAH), epidural (EDH), intraparenchymal (IPH), and intraventricular hemorrhage (IVH). Frequency, demographics, clinical characteristics, procedures, and outcomes were compared among groups. SDH was the most common STCB (53%) and occurred mostly in elderly patients after a fall (78%), 30% underwent craniotomy and their mortality was 7%. SAH occurred in 32% of patients and carried the lowest mortality (3%). SAH were least likely to have a severe brain injury (7%), and had the lowest Injury Severity Score (ISS, median 8) and complication rate (1%), as well as the shortest hospital length of stay (HLOS, 4.6 ± 6.4 days). EDH was uncommon (2%), occurred in younger patients (median 35 years), and had the highest percentage of traffic related injuries (28%). While EDH patients presented with the poorest neurological status (16% Glasgow Coma Scale ≤ 8, ISS median 18) and were operated on more than any other STCB type (51%), their mortality was lower (4%) and they had the highest discharge to home rate (71%). IVH was the least common (2%), but most lethal (9%) STCB type. These patients had the highest HLOS and intensive care unit LOS, and the lowest craniotomy rate (21%). STCB types have different clinical course, and outcomes. Understanding these differences can be useful in managing patients with STB.

Introduction

Each year, approximately 1.6 million people experience a Traumatic Brain Injury (TBI), the most common cause of disability and mortality among trauma patients [1], [2]. The leading causes of TBI are falls, traffic accidents, and assaults [3]. A common complication of TBI is an intracranial bleed (ICB), which can be classified into specific categories based upon injury location: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), intraparenchymal hemorrhage (IPH), and intraventricular hemorrhage (IVH).

The presence of an intracranial bleed (ICB) is attributed to poorer outcomes, including higher rates of long-term disabilities and mortality, than a TBI without an ICB [4], [5]. Other predictive factors for unfavorable outcomes from a TBI include age [6], [7], Glasgow Coma Scale (GCS) [8], [9], [10], coagulopathy [1], elevated intracranial pressure [11], and midline shift [7], [11]. Although previous studies have determined that ICB attributed to TBI may have prognostic importance [6], [11], [12], [13], [14], an examination of the overall distribution and profile of traumatic supratentorial ICB (STCB) in a large population has not been reported. Specifically, previous studies did not conduct a broad analysis and direct comparison of the various STCB types and their implications for patient care.

Deep understanding of supratentorial cranial bleeds’ clinical outcomes, such as discharge disposition and mortality, can contribute towards better understanding and potentially predicting long-term outcomes in TBI patients. We used a large cohort derived from the National Trauma Data Bank (NTDB) data set to distinguish among different types of supratentorial bleeds through describing their clinical profiles, frequencies, distribution, management and clinical outcomes.

Section snippets

Patients and methods

The methods presented in this study were also utilized in a concurrent study we submitted which investigated the profile of blunt traumatic supratentorial cranial bleed types (Ng et al., 2018).

Data abstraction

The study was approved by the Tufts Medical Center Institutional Review Board. The American College of Surgeons (ACS) granted access to the data from the NTDB 2014. The NTDB remains the full and exclusive copyrighted property of the ACS. All patients with a single, isolated, blunt trauma-related,

Frequencies and distribution

A total of 57,278 ICB were identified. Detailed results are provided in Table 1. Of note, SDH was the most common ICB (53%) followed by SAH (32%) whereas IVH (2%) and EDH (2%) were the least common.

Demographics, pre-existing comorbidities and clinical characteristics

These parameters are presented in detail in Table 2.

Several observations should be emphasized. First, SDH patients were older (median 72 years) and sustained more falls than any of the other ICB groups (78%). Second, patients with SAH were slightly younger (median 63 years) and presented with the

Discussion

This large study has illuminated trends that define patient characteristics, clinical presentation, hospital course and outcome for each of the traumatic supratentorial cranial bleed subtypes.

SDH is the most frequently occurring ICB, and tends to occur in older patients after falls. Although these patients mostly present with mild TBI (GCS ≥13), they have high rates of comorbidities, complications and mortality. Brain atrophy, which is more common in elderly, creates a potential space for an

Conclusions

Our study described the largest cohort of patients with traumatic isolated supratentorial intracranial bleeds, which included patient characteristics, frequency, clinical course, and outcomes associated with each STCB subtype.

Funding sources

This manuscript was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, Award UL1TR001064.

Declarations of interest

There are no conflicts of interest to declare.

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