ABSTRACT

Introduction: A common pathology in the Neurosurgery Service is chronic subdural hematoma (CSDH), affecting elderlymalepatients.Itisanaccumulationofbloodthatislocatedinthesubduralspacethatcanoccur spontaneously or be the result of a head injury or other pathologies such as high blood pressure (HBP), type 2 diabetes mellitus (DM2), alcoholism, or external factors such as head trauma (CT) and consumption of platelet antiaggregants. Objective: To determine how predisposing factors are associated with CSDH in adults and older adults treated at the Neurosurgery and Geriatrics Service at the María Auxiliadora Hospital (HMA) in 2016-2020. Methods:An analytical, observational, retrospective study of cases and controls was carried out through data collection from medical records. Results: Association was found with age 60 to 96 years (adjusted OR = 2,52; 95% CI: 1,43 - 4,80), male gender (adjusted OR = 4,10; 95% CI: 2,30 - 7,60), alcohol consumption (adjusted OR = 3,06; 95% CI: 1,06– 8,83), hypertension (adjusted OR = 2,51; 95% CI: 1,16– 5,43), DM2 ( Adjusted OR = 2,49; 95% CI: 1,03–6,01) and CT (adjusted OR = 3,35; 95% CI: 1,87– 6,03). Conclusions: The sociodemographic factors age and sex are associated with HSDC. Alcohol consumption, hypertension, DM2, and history of TC are associated with HSDC.

Keywords: Predisposing factors; Chronic subdural hematoma; Adult; Elderly.(Source: MeSH NLM).

RESUMEN

Introducción: Una patología común en el servicio de neurocirugía es el hematoma subdural crónico que afecta principalmente a pacientes varones de edad avanzada. Es una acumulación de sangre que se localizan el espacio subdural que puede ocurrir espontáneamente o ser el resultado de una lesión en la cabeza u otras patologías como hipertensión arterial, diabetes mellitus tipo 2, alcoholismo o factores externos como un trauma craneal y consumo de antiagregantes plaquetarios. Objetivos: Determinar de qué forma los factores predisponentes se asocian a hematoma subdural crónico en adultos y adultos mayores atendidos en el servicio de neurocirugía y geriatría en el hospital María Auxiliadora en el periodo 2016 – 2020 Métodos: Se realizó un estudio analítico, observacional, retrospectivo de casos y controles a través de recolección de datos de las historias clínicas. Resultados: Se encontró asociación con la edad 60 a 96 años (OR ajustado = 2,52; IC95%: 1,43 – 4,80), sexo masculino (OR ajustado = 4,10; IC95%: 2,30 – 7,60), consumo de alcohol (OR ajustado = 3.06; IC95%: 1,06– 8,83), Hipertensión arterial (OR ajustado = 2,51; IC95%: 1,16– 5,43), Diabetes mellitus tipo 2 (OR ajustado = 2,49; IC95%: 1,03– 6,01) y trauma craneal (OR ajustado = 3,35; IC95%: 1,87– 6,03). Conclusiones: Los factores sociodemográficos edad y sexo están asociados al hematoma subdural crónico. El consumo de alcohol, Hipertensión arterial, Diabetes mellitus tipo 2 y antecedente de trauma craneal están asociados a hematoma subdural crónico.

Palabras Clave: Factores predisponentes; Hematoma subdural crónico; Adulto; Adulto mayor. (fuente: DeCS BIREME).

INTRODUCTION

HSDC is one of the most common clinical conditions in neurosurgery. ⁽¹⁾ It mainly affects elderly patients, which is more prevalent. In addition, mortality from this disease is high and significantly reduces life expectancy ⁽²⁾ .

DCHS is defined as an accumulation of blood, with traces of its degradation, located in the subdural space. ⁽³⁾ it can occur spontaneously or be the result of a head injury or other pathologies. ⁽⁴⁾ Clinically it can present itself in various ways, it is recognized as the “great simulator” of various neurological diseases. Trepanation is currently a conventional neurosurgical procedure for the treatment of CSDH.⁽⁵⁾ According to data from the World Health Organization (WHO), the incidence may double in people over 65 years of age between 2010 and 2050 More frequently in males, with a ratio of 3:1 in the age group.

Intrinsic factors: age, walking and mobility disorders, balance problems, poor health, emotional disorders and effects of medicines. Extrinsic factors such as: unfamiliar environments, use of inappropriate footwear, and poor lighting ⁽⁶⁾ The overall incidence of HSDC was reported to range from 1.72 to 20.6/100,000 persons per year, with a significantly higher incidence in the elders. A trend towards an increase in incidence has been observed, which can be attributed to the aging of the general population as a result of an increase in life expectancy. ⁽⁷⁾

According to data from the Instituto Nacional de Estadística e Informática (INEI) of Peru, the number of older adults in 2020 increased to 4.1 million.⁽³⁾

The mean age of patients with HSDC has been reported as 60.4 years in India, 64.3 years in Brazil, 68.9 years in Switzerland, 69.0 years in Korea, 69.3 years in Canada, 71 .4 years in Germany, and 72.7 years in Spain. Analysis according to patient age (in decades) showed that 60-year-old patients were the most common in Brazil ⁽⁸⁾

The elderly population is increasing and there are several risk factors, it is necessary to identify each of them and reduce the prevalence of this diagnosis. In the elderly, falls, traffic accidents, due to advanced age, are more frequent, they have different alterations such as gait, vision, their state of consciousness, it is a vulnerable population. The evaluation of these risk factors is very important for future research. Thus, cases have also been seen in adults, for which we want to identify and associate predisposing factors.

METHODS

Type and design

Retrospective, observational, analytical case-control study, based on HCs from 2016 to 2020.

Population and sample

Patients aged between 33 and 96 years, who were treated at the HMA, in addition to meeting the inclusion and exclusion criteria. Information was collected from the HCs of patients with and without HSDC in the neurosurgery and geriatric services during the period 2016 - 2020. With a sample size of 220 HCs in accordance with our inclusion criteria. The sampling was non-probabilistic.

Statistic analysis

The statistical software SPSS version 27 was used. A data le was rst created in Microsoft Excel, which was then exported to SPSS. The data entry was veried in such a way that no errors or omissions were made during the entry of the information. Qualitative variables were analyzed by creating frequency tables and calculating percentages.Forthebivariateanalysis,weuseda double-entry table or contingency tables for the bivariate analysis to analyze two qualitative variables, calculating frequencies and percentages.The crude Odds Ratio (OR) was used to verify the association between variables, accompanied by their condence intervals. Finally, the binary logistic regression model was used to identify the associated risk factors, calculating adjusted ORs accompanied by their condence intervals. All tests of statistical signicance were tested at the 0,05 level.

Ethical aspects

The present study is based on the analysis of information extracted from the HCs of the HMA in the period 2016-2020. With approved permits. In addition, the research project has been evaluated and approved by the Ethics Committee of the Ricardo Palma University and the Institutional Ethics Committee of the HMA.

RESULTS

In this research work, 218 patients from the neurosurgery and geriatrics service were analyzed, of which 109 corresponded to patients with CSDH and 109 controls. The average age of the patients was 64 years, while in the cases it was 68 and the controls 60 years old.

With respect to table 1, it is observed that for the year 2016 information was collected from 15.1% (33) HCs. In 2017 there were 17.9% (39) HCs. In 2018, 20.6% (45) were collected. In 2019, 22% (48) were collected and in 2020, 24.3% (53) CHs were collected.

table 2 shows that 63.8% (139) of the patients presented an age between 60 and 96 years; 59.2% (129) were male.

Regarding the clinical factors (table 3), 8.7% (19) of the patients were alcohol consumers, 16.1% (35) had hypertension, 11.9% (26) had DM2 and 35.3% (77) had head trauma.

Regarding sociodemographic factors, they showed a statistically significant association with age (p value = 0.001) and sex (p= 0.000) as a predisposing factor for HSDC.

According to the clinical factors analyzed (table 5), all presented a statistically significant association with HSDC. Alcohol consumption (p=0.031), hypertension (p=0.016), MD2 (p=0.037) and finally head trauma (p=0.000) are associated with SHDC.

The sociodemographic variables analyzed resulted in a statistically significant association with HSDC. Patients aged between 60 and 96 years have a 2,52 times greater risk of CSDH compared to patients aged between 34 and 59 years (adjusted OR = 2,52; 95% CI: 1,43 - 4,80), as well as male patients presented a 4,10-fold higher risk of CSDH compared to female patients (adjusted OR = 4,10; 95% CI: 2,30 – 7,60).

Finally,the clinical variables analyzed presented a statistically signicant association.The variables alcohol consumption,hypertension,DM2 and TC presented a higher risk of CSDH, with 3,06 (adjusted OR = 3,06; 95% CI: 1,06 –8,83), 2,51(adjusted OR = 2,51;Ci95%: 1,16–5,43) and 2,49 (adjusted OR = 2,49; CI95%: 1,03–6,01) respectively. Lastly, TC represents a 3,35-fold greater predisposing risk for developing CSDH (adjusted OR = 3,35; 95% CI: 1,87–6,03).

DISCUSSION

In this study, a statistically signicant association of HSDC with the sociodemographic characteristics analyzed was found. Being between 60 and 96 years old had a higher risk of CAH compared to patients aged 34 to 59 years; this is consistent with studies such as the one by Toi et al.⁽⁹⁾who shows in his study that the most frequent age range is the ninth decade of life, Gallardo et al.⁽¹⁰⁾ highlights patients older than 60 years (95%), García-González et al.⁽¹¹⁾report that the incidence of patients was higher between 60 and 80 years; similarly in the study by Kostic et al.⁽¹²⁾ the mean age in the HSDC group is 74,5 years ± 8,2 years.

In the work of Vanegas et al.⁽¹³⁾ patients older than 65 years predominate, in the study by Mendoza et al.⁽¹⁴⁾ patients older than 60 years (70,7%), while Julcamoro⁽¹⁵⁾ reports a mean age of 71years. According to the literature, HSDC is more common in older adults due to the normal shrinkage of the brain that occurs with age; this shrink age stretches and weakens the emissary veins that are more likely to rupture in older adults, even after a minor CT scan. Rodríguez-Venegas et al.⁽¹⁶⁾ report a lower age range, from 19 to 33 years.

Being male represented a higher risk of developing HSDC. Garcia-González et al.⁽¹¹⁾ finds a male-female ratio (2)of 4:1 and Castro-Rodríguez et al.⁽²⁾ a male-to-female ratio of 1:1.1⁽²⁾.

Vanegas et al.⁽¹³⁾ , Gelabert-González et al.⁽¹⁸⁾ and Sikahall Meneses et al.report more cases of HSDC in males. The same predominance of the male sex is found by Santos et al.⁽¹⁹⁾ (70,4%), Motoie et al.⁽²⁰⁾ (80,2%), Jimenez et al.⁽²¹⁾(75%), Rule et al.⁽²²⁾(81,5%) and Mendoza (66,3%)⁽¹⁴⁾. Finally, Arteta⁽²³⁾ shows that male gender is a risk factor for developing HSDC.

In this study, a statistically significant association was found between chronic subdural hematoma and the clinical characteristics analyzed. Being an alcohol consumer represented a higher risk of chronic subdural hematoma. According to the study by “García-González et al”, consuming alcohol was a risk factor involved in most cases of chronic subdural hematoma ⁽¹⁰⁾ . Similar to the study by "Aleksandar Kostic et al" that consuming alcohol represented a higher risk of developing hematoma ⁽¹¹⁾ . In the study by "Vanegas Cerna, et al" consuming alcohol was associated with chronic subdural hematoma⁽¹²⁾ . In the work of "Katia Pereira et al" one of the most frequent risk factors was consuming alcohol ⁽²⁰⁾. In the study by "Miguel Esquivel et al" consuming alcohol was present with a lower percentage, 5.3%. ⁽²²⁾ In the study by "Regla Maylín et al" consuming alcohol represented 33.3% ⁽¹⁹⁾ . Regarding the literature, alcohol consumption causes death and disability at a relatively early age. Alcohol has generalizable effects at all ages, altering physiology and neuropsychological functions and framed as a risk factor for chronic subdural hematomas.

Having a history of arterial hypertension (HTN) was shown to be a predisposing factor for hematoma. In the study of "Aleksandar Kostic et al" Patients in the 70-79 years diagnosed with chronic subdural hematomas had higher rates of arterial hypertension ⁽¹¹⁾. In a study by "Miguel Esquivel et al" they presented 42.1% AHT ⁽²²⁾ . Similar to the study by "Pomar Arteta, María Alejandra" it was shown that a history of hypertension was a predisposing factor ⁽²¹⁾ .

Having type 2 diabetes mellitus as a history is a predisposing factor for hematoma. In the study by "Miguel Esquivel et al." DM2 was found as a predisposing factor ⁽²²⁾ . Unlike the work of "Pomar Arteta, María Alejandra" there was no association with DM2⁽²¹⁾ .

Having a history of head trauma is a predisposing factor for developing chronic subdural hematoma. Similar to the study by "Castro-Rodríguez C et al" that represented 57% of patients with a history of head trauma. (two) . Similar to the study by "García-González et al" where the traumatic etiology was the most frequent with 67.07% ⁽¹⁰⁾ . In the study by "Kitya, MMed et al" the majority of hematomas occurred as a result of head trauma with 60.5% ⁽²³⁾. In the study of "Ki-Su Park, et al" the intensity of head trauma was related to higher concentrations of molecules in chronic subdural hematoma ⁽²⁴⁾ . In the work of "Rodríguez-Venegas et al" light injuries stood out with 72% ⁽¹⁴⁾ .

Similar to the study by “Vanegas Cerna, et al” where 96% had a history of trauma ⁽¹²⁾ . In the study by "Minna Rauhala, et al" traumatic brain injury was documented in 59% of cases ⁽²⁵⁾ . In the study by “Katia Pereira et al” the most frequent risk factor was head trauma (66.6%) ⁽¹⁷⁾ . In the study by "Jen-Ho Tseng, et al" one of the risk factors was head trauma⁽²⁶⁾ . Similar to the study by "Edna Sikahall et al" 92% had a history of head trauma ⁽²⁷⁾ In the work of "Regla Maylín et al" the history of head trauma prevailed with 92.6% ⁽¹⁹⁾ . In the study by "Pomar Arteta, María Alejandra" an association was shown with a history of head trauma. (2NAC). Similarly, the “Julcamoro yopla” study presented 70.7% of patients with head trauma⁽¹³⁾ . Regarding head trauma, if the person suffers a fortuitous blow to the head, the bone moves quickly, but the brain has a different inertia and moves at a different speed and time. This causes these drainage veins to tighten. If the blow is strong enough and the veins are already tense due to the distance between the cerebral cortex and the bone, due to atrophy, a rupture of said veins and the consequent hemorrhage can occur. The process of formation of the subdural hematoma begins.

CONCLUSIONS

The sociodemographic factors age and sex are associated with chronic subdural hematoma.

Alcohol consumption, hypertension, DM2 and Santecedent of TC are associated with HSDC.

It is recommended that care be prioritized in the elderly because they are exposed to falls. Alcohol consumption should be reduced as it is a triggering factor for hematoma. Patients with high blood pressure should have regular check-ups to keep their pressures within normal parameters. In the case of diabetic patients, maintain adequate treatment and respective glycemic control. Finally, in case of head trauma, the necessary imaging tests should be performed to avoid future complications.

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