A Comparison of Initial GCS and Frailty for Predicting Outcomes Following Chronic Subdural Hemorrhage: A Retrospective Cohort Analysis. (16th November 2020) - McIntyre, Matthew
Abstract: INTRODUCTION: Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature however, there is no consensus on the best measure of frailty. To date, no study has compared frailty's ability to predict cSDH outcomes versus iGCS. METHODS: Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using ICD codes. mFI-5, mFI-11 and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analysis was performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints. RESULTS: Of the 109 patients identified, the average age was 72.6 ± 1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ± 0.2, 1.5 ± 0.1, and 2.2 ± 0.1, respectively. 50 (45.9%) patients required a surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR = 0.58; 95%CI:0.44-0.77; P = . 0001), the CCI (OR = 0.73; 95%CI:0.58-0.92; P = . 0082) was a superior predictor of discharge home compared to iGCS (OR = 1.46; 95%CI:1.13-1.90; P = . 0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR = 4.24; 95%CI:1.01-17.86; P = . 0491) and discharge home (OR = 0.55; 95%CI:0.33-0.90; P = . 0170). Neither mFI nor age predicted primary outcomes in multivariate analysis. CONCLUSION: While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI has not been explored in cSDH. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.