Subdural Hematoma in Patients with Hematologic Malignancies: An Outcome Analysis and Examination of Risk Factors of Operative and Nonoperative Management Christina Huang Wright 1,4 , James Wright 1,4 , Andrea Alonso 4 , Alankrita Raghavan 4 , Hasina Momotaz 5 , Christopher Burant 6 , Xiaofei Zhou 1,4 , Warren Selman 1,4 , Martha Sajatovic 2,3 , Alan Hoffer 1,4 - BACKGROUND: Patients with hematologic disorders who present with subdural hematomas (SDH) present a surgical decision-making challenge. Because of intrinsic coagulopathy, platelet dysfunction, and immunosuppres- sion, surgical intervention poses a unique set of risks. - OBJECTIVE: To describe a clinical sample of patients with hematologic disorders and concurrent SDH, to compare baseline and outcome variables, including complication rates and survival, in surgical versus nonsurgical management, and to identify clinical variables that may predict outcomes. - METHODS: A 12-year retrospective case-control study was carried out of 50 adult patients with hematologic malignancies and SDH. Patients underwent surgical evacuation for SDH. Controls did not. Outcomes included discharge disposition, Glasgow Outcome Scale score, 30-day mortality, and overall survival. Complications included seizure, reoperation, and readmission. A Fisher exact test or c 2 analysis compared categorical variables; continuous outcomes were compared with a Student t test. A Kaplan-Meier survival analysis was performed and multivariable Cox logistic regression evaluated variables associated with overall mortality. - RESULTS: Surgical and nonsurgical groups differed only by Glasgow Coma Scale score, with slightly lower Glas- gow Coma Scale scores in the surgical group. Complica- tion rates did not differ; however, the 30-day reoperation rate was 35% for the surgical cohort. Overall, seizure incidence was 18%, readmission was 30%, 30-day mortality was 38%, median survival was 140.5 days, and 75% had a Glasgow Outcome Scale score of 1e3 at censorship. Increased age, low hemoglobin levels, and low platelet levels were associated with increased risk of mortality. - CONCLUSIONS: Low platelet and hemoglobin levels are consistent markers of poor prognosis and surgical inter- vention, either as a proxy of or as a cause for clinical deterioration, is associated with increased mortality risk. INTRODUCTION S ubdural hematomas (SDH) are one of the most commonly encountered neurosurgical diseases and are associated with short-term and long-term mortality ranging from 2% to 32% in reported surgical series. 1-6 Patients with hematologic dis- orders and malignancies represent a small fraction of SDH cases. 7-11 Compared with patients who present with traumatic, solid tumorerelated, or anticoagulation-related SDH, those with he- matologic disorders show higher rates of SDH recurrence, surgical morbidity, and mortality. 12 Patients with hematologic disorders are high-risk surgical candidates. Perioperative transfusion to correct intrinsic coagulopathies and clotting dysfunction is often recommended; however, correction of abnormal hematologic measures is only temporary. The decision to pursue operative intervention in cases of symptomatic SDH is made difficult by the Key words - Hematologic malignancy - Myelodysplastic syndrome - Subdural hematoma Abbreviations and Acronyms CI: Confidence interval CT : Computed tomography GCS: Glasgow Coma Scale GOS: Glasgow Outcome Scale HR: Hazard ratio ICH: Intracranial hemorrhage ICU: Intensive care unit LOS: Length of stay SDH: Subdural hematoma From the Departments of 1 Neurological Surgery and 2 Neurology and Psychiatry, and 3 Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio; 4 Case Western Reserve University School of Medicine, Cleveland, Ohio; and 5 Frances Payne Bolton School of Nursing and 6 Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, Ohio, USA To whom correspondence should be addressed: Christina Huang Wright, M.D. [E-mail: Christina.wright@uhhospitals.org] Citation: World Neurosurg. (2019) 130:e1061-e1069. https://doi.org/10.1016/j.wneu.2019.07.079 Journal homepage: www.journals.elsevier.com/world-neurosurgery Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2019 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY 130: e1061-e1069, OCTOBER 2019 www.journals.elsevier.com/world-neurosurgery e1061 Original Article