title: Flow, Liver, Flow: A Retrospective Analysis of the Interplay of Liver Disease and Coagulopathy in Chronic Subdural Hematoma.
abstract: BACKGROUND
  Chronic subdural hematoma (cSDH) is a common neurosurgical ailment, particularly in elderly patients. A recent study uncovered an association between liver disease and recurrence in patients with cSDH. Here, we explored that relationship to identify recurrence predictors in at-risk patients.
  
  
  OBJECTIVE
  We hypothesized that the association between liver disease and recurrence was attributable to coagulopathy secondary to liver disease.
  
  
  METHODS
  We retrospectively reviewed all patients with cSDH treated with burr-hole drainage by 2 surgeons between 2007 and 2015. Comorbidities and laboratory findings for each patient were examined by Pearson χ2analysis or Mann-Whitney U tests.
  
  
  RESULTS
  We identified 261 cSDH in 215 patients. Patients were a mean age of 65.6 years, and 72% were male. Sixteen patients with cSDH required repeat surgery (6.1%). There were 123 coagulopathic patients (47.1%), and 14 with liver disease (5.4%), all of whom were coagulopathic (P < 0.001). Coagulopathic patients with liver disease were more likely to experience recurrence than patients with coagulopathy alone (relative risk = 4.09, P = 0.019). Patients with liver disease had significantly elevated prothrombin time (P = 0.013) and reduced platelet counts (P < 0.001). Platelets also were reduced in coagulopathic patients with liver disease, as compared with those with coagulopathy alone (P = 0.002). Thrombocytopenia remained significant in a multivariate analysis (P < 0.001).
  
  
  CONCLUSIONS
  Liver disease is significantly associated with the recurrence of cSDH. Although coagulopathy alone does not predict recurrence, patients with coagulopathy and liver disease are at greater risk for recurrence than those with coagulopathy alone. Liver disease effects are reflected in certain hematologic laboratory values.
authors.affiliation: Department of Neurosurgery, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA.
authors.forename: John Paul George
authors.initials: JPG
authors.lastname: Kolcun
authors.affiliation: Department of Neurosurgery, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA. Electronic address: Jgernsback@gmail.com.
authors.forename: Joanna Elizabeth
authors.initials: JE
authors.lastname: Gernsback
authors.affiliation: Department of Neurosurgery, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA.
authors.forename: Angela Mae
authors.initials: AM
authors.lastname: Richardson
authors.affiliation: Department of Neurosurgery, University of Miami, Jackson Memorial Hospital, Miami, Florida, USA.
authors.forename: Jonathan Russell
authors.initials: JR
authors.lastname: Jagid
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001778:Blood Coagulation Disorders / Q000453:epidemiology* / Q000209:etiology*; D004322:Drainage / Q000009:adverse effects; D005260:Female; D020200:Hematoma, Subdural, Chronic / Q000150:complications* / Q000601:surgery; D006801:Humans; D008107:Liver Diseases / Q000453:epidemiology*; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects; D012008:Recurrence; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D014207:Trephining
keywords: Burr hole drainage; Chronic subdural hematoma; Cirrhosis; Coagulopathy; Liver disease; Recurrence