IMPORTANCE OF A RELIABLE ADMISSION GLASGOW COMA SCALE SCORE FOR DETERMINING THE NEED FOR EVACUATION OR POSTTRAUMATIC SUBDURAL HEMATOMAS - APROSPECTIVE-STUDY OF 65 PATIENTS

Background: Patients who have an acute subdural hematoma with a thickn ess of 10 mm or less and with a shift of the midline structures of 5 m m or less often can be treated nonoperatively. We wonder whether the k nowledge of the clinical status both in the prehospital determination and on admission to the neurosurgical center can predict the bleed for evacuation of subdural hematomas as well as the computed tomographic (CT) parameters. Methods: From January 1, 1994, to May 31, 1996, 65 co matose patients harboring an acute subdural hematoma of 5 mm or more a nd not brain dead were admitted to our intensive care unit, Of the 65 patients, 15 patients were initially managed conservatively according to a protocol based on clinical, CT, and intracranial pressure paramet ers. During the study period, the use of long-lasting paralytic agents has been eliminated to allow detection of clinical deterioration in t he Glasgow Coma Scale (GCS) score from the prehospital determination t o the hospital admission assessment. Results: Of the 15 patients initi ally managed conservatively, two were subsequently operated on because of evolving parenchymal hematomas. When comparing demographic, clinic al, and CT parameters between the surgical group of patients and the p atients initially conservatively treated, hematoma thickness (mean, 17 .1 mm vs. 7.5 mm, p < 0.0001) and shift of the midline structures (mea n, 12.8 mm vs. 4.7 mm, p < 0.008) were predictive of the need for surg ery. A statistically significant change in the GCS score between preho spital determination and admission assessment was shown in the surgica l group of patients (mean GCS score, 8.4 vs. 6.7, p < 0.01), and it wa s not present (mean GCS score, 7.3 vs, 7.2) in the patients initially conservatively treated, Functional outcomes were present in 23 cases ( 35.4%); functional outcomes in the initially conservatively treated pa tients were reached by 10 patients (66.7%). Conclusions: Nonoperative management for selected cases of acute subdural hematomas is at least as safe as surgical management. GCS scoring at the scene and in the em ergency room combined with early and subsequent CT scanning is crucial where making the decision for nonoperative management. This strategy requires that administration of long-lasting sedatives and paralytic m edications be avoided before the patient arrives at the neurosurgical center.