CLINICAL ARTICLE

Factors influencing the presence of hemiparesis in chronic

subdural hematoma
Rouzbeh Motiei-Langroudi, MD,1,2 Ron L. Alterman, MD,1 Martina Stippler, MD,1
Kevin Phan, MD, BSc, MSc, MPhil,3 Abdulrahman Y. Alturki, MBBS, MSC, FRCSC,1,4
Efstathios Papavassiliou, MD,1 Ekkehard M. Kasper, MD, PhD,5 Jeffrey Arle, MD, PhD,1
Christopher S. Ogilvy, MD,1 and Ajith J. Thomas, MD1
1
Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; 2Department
of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio; 3University of Sydney Westmead
Clinical School, Westmead, New South Wales, Australia; 4Department of Neurosurgery, The National Neuroscience Institute,
King Fahad Medical City, Riyadh, Saudi Arabia; and 5Division of Neurosurgery, Hamilton General Hospital, McMaster University
and Hamilton Health Sciences, Hamilton, Ontario, Canada

OBJECTIVE  Chronic subdural hematoma (CSDH) has a variety of clinical presentations, including hemiparesis. Hemi-
paresis is of the utmost importance because it is one of the major indications for surgical intervention and influences
outcome. In the current study, the authors intended to identify factors influencing the presence of hemiparesis in CSDH
patients and to determine the threshold value of hematoma thickness and midline shift for development of hemiparesis.
METHODS  The authors retrospectively reviewed 325 patients (266 with unilateral and 59 with bilateral hematomas) with
CSDH who underwent surgical evacuation, regardless of presence or absence of hemiparesis.
RESULTS  In univariate analysis, hematoma loculation, age, hematoma maximal thickness, and midline shift were sig-
nificantly associated with hemiparesis. Moreover, patients with unilateral hematomas had a higher rate of hemiparesis
than patients with bilateral hematomas. Sex, trauma history, anticoagulant and antiplatelet drug use, presence of co-
morbidities, Glasgow Coma Scale score, hematoma density characteristics on CT scan, and hematoma signal intensity
on T1- and T2-weighted MRI were not associated with hemiparesis. In multivariate analysis, the presence of loculation
and hematoma laterality (unilateral vs bilateral) influenced hemiparesis. For unilateral hematomas, maximal hematoma
thickness of 19.8 mm and midline shift of 6.4 mm were associated with a 50% probability of hemiparesis. For bilateral
hematomas, 29.0 mm of maximal hematoma thickness and 6.8 mm of shift were associated with a 50% probability of
hemiparesis.
CONCLUSIONS  Presence of loculations, unilateral hematomas, older patient age, hematoma maximal thickness, and
midline shift were associated with a higher rate of hemiparesis in CSDH patients. Moreover, 19.8 mm of hematoma
thickness and 6.4 mm of midline shift were associated with a 50% probability of hemiparesis in patients with unilateral
hematomas.
https://thejns.org/doi/abs/10.3171/2018.8.JNS18579
KEYWORDS  chronic subdural hematoma; neurologic deficit; hemiparesis; traumatic brain injury

C
hronic subdural hematoma (CSDH), a common
form of intracranial hemorrhage, has a variety of
clinical presentations, including headache, deterio-
ration in consciousness, and neurological deficit.3 Among
these, hemiparesis is one of the most important because
it is one of the major indications for surgical intervention
and is a predictor of outcome after surgery.1,3,7,9 Therefore,
defining causative factors for hemiparesis may guide treat-
ment decisions and help surgeons to avoid unnecessary
conservative management in CSDH patients.

ABBREVIATIONS  CSDH = chronic subdural hematoma; GCS = Glasgow Coma Scale; MLS = midline shift; MRC = Medical Research Council Manual Muscle Testing
scale.
SUBMITTED  March 10, 2018.  ACCEPTED  August 28, 2018.
INCLUDE WHEN CITING  Published online January 11, 2019; DOI: 10.3171/2018.8.JNS18579.

©AANS 2019, except where prohibited by US copyright law J Neurosurg  January 11, 2019 1
Motiei-Langroudi et al.
Although hemiparesis is frequently seen in patients
with CSDH and is a major determining factor for surgi-
cal intervention and also outcome, there are still many
aspects that are not well studied. For instance, large he-
matomas may be seen in patients who are neurologically
intact, while other patients develop deficits with smaller
hematomas. Few studies have examined the clinical and
radiographic factors associated with hemiparesis in pa-
tients with CSDH. Midline shift (MLS), observed on
non–contrast-enhanced CT, 3,7,9 and decreased cerebral
blood flow, measured with xenon CT, 2 have been sug-
gested as causative factors for hemiparesis; however,
there are as yet no definitive correlative metrics for these
factors. Despite investigative efforts to date, strong data
and consensus are lacking to support cutoff measure-
ment values for hematoma thickness and/or volume,
MLS magnitude, or other demographic and radiological
factors related to the development of hemiparesis in pa-
tients with CSDH.
Because the presence of hemiparesis in a patient pre-
senting with CSDH is important for decision-making
regarding conservative versus surgical treatment, we per-
formed the current study to assess if any demographic or
imaging data were related to the presence of hemiparesis.
We employed a large database of CSDH patients treated at
a single large academic institution over a 10-year period to
identify those factors associated with preoperative hemi-
paresis. We also studied the factors, if any, that influenced
resolution of hemiparesis after surgery.
Methods
Inclusion of Patients
Information regarding the patients included in this
study was obtained from an institutional database of con-
secutive patients with a diagnosis of CSDH who were
treated surgically between 2006 and 2016 at Beth Israel
Deaconess Medical Center (Boston, MA), which is an aca-
demic level I trauma tertiary care center. Patients were in-
cluded regardless of their neurologic deficit/paresis status.
Patients only receiving conservative management were
not included the database and study.
IRB approval was obtained for this study.
Included Variables
The following preoperative data were recorded: sex,
age, history of trauma, comorbidities, anticoagulant use
and type, presenting Glasgow Coma Scale (GCS) score,
hematoma characteristics on imaging (laterality [bi- vs
unilateral], side, hematoma density on CT, hematoma
signal intensity on MRI, maximal thickness, presence
of membranes and loculations, and degree of MLS), and
presence of neurological deficits (hemiparesis).
Univariate (independent t-test), bivariate (chi-square
test), and multivariate (multiple logistic regression) analy-
ses were performed to determine which, if any, of the stud-
ied factors were associated with an increased incidence
of hemiparesis. Presence of both loculations (septations
which make the hematoma appear as compartmentalized)
and membranes (thin adhesions seen as a membrane with-
in the hematoma) was diagnosed by preoperative CT stud-
2 J Neurosurg  January 11, 2019
ies. The presence of membranes was further confirmed by
intraoperative findings. Muscle force grading was done
based on the Medical Research Council Manual Muscle
Testing scale (MRC).5 Multivariate logistic regression
analysis was performed only with variables that yielded
a p value < 0.1 in uni- and bivariate analyses. Moreover,
probit analysis was used to determine a threshold for the
development of hemiparesis based on hematoma thickness
and MLS. Statistical analysis was performed using PASW
Statistics 18 (Predictive Analytics Software, SPSS, Inc.).
Statistical significance was defined as having a p value <
0.05.
Results
Patient and Treatment Demographics
During the study period, 325 patients (mean age 71.6
years, range 28–98 years, M/F ratio 2.3) with CSDH who
underwent surgery were reviewed. Unilateral hematoma
evacuations were performed in 266 patients and bilateral
evacuations in 59.
Univariate and Bivariate Analyses of Factors Influencing
Hemiparesis
One hundred fifty-six patients (48%) had hemiparesis
before surgery (MRC grade range 3/5 to 4/5). We first
evaluated the association of various individual clinical
variables with the presence of hemiparesis. Univariate
analysis showed that hematoma loculation, older patient
age, hematoma maximal thickness, and MLS were sig-
nificantly associated with hemiparesis. Moreover, patients
with unilateral hematomas exhibited a higher incidence of
hemiparesis than patients with bilateral hematomas. Sex,
trauma history, anticoagulant and antiplatelet drug use
(including aspirin, clopidogrel, warfarin, and ticagrelor),
presence of comorbidities, GCS score, hematoma density
on CT (either hypodense, isodense, or mixed hyper- and
hypodense), and hematoma signal intensity on T1- or T2-
weighted MRI were not correlated with hemiparesis (Ta-
ble 1). Maximal hematoma thickness was correlated with
MLS in unilateral (r = 0.14, p = 0.02) and bilateral (r =
0.28, p = 0.04) hematomas.
Multivariate Analysis of Factors Influencing Hemiparesis
Multivariate analysis showed that the presence of locu-
lation and hematoma laterality (unilateral vs bilateral)
were associated with hemiparesis (Table 2).
Analysis of the Probability of Hemiparesis Based on MLS
and Hematoma Maximal Thickness
We performed a probit analysis to examine the prob-
ability of hemiparesis based on maximal hematoma thick-
ness and MLS. For unilateral hematomas, maximal hema-
toma thicknesses ≥ 19.8 mm and MLS ≥ 6.4 mm were as-
sociated with a 50% probability of hemiparesis (p < 0.001
and p < 0.09, respectively). For bilateral hematomas, the
larger hematoma was analyzed. In patients with bilateral
CSDH a 50% probability of hemiparesis was associated
with a maximal hematoma thickness ≥ 29.0 mm and MLS
≥ 6.8 mm (p = 0.11 and 0.04, respectively).
 Motiei-Langroudi et al.

TABLE 1. Univariate and bivariate analysis of factors influencing TABLE 2. Multivariate analysis of factors influencing hemiparesis
hemiparesis
Parameter OR 95% CI p Value
Patients Patients
Unilateral vs bilateral hematoma 1.96 1.04–3.76 0.033
With Without p
Parameter Hemiparesis Hemiparesis Value Loculation vs no loculation 2.00 1.11–3.22 0.004

Sex 0.71
 Female 47 (49.5%) 48 (50.5%)
 Male 99 (46.5%) 114 (53.5%) Discussion
Trauma history 0.43 Chronic subdural hematoma (CSDH) may present with
 No 32.4% 67.6% a variety of symptoms, including headache, nausea and
 Yes 41.5% 58.5% vomiting, deterioration in consciousness, and neurological
Comorbidity 0.58
deficits (most commonly hemiparesis).3 Along with hema-
toma volume and state of arousal, hemiparesis is a key
 No 5 (33.3%) 10 (66.7%) indication for surgical intervention. Moreover, it is an in-
 Yes 46 (43.0%) 61 (57.0%) dicator of a more critical state in CSDH.1,3,7,9 Indeed, neu-
Anticoagulant or antiplatelet use 0.99 rological status on presentation (including hemiparesis)
 No 29 (42.0%) 40 (58.0%) has been shown by some to be the single most important
 Yes 33 (42.3%) 45 (57.7%) prognostic indicator for CSDH patients.9 Brain MRI stud-
Hematoma laterality 0.02*
ies reveal signal changes in structures such as the cerebral
peduncles in patients with hemiparesis, which may pres-
 Unilateral 133 (51.4%) 126 (48.6%) age poorer surgical outcome.4 Consequently, early diagno-
 Bilateral 19 (33.3%) 38 (66.7%) sis and intervention are important in CSDH patients with
Hematoma CT density 0.43 hemiparesis.
 Hypodense 37 (55.2%) 30 (44.8%) Despite the apparent importance of hemiparesis in
 Isodense 34 (45.9%) 40 (54.1%) CSDH, very few studies have tried to identify imaging
  Mixed hyper- & hypodense 77 (46.4%) 89 (53.6%)
hallmarks that would predict it. In a study of 83 patients
with both unilateral and bilateral hematomas, Juković et
Hematoma T1 MRI intensity 0.35 al. found that the maximal diameter of the hematoma and
 Hypointense 1 (25.0%) 3 (75.0%) the degree of MLS measured on noncontrast CT were as-
  Mixed hypo- & isointense   1 (100.0%) 0 (0%) sociated with hemiparesis.3 Ikeda et al. employed xenon
 Isointense 4 (44.4%) 5 (55.6%) CT to measure regional cerebral blood flow (rCBF) in 38
  Mixed iso- & hyperintense 1 (100%) 0 (0%) patients with unilateral CSDH and found that while rCBF
 Hyperintense 12 (66.7%) 6 (33.3%)
was normal in all patients without hemiparesis, it was gen-
erally decreased in patients with hemiparesis, especially
Hematoma T2 MRI intensity 0.45 in the rolandic region ipsilateral to the hematoma.2 Oh et
 Isointense 4 (57.1%) 3 (42.9%) al. observed corticospinal tract degeneration on diffuse
  Mixed iso- & hyperintense 2 (100%) 0 (0%) tensor MRI in one CSDH patient whose hemiparesis did
 Hyperintense 13 (54.2%) 11 (45.8%) not resolve after surgery.6
Loculation 0.001* The present study, based on 325 patients, is to our
 Yes 84 (57.9%) 61 (42.1%)
knowledge the largest series of CSDH reported to date. In
accordance with previous studies, we found that hemato-
 No 59 (38.6%) 94 (61.4%) ma maximal thickness and midline shift were significant
Age (yrs) 74.6 ± 12.6 69.6 ± 13.4 0.03* predictors of hemiparesis in CSDH. In addition, we found
GCS score 14.3 ± 1.6 14.5 ± 1.4 0.24 for the first time that hematoma loculation and patient age
Hematoma maximal thickness 22.8 ± 5.8 18.5 ± 6.0 0.001* also predicted hemiparesis. Loculation was an indepen-
(mm) dent causative factor for hemiparesis (as shown in both
Midsagittal line shift (mm) 7.8 ± 5.4 6.0 ± 5.4 0.003* univariate and multivariate analysis). The mechanism by
which loculation may induce hemiparesis is unknown;
Values are presented as number of patients (%) or mean ± SD. however, compression of the motor cortex is certainly a
* Statistically significant. possibility. Another possible explanation is that loculated
hematomas may have higher local pressure and tension
rather than more diffusely increased pressure. Tension in
Postoperative Resolution of Hemiparesis CSDH has recently been reported to be an influencing fac-
At their final follow-up, all patients with preopera- tor in the development of hemiparesis in these patients.8
tive hemiparesis had completely recovered their muscle We also showed a higher rate of hemiparesis in unilateral
strength. Analysis showed that age, hematoma size, surgi- than bilateral hematomas, possibly due to greater hema-
cal evacuation type (burr hole drainage vs craniotomy), toma thickness and increased MLS. Finally, we found
or presence of loculations did not affect hemiparesis re- that there are different thresholds for the development of
covery after surgery (p = 0.5, 0.45, 0.79, and 0.3, respec- hemiparesis depending on hematoma thickness and MLS
tively). in unilateral and bilateral hematomas, though the analysis

J Neurosurg  January 11, 2019 3

Motiei-Langroudi et al.
in patients with bilateral hematomas is less reliable due
to the small sample size. Among patients with unilateral
hematomas, we found that hematoma maximal thick-
ness of approximately 20 mm and midline shift of 6 mm
were associated with a 50% probability of hemiparesis.
One prior study also noted different thresholds of MLS
for hemiparesis in unilateral and bilateral CSDHs (10 mm
and 4.5 mm, respectively).3 Our results, based on a larger
patient database, showed that lower thresholds should be
taken into account when managing CSDH patients. Of
note, imaging factors like hematoma size and MLS are
not the only factors determining the need for surgery, as
other factors such as severity of symptoms (headache for
instance), neurological status, hematoma progression in
subsequent CTs, etc. should also be considered. As such,
surgery may be considered for a smaller hematoma with
lower shifts if clinically indicated. On the other hand, in
many practices larger hematomas (more than 15 or 20 mm
maximal thickness) are frequently indicated for surgery
based only on their size, regardless of neurological status
and presence of paresis.
Although hemiparesis resolution after surgery was not
the main outcome of the current study, we failed to show
an effect for age, hematoma size, presence of loculations,
surgical evacuation type, or other factors to predict hemi-
paresis resolution. The main reasons for this observation
could be the following: 1) all patients improved after sur-
gery; 2) the initial MRC hemiparesis grade before surgery
was 4/5 or 3/5 at most in our series; and 3) a large number
of patients (52%) were neurologically intact (MRC grade
5/5). All of these factors contributed to the fact that the
improvement in motor scale after surgery yielded small
numbers (ranging from 0 to 2), resulting in a statistical-
ly negative analysis. More studies focusing only on the
course of postoperative hemiparesis are needed to further
address this issue.
Our study was aimed at investigating patient and imag-
ing factors related to the development of hemiparesis and
was not designed to answer the question of whether to de-
cide for surgical intervention versus continuing conserva-
tive management, which is more extensively investigated
and addressed in literature. Instead, we tried to investi-
gate a question about an important presentation of CSDH,
which has both decision-making and prognostic value. As
such, our results cannot directly suggest thresholds for
surgery based on imaging or patient factors. This question
remains unanswered until a later date.
Limitations
The major limitation of the current study is its retro-
spective design. Nevertheless, the relatively large sample
size in a group of consecutively treated patients allows
for statistically reliable observations to be made that may
serve as a focus of future prospective studies. One other
major limitation is that our series is a surgical series and
all patients were included if they underwent surgery. A
study including all patients presenting with CSDH, re-
gardless of treatment option, would be more appropriate
to answer the questions raised in this study. Specifically,
any recommendations for surgical intervention instead of
conservative management would be more appropriate in
4 J Neurosurg  January 11, 2019
a series of patients including both nonsurgical and surgi-
cal patients. This requirement, nonetheless, needs a larger
study involving multiple practices. Another issue with
the current study is that we did not evaluate the effect of
CSDH duration prior to surgery on hemiparesis, as longer
durations may cause higher rates of hemiparesis. Although
we showed that the presence of loculations (as an indicator
of hematoma chronicity) is associated with a higher rate of
hemiparesis, we could not directly assess the time factor.
To evaluate this variable, the exact time of CSDH onset
should be determined through CT imaging studies before
surgery, which is not done in all patients. Future studies
focusing on this issue may be helpful for clarification.
Conclusions
The results of our study showed that the presence of
loculations, unilateral hematomas, older patient age, he-
matoma maximal thickness, and MLS are associated with
a higher rate of hemiparesis in CSDH. Among these vari-
ables, only hematoma loculation and laterality remained
as significant predictors in multivariate analysis. More-
over, 19.8 mm of hematoma thickness and 6.4 mm of MLS
are associated with a 50% probability of hemiparesis in
unilateral hematomas.
Acknowledgments
We thank Ms. Patricia Baum, BSc, for her help with this study.
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Disclosures
The authors report no conflict of interest concerning the materi-
 Motiei-Langroudi et al.

als or methods used in this study or the findings specified in this analysis: Motiei-Langroudi, Phan. Administrative/technical/mate-
paper. rial support: Thomas. Study supervision: Thomas, Stippler.

Author Contributions Correspondence

Conception and design: Thomas, Motiei-Langroudi. Acquisition Ajith J. Thomas: Beth Israel Deaconess Medical Center, Harvard
of data: Motiei-Langroudi. Analysis and interpretation of data: Medical School, Boston, MA. athomas6@bidmc.harvard.edu.
Motiei-Langroudi, Phan. Drafting the article: Motiei-Langroudi.
Critically revising the article: Thomas, Motiei-Langroudi, Alter-
man, Stippler, Alturki, Papavassiliou, Kasper, Arle, Ogilvy.
Reviewed submitted version of manuscript: all authors. Statistical

J Neurosurg  January 11, 2019 5