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Open Access

Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma

Matheus Rodrigues de Souza, Caroline Ferreira Fagundes, Davi Jorge Fontoura Solla, Gustavo Carlos Lucena da Silva, Rafaela Borin Barreto, Manoel Jacobsen Teixeira, Robson Luis Oliveira de Amorim, Angelos G Kolias, Daniel Godoy, Wellingson Silva Paiva
DOI: 10.1136/tsaco-2021-000707 Published 21 May 2021
Matheus Rodrigues de Souza
1Department of Medicine, Mato Grosso State University, Caceres, Mato Grosso, Brazil
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Caroline Ferreira Fagundes
1Department of Medicine, Mato Grosso State University, Caceres, Mato Grosso, Brazil
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Davi Jorge Fontoura Solla
2Department of Neurology, University of São Paulo, São Paulo, Brazil
3Department of Neurology, University of Cambridge, Cambridge, UK
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Gustavo Carlos Lucena da Silva
1Department of Medicine, Mato Grosso State University, Caceres, Mato Grosso, Brazil
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Rafaela Borin Barreto
1Department of Medicine, Mato Grosso State University, Caceres, Mato Grosso, Brazil
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Manoel Jacobsen Teixeira
2Department of Neurology, University of São Paulo, São Paulo, Brazil
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Robson Luis Oliveira de Amorim
2Department of Neurology, University of São Paulo, São Paulo, Brazil
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Angelos G Kolias
4Department of Clinical Neuroscience - Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
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Daniel Godoy
5Intensive Care Unit, San Juan Bautista Hospital, San Fernando del Valle de Catamarca, Argentina
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Wellingson Silva Paiva
2Department of Neurology, University of São Paulo, São Paulo, Brazil
3Department of Neurology, University of Cambridge, Cambridge, UK
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  • Figure 1
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    Figure 1

    The thickness of the acute subdural hematoma (red arrow) was measured on a CT scan as the largest distance between the cortex and the internal table: midline, orange line; midline shift, orange arrow. HT, hematoma thickness; MLS, midline shift.

  • Figure 2
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    Figure 2

    ROC curves for the multivariate model including age, Glasgow Coma Scale and categorical Zumkeller index (model 1), Helsinki CT score (model 2), Rotterdam CT score (model 3). AUC, area under the ROC curve; ROC, receiver operating characteristic.

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    Figure 3

    Survival function for each category of Zumkeller index for 14-day mortality outcome.

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  • Table 1

    Clinical and radiological characteristics according to ZI category

    ZI <0ZI 0–3 mmZI >3P value
    Age*49.8 (19.6)36.7 (12.9)49.7 (15.6)0.061
    GCS†6 (3–10)5 (3–11)3 (3–4)0.031
    Pupil reactivity0.257
     Both pupils62.2 (56)76.9 (10)36.4 (4)
     One pupil17.8 (16)15.4 (2)36.4 (4)
     Neither pupil11.1 (2)7.7 (1)27.3 (3)
    TBI class0.874
     Mild15.6 (14)7.7 (1)1 (9.1)
     Moderate14.4 (13)15.4 (2)1 (9.1)
     Severe64.4 (58)53.8 (7)81.1 (9)
    MLS, mm*6.7 (5.45)14.1 (7.8)16.7 (5.1)<0.001
    HT, mm*14.1 (7.12)13.1 (7.9)10.9 (7.7)0.368
    Rotterdam score†5 (3–6)5 (4.5–6)6 (6–6)0.002
    Helsinki score†6 (4–9)9 (5–10)11 (9–14)0.001
    Other injuries
     Fractures42.2 (38)46.2 (6)63.6 (7)0.401
     tSAH5.6 (5)100 (13)100 (11)0.498
     IVH21.1 (19)7.7 (1)45.5 (5)0.077
     ICH50 (45)46.2 (6)90.9 (10)0.032
    DC81.1 (73)92.3 (12)90.9 (10)0.466
    Outcome
     14-day mortality36.7 (33)30.8 (4)81.1 (9)0.012
     In-hospital mortality48.9 (44)46.2 (6)90.9 (10)0.027
    • *Mean (SD).

    • †Median (IQR); all other variables: % (number).

    • DC, decompressive craniectomy; GCS, Glasgow Coma Scale; HT, hematoma thickness; ICH, intracerebral hematoma; IVH, intraventricular hemorrhage; MLS, midline shift; TBI, traumatic brain injury; tSAH, traumatic subarachnoid hemorrhage; ZI, Zumkeller index.

  • Table 2

    Univariate logistic and Cox regression values in predicting 14-day mortality outcome according to Zumkeller index categories

    Zumkeller indexLogistic regressionCox regression
    OR95% CIP valueHR95% CIP value
    <0.00*––0.033––0.014
    0.01–30.7680.219 to 2.6890.6790.8540.303 to 2.4120.766
    >37.7731.583 to 38.1550.0122.9241.388 to 6.1600.005
    • *Zumkeller index values <0.00 were included as a reference category in the model.

Supplementary Materials

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  • Supplementary data

    [tsaco-2021-000707supp001.pdf]

Additional Files

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  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    • Data supplement 1
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Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma
Matheus Rodrigues de Souza, Caroline Ferreira Fagundes, Davi Jorge Fontoura Solla, Gustavo Carlos Lucena da Silva, Rafaela Borin Barreto, Manoel Jacobsen Teixeira, Robson Luis Oliveira de Amorim, Angelos G Kolias, Daniel Godoy, Wellingson Silva Paiva
Trauma Surg Acute Care Open May 2021, 6 (1) e000707; DOI: 10.1136/tsaco-2021-000707

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Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma
Matheus Rodrigues de Souza, Caroline Ferreira Fagundes, Davi Jorge Fontoura Solla, Gustavo Carlos Lucena da Silva, Rafaela Borin Barreto, Manoel Jacobsen Teixeira, Robson Luis Oliveira de Amorim, Angelos G Kolias, Daniel Godoy, Wellingson Silva Paiva
Trauma Surg Acute Care Open May 2021, 6 (1) e000707; DOI: 10.1136/tsaco-2021-000707
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Mismatch between midline shift and hematoma thickness as a prognostic factor of mortality in patients sustaining acute subdural hematoma
Matheus Rodrigues de Souza, Caroline Ferreira Fagundes, Davi Jorge Fontoura Solla, Gustavo Carlos Lucena da Silva, Rafaela Borin Barreto, Manoel Jacobsen Teixeira, Robson Luis Oliveira de Amorim, Angelos G Kolias, Daniel Godoy, Wellingson Silva Paiva
Trauma Surgery & Acute Care Open May 2021, 6 (1) e000707; DOI: 10.1136/tsaco-2021-000707
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