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Failure to improve-identifying risk factors for poor functional recovery following chronic subdural hematoma surgery
Rahul Raj1, Pihla Tommiska1, Teemu Luoto2
1Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki Uusimaa, Finland.
Insights
Predictors of poor functional outcomes after chronic subdural hematoma (CSDH) surgery were identified. Dementia significantly predicted failure to improve, highlighting the need for better patient risk stratification and alternative treatments for CSDH.
Area of Science:
- Neurosurgery
- Geriatrics
- Clinical Outcomes Research
Background:
- Chronic subdural hematoma (CSDH) is prevalent in frail elderly individuals.
- Surgical outcomes for CSDH are generally favorable, but a notable percentage of patients do not experience functional improvement.
- Identifying predictors of surgical failure is crucial for optimizing patient care.
Purpose of the Study:
- To identify predictors of failure to improve functional outcomes following surgical treatment for CSDH.
- To analyze factors associated with persistent or worsened functional status six months post-surgery.
Main Methods:
- Post-hoc analysis of the nationwide FINISH trial (n=589) involving adult patients with symptomatic CSDH.
- Functional outcome assessed using the modified Rankin Scale (mRS) at six months post-surgery.
- Multivariable logistic regression utilized to determine factors predicting failure to improve (unchanged or worsened mRS).
Main Results:
- Twenty percent (115/568) of patients demonstrated no functional improvement at six months.
- Pre-existing dementia (OR 2.62), walker use (OR 3.19), smaller hematoma width (OR 0.96), and lesser midline shift (OR 0.91) predicted failure to improve.
- Despite this, 88% had stable/improved residence status, and 85% maintained/improved mobility.
Conclusions:
- A significant proportion of surgically treated CSDH patients do not achieve functional improvement.
- Dementia is a key predictor of poor surgical outcomes in CSDH.
- Further research is needed to identify high-risk patients and explore alternative treatment strategies to avoid overtreatment.
Background:
Chronic subdural hematoma (CSDH) is a common condition among older people living with frailty. Outcome after surgery is generally good, but there is a significant proportion of patients who do not benefit from surgery. This study aimed to identify predictors of failure to improve functional outcomes after CSDH surgery.
Methods:
This is a post-hoc analysis of the nationwide FINISH trial, which enrolled 589 adult patients undergoing burr-hole drainage for symptomatic CSDH during 2020-22. Functional outcome was assessed using the modified Rankin Scale (mRS). Failure to improve was defined as unchanged or worsened mRS at 6 months compared to preoperative mRS. Multivariable logistic regression was used to identify factors associated with failure to improve.
Results:
Of the 568 patients with available mRS data at 6 months, 20% (n = 115) showed no improvement in mRS between the preoperative and 6-month period. Factors associated with failure to improve included pre-existing dementia (OR 2.62, 95% CI 1.21-5.66), use of a walker (OR 3.19, 95% CI 1.64-6.23), smaller hematoma width (OR 0.96, 95% CI 0.93-0.99), and lesser midline shift (OR 0.91, 95% CI 0.86-0.97). Despite this, 88% of patients had stable or improved residence status, and 85% maintained or improved mobility.
Conclusion:
A substantial proportion of surgically treated CSDH patients do not improve in functional status. Dementia was a significant predictor of poor outcomes. Future research should focus to better identify patients at risk of poor outcomes in order to avoid overtreatment and explore possible alternative treatment strategies.
