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Obesity Paradox and Surgical Evacuation for Chronic Subdural Hematoma
David R Hallan1, Zachary Freedman1, Elias Rizk1
1Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA.
Insights
Obesity in patients undergoing surgery for chronic subdural hematoma (cSDH) is linked to better survival rates. However, obese patients experienced higher risks of deep vein thrombosis (DVT) and pulmonary embolism (PE).
Area of Science:
- Neurosurgery
- Epidemiology
- Clinical Outcomes
Background:
- Chronic subdural hematoma (cSDH) recurrence has known risk factors, with obesity being a potential contributor.
- Obesity paradoxically offers survival benefits in various conditions like ischemic stroke and post-PCI.
- The impact of obesity on cSDH patient mortality remains unclear, necessitating further investigation.
Purpose of the Study:
- To investigate whether obesity confers a mortality benefit in patients with cSDH undergoing surgical drainage.
- To analyze secondary outcomes including seizures, thromboembolic events, and need for interventions.
Main Methods:
- Retrospective analysis of a multi-institutional database (TriNetX) comparing obese and non-obese cSDH patients.
- Propensity score matching was employed to control for confounding variables.
- Kaplan-Meier survival analysis and hazard ratio calculations assessed mortality and secondary endpoints.
Main Results:
- After propensity score matching, obese patients (n=1,746) demonstrated significantly improved survival rates at 30 days, 90 days, 365 days, and 5 years compared to non-obese patients (n=1,746) (p < 0.0001).
- Obese patients had a lower risk difference, relative risk, and odds ratio for mortality.
- While seizures and other complications were similar, obese patients showed increased rates of pulmonary embolism (PE) and deep vein thrombosis (DVT).
Conclusions:
- Obesity is associated with reduced mortality in patients undergoing surgical evacuation for cSDH.
- Despite the survival benefit, obese patients face elevated risks for DVT and PE, requiring careful perioperative management.
Background:
Chronic subdural hematoma (cSDH) has a number of risk factors for recurrence, and some studies suggest obesity is one of them. Yet obesity has been shown to have a positive survival benefit in many diseases such as ischemic stroke, chronic obstructive pulmonary disease, percutaneous coronary intervention, and mechanical thrombectomy. Therefore, we sought to determine if obesity provided a mortality benefit in patients with cSDH undergoing burr hole drainage or craniotomy.
Methods:
We performed a retrospective database analysis using a multi-institutional (TriNetX) database looking at obese versus non-obese patients with cSDH undergoing surgical drainage. Our primary endpoint was mortality. Secondary endpoints included seizure, pulmonary embolism (PE), myocardial infarction (MI), cerebral infarction, deep vein thrombosis (DVT), tracheostomy, and percutaneous endoscopic gastrostomy (PEG). These were looked at to obtain a better idea of prognosis. Cohorts were propensity score-matched for confounders, using the greedy-nearest neighbor algorithm with a caliper of 0.1 pooled standard deviations. Kaplan-Meier survival curves were also developed, and hazard ratios were calculated. Chi-square analysis was performed on categorical variables.
Results:
A total of 1,849 patients were identified as obese with a drainage procedure, while 12,371 were identified as non-obese. Some 1,746 patients remained in each group after propensity score matching. Thirty-day survival rates were 88.08% in the obese vs. 83.82% in the non-obese cohorts, 90-day survival 85.15% vs. 79.35%, 365-day survival at 80.89% vs. 71.90%, and five-year survival at 64.75% vs. 54.84% (p < 0.0001). The risk difference was -8.02% (95% confidence interval, Cl -11.02, -5.021%); relative risk, RR 0.757, 95% Cl (0.67, 0.841); odds ratio, OR 0.676 (0.583, 0.783); p < 0.0001). Seizures, ventilator dependence, MI, cerebral infarction, tracheostomy, and PEG rates were all non-significant. Obese patients had a higher rate of PE (7.90% vs. 4.47%, p < 0.0001) and DVTs (12.37% vs. 10.02%, p = 0.0278).
Conclusions:
Obesity in patients with cSDH undergoing surgical evacuation is associated with decreased mortality but higher rates of DVT and PE.
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