The risk factors for recurrence of chronic subdural hematoma

Chronic subdural hematoma (CSDH) is a common disease in the elderly, and the recurrence rate of CSDH is reported to range from 2.3 to 33%. We performed a retrospective review of a number of CSDH cases and the potential factors associated with CSDH recurrence. The patient population comprised 112 men and 65 women with a mean age of 74.7 years. We analyzed the following factors: age, sex, antiplatelet and anticoagulant use, hematoma laterality, hematoma thickness, degree of midline shift and internal architecture of the hematoma in the preoperative CT films, use of irrigation, direction of the drainage tube, width of the subdural space, and degree of midline shift and the presence of a massive subdural air collection in the postoperative CT films. Univariate analysis revealed that there was a trend for different rates of recurrence among the different types of hematomas. The presence of a postoperative massive subdural air collection tended to be associated with the recurrence of hematoma. Multivariate analysis revealed that separated hematomas were significantly associated with CSDH recurrence, whereas the presence of postoperative massive subdural air collection tended to be associated with hematoma recurrence. Neither univariate nor multivariate analysis could demonstrate an association between the direction of the drainage tube and the recurrence of CSDH.

Changing trends in chronic subdural haematoma in Nigeria

OBJECTIVE

Chronic subdural haematoma (CSDH) is common in the elderly and is often associated with serious morbidity and mortality. Previous reports from Africa indicate earlier age of onset and a generally better tolerated condition compared with more developed countries. As the average age of the Nigerian population increases with associated medical problems, the pattern of the disease is expected to change towards that seen in more developed countries.

METHODS

The study is a retrospective review of 130 patients presenting to the Memfys hospital for Neurosurgery Enugu. The demographic, causal and clinical patterns were analysed. These were compared with previous studies from Africa. 116 patients who had surgical intervention were further analysed for management and outcome.

RESULTS

The male female ratio was 3:1 and the peak age incidence was in the 6th decade. 50.8% of cases resulted from road traffic accidents (RTA) and 21.5% from falls. Other causes included Neurosurgical procedure in 2.3%. The commonest presentations were headaches and altered consciousness. Nineteen patients were on antiplatelet drugs. Surgical treatment was with burr hole craniostomy and drainage in all cases with a perioperative mortality of 0.8%. Reoperation rate was 7.8% in all cases but 36% in patients on antiplatelet/anticoagulants. The outcome at six weeks using the Glasgow Outcome Scale (GOS) was good in 87%.

CONCLUSION

The pattern of CSDH in Nigeria has changed towards that seen in developed countries. There is also a general increase in frequency of the condition, and health care systems must be planned to meet this change.

[Epidemiology of chronic subdural hematomas]

BACKGROUND AND PURPOSE

The Japanese population is aging faster than any other population in the world, affecting the epidemiology of which frequently occurs in the elderly. In this study, the epidemiological aspect of chronic subdural hematoma (CSDH) is investigated, using data of the Miyagi Traumatic Head Injury Registry Project.

PATIENTS AND METHODS

From January 2005 to December 2007, 1,445 patients with CSDH were registered in the project (M:F=1,021:424, mean age 71.2±12.8 y.o.). Using these patient's records, the incidence of CSDH was investigated, as well as causes of head injury, severity, and outcome.

RESULTS

The overall incidence of CSDH was 20.6/100,000/year, with 76.5 in the age group of 70-79 y.o. and 127.1 in the over 80 y.o. group. Ground level fall was the most frequent cause of trauma in the elderly, in contrast to traffic accident, which was the most frequent cause in the younger generation. Compared to the younger generation, neurological condition was severer in the elderly at the time of admission, and the outcome was poorer at the time of discharge.

CONCLUSION

Compared to previous reports, this study demonstrates a marked increase in the incidence of CSDH. Not only population aging but also current medical trends (such as increases of the elderly patients who receive hemodialysis, anticoagulant, and/or antiplatelet therapy) may influence the increase of CSDH incidence.

[Chronic subdural haematoma in a patient with idiopathic thrombocytopenic purpura]

Chronic subdural haematoma (cSDH) is a rare form of bleeding in patients with idiopathic thrombocytopenic purpura (ITP). In patients with ITP cSDHs may resolve spontaneously or with medical treatment. Surgery can be postponed if the patient does not have neurological symptoms. Medical treatment and close observation may be appropriate in the management of patients without neurological findings, because surgery might be complicated with intracranial bleeding.

[A case of multifocal fibrosclerosis presenting with chronic subdural hematoma]

Multifocal fibrosclerosis(MFS) is a rare disorder of unknown etiology, characterized by chronic inflammation with dense fibrosis and lymphoplasmacytic infiltration into the connective tissue of various organs. Recently, MFS was classified as IgG4-related systemic disease. In this paper, we report a 60-year-old man with no history of head injury presenting with chronic subdural hematoma(CSDH). After surgery, he complained of severe, continuous headache and persistent high-grade fever. Extensive evaluation, including ⁶⁷Ga scintigraphy suggesting inflammations in various organs, liver needle biopsy showing sclerosing cholangitis, and blood examination showing elevated serum IgG4 levels, led to the diagnosis of MFS. To our knowledge this is the first report of MFS causing CSDH. The mechanism of the formation of CSDH is presumed to involve reactive granular membrane together with exudative subdural collection caused by MFS, which gives rise to minor and repeated bleeding. In this case, oral corticosteroid therapy was dramatically effective in the treatment of the condition.

[Two cases of spontaneous intracranial hypotension with bilateral chronic subdural hematomas]

Spontaneous intracranial hypotension (SIH) is characterized by postural headaches without obvious cause and is occasionally related to chronic subdural hematomas (CSHs). Brain sag due to decrease in cerebrospinal fluid, and growing CSHs may occur secondary to a decrease in intracranial pressure. Therapy for this condition differs from that for mere traumatic CSHs and is controversial. We report 2 cases of CSH related to SIH. One patient required drainage of the CSHs and an epidural self-blood patch. Furthermore, this patient had to undergo reoperation for drainage of the CSHs. The other patient was cured after the first time the CSHs were drained.

[Chronic subdural hematoma - assessment and management]

Subdural hematomas (SDH) are associated with an increased morbidity and mortality and generally occur as chronic SDH among older patients. The most frequent signs and symptoms - like headache, alteration of consciousness, gait impairment and hemiparesis - are also prevalent among other diseases, which has to be taken into account in the differential diagnosis. In the case of symptomatic patients with focal neurological deficits, a surgical intervention should be considered, whereas in case of asymptomatic patients or patients with only slight headaches, also a conservative treatment with a clinical and radiological follow-up might be a possibility. Also after surgical intervention, the recurrence rate is between 5 and 33%. Therefore, all patients with chronic SDH depict, irrespective of the indication for an oral anticoagulation, a challenge for the treating physicians.

Spontaneous resolution of post-traumatic chronic subdural hematoma: case report

Spontaneous resolution of post-traumatic chronic subdural hematoma is a very rare and unexpected event. It has been rarely reported in the literature, mostly cases of chronic subdural hematoma resolution in idiopathic thrombocytopenic purpura. Operative procedure is generally considered the treatment of choice for chronic subdural hematoma. We present a rare case, which did not require an open surgery, i.e. a case of post-traumatic chronic subdural hematoma spontaneous resolution in a 76-year-old female having sustained a fall without classic head injury. The possibility of conservative treatment is extremely rare in patients with chronic subdural hematoma, but it should be considered based on the patient's neurological and physical condition.

[Postpartum chronic subdural hematoma following spinal anesthesia: case report]

Chronic subdural hematoma is a rare complication of epidural anesthesia. This report describes the case of a 34-year-old woman who presented with postpartum headache after she received epidural anesthesia for labor pain. The anesthesiologist's record did not show any anesthesia-related complication. Two days after the delivery (on day 2), the patient complained of headache. Postdural puncture headache was diagnosed, so she was administered analgesics, hydration therapy, and bed rest. On day 4, she reported a slight improvement and was discharged. The postural headache persisted even on day 7 after delivery. During the conservative treatment, she had suffered a mild head trauma. On day 13, she started to feel a non-postural and severe throbbing headache. On day 24, she was referred to our department. Bilateral chronic subdural hematoma was confirmed by a computed tomography scan. Physical examination revealed only mild right hemiparesis. Left burr hole trepanation was performed and this was followed by uneventful postoperative course. Right chronic subdural hematoma was managed by conservative treatment, and it completely recovered after 4 weeks. Chronic subdural hematoma should be considered when postpartum patients who have received epidural anesthesia present with mild to severe, persistent, and non-postural headache.

[Chronic subdural hematoma associated with arachnoid cyst. Report of 12 cases]

INTRODUCTION

We designed this study to investigate the clinical, neurological, and radiological outcome of patients with chronic subdural hematoma related to an intracranial arachnoid cysts.

PATIENTS AND METHODS

Medical records of 12 cases of patients with arachnoids cyst complicated with chronic subdural hematoma were retrospectively reviewed.

RESULTS

Between January 1984 and April 2008, 12 patients (0.9%) of 1.253 cases of chronic subdural hematoma surgically treated in our hospital had associated arachnoid cyst. Arachnoid cysts were located in the middle fossa (10 cases) and convexity (2 cases). The most frequent symptom was headache (6 cases), followed by seizures (3 cases). Eleven patients underwent burr hole and drainage; the oldest patient was treated conservatively.

CONCLUSIONS

Patients with AC, especially when these are located in temporal fossa, appear to harbour a life-long risk of contracting subdural hematoma. Hematoma evacuation is adequate at first operation and if arachnoid cyst is symptomatic or preoperative symptoms persist, additional arachnoid cyst surgery should be considered.

[Neurosurgical treatment for chronic subdural hematoma in a patient with chronic autoimmune thrombocytopenic purpura]

Intracranial hemorrhage in patients with chronic autoimmune thrombocytopenic purpura (CATP) is a rare and severe complication of the disease. By taking into account a concomitance of chronic subdural hematoma (CSH) and CATP and no generally accepted approaches to managing the patients with this concomitance, the authors describe a clinical case of mini-invasive CSH drainage in a patient with CATP.

Chronic emispheric subdural hematoma in a patient with antibodies antiphospholipid syndrome: case report

The treatment of chronic subdural hematoma (CSDH) was developed through a wide range of methods and technique. The excellent surgical treatment of CSDH is still controversial. The authors report a case of chronic subdural hematoma in a patient with antibodies antiphospholipidis syndrome (S. of Hughes). Antiphospholipid syndrome is characterized by arterial or venous thrombosis, and the presence of antiphospholipid antibodies (APL). APL are considered to be a cause of an acquired hypercoagulable state leading to stroke and transient ischemic attack (TIA).

ReviewNatural history of chronic subdural haematoma

This review will clarify the natural history of chronic subdural haematoma (SDH). Chronic SDH has dual origins, one from subdural hygromas (SDG) and the other from acute SDHs. It occurs only in patients with a suitable pre-morbid condition, i.e. sufficient potential subdural space (PSS). In unresolved SDGs, proliferation of dural border cells produces the neomembrane. Unresolved SDGs become chronic SDHs by repeated micro-haemorrhages from fragile new vessels, which were grown into the neomembrane. When PSS is sufficient, acute SDHs may become chronic SDHs. Chronic SDHs enlarge when rebleeding exceeds absorption and they become symptomatic. When the neomembrane is matured, the neocapillary is no longer fragile. If absorption exceeds rebleeding, the haematoma will disappear. Maturation of the neomembrane and stabilization of the neovasculature eventually result in spontaneous resolution. The fate of chronic SDH depends on the pre-morbid status, the dynamics of absorption-expansion and maturation of the neomembrane.

Intracranial chronic subdural haematoma as a complication of epidural anesthesia

We report the case of a 39-year-old woman with unilateral intracranial chronic subdural haematoma that occurred after epidural anesthesia for excision of a skin scar, complicated by postdural puncture headache. The patient had no history of trauma, headache, coagulation abnormalities, or neurological disorders. Most physicians encountering a case of headache after epidural or spinal anesthesia first think of a postdural puncture headache. Nonetheless, the symptoms subside within 7 days when treated with analgesics and bed rest in the majority of cases. The presence of a continued postdural puncture headache without neurological deterioration, as in this case, should prompt a search for an intracranial lesion.

[Rapid recurrence of chronic subdural hematoma by CSF entrapment]

A case of chronic subdural hematoma with multiple rapid recurrences is reported. A 41-year-old woman was admitted to hospital because of a traumatic subarachnoid hemorrhage and an intracerebral hematoma in the left frontal lobe. Both regions were conservatively treated, and she was discharged with no neurological deficit. Four months after this injury, she was readmitted to our clinic with complaints of severe headache and mild left hemiparesis. A CT scan showed a right chronic subdural hematoma. A burr hole and irrigation was performed, and the hematoma cavity disappeared on the following day. However, a deterioration of consciousness and left hemiparesis appeared ten days after the first operation. A second CT scan showed the recurrence of a left chronic subdural hematoma, so a second operation was performed. The patient showed a good postoperative course, and once again the hematoma cavity disappeared on the day following the operation. Nevertheless, a deterioration of consciousness and left hemiparesis appeared eight days after the second operation. A CT scan showed a second recurrence with low-density findings. Intraoperative findings during the third operation showed an almost water-like subdural fluid, and entrapment of cerebrospinal fluid by the inner membrane was suspected. A craniotomy and the removal of the outer and inner membranes were performed. Macroscopically, the inner membrane was intact and showed no signs of injury. No further recurrences occurred after the craniotomy. The suspected cause of the multiple subdural hematomas was the flow and entrapment of cerebrospinal fluid in some area of the inner membrane.

Spontaneous chronic subdural hematoma in a young adult

Chronic subdural hematoma (CSDH) is a common pathology in the elderly but very rare in young adults. When CSDH occurs in this age group, severe head injury or some promotive factors are usually present. This article reports the case of a 29-year-old female presented at our Emergency Department with a few days' history of progressive frontal headache. Computed tomography scan of the head showed a right frontal CSDH. Only a decreased level of consciousness without focal deficits was present at clinical examination and her medical history was negative for trauma or promotive factors. Blood count showed a mild sideropenic anemia while coagulation tests were normal. No vascular malformations were shown at digital subtraction angiography. The patient underwent craniotomic evacuation. After surgery, the patient showed a full neurological recovery. Spontaneous CSDH in young adults is very rare. In the worldwide literature, many cases of non-traumatic CSDH are reported, but a promotive factor is generally present. We described a case of spontaneous CSDH, whose etiology remains unknown.

Chronic subdural haematoma after endoscopic treatment of a supracellar arachnoid cyst

Neuroendoscopy is considered a safe treatment option for intracranial arachnoid cysts. However a variety of complications has been reported after such interventions. Here we present the first case of a chronic subdural hematoma two months after the combined treatment of a supracellar arachnoid cyst with endoscopic third ventriculostomy and cyst fenestration.

[Headache following laparotomy; chronic subdural haematoma following epidural anaesthesia]

A 63-year-old man underwent an exploratory laparotomy because of rectal carcinoma. The operation was performed under general anaesthesia in combination with epidural anaesthesia. Since the operation the patient complained of a headache. Eight weeks after the operation he was hospitalized because of worsening of the headache and also drowsiness. A physical examination showed a slight tendency to incline to the left. A CT scan showed a subdural haematoma, which was relieved with surgery. We suspected that accidental puncture of the dura caused the haematoma. The incidence, causes, symptoms, diagnosis and treatment of this rare complication are discussed.

Chronic subdural hematoma in capoeira sport

Chronic subdural hematomas in young people is extremely rare and has some provoking factors such as V-P shunts, arachnoid cyst, anticoagulant drug usage, vigorous sports and coagulopathies. A static or dynamic mechanical load is almost always delivered to skull associated with either mild or severe head trauma. A 25-year old-man who was previously healthy has complained of intermittent headache for six months. He had been interested in capoiera (Brazilian exciting sport) for two years and has had no any evidence of head injury. After admission, he was operated immediately because of chronic subdural hematoma. We report a patient who is the first chronic subdural hematoma in the literature due to playing capoeira.

Uncommon presentation of ruptured intracranial aneurysm during surgical evacuation of chronic subdural hematoma: case report

BACKGROUND

There are many factors that predispose an aneurysm to rupture, but there are few real, demonstrable causes that lead to rupture of the aneurysmal sac with a precise cause-effect mechanism.

CASE DESCRIPTION

We report a 74-year-old male patient with chronic subdural hematoma after head trauma, who underwent surgery for evacuation of the hematoma. During surgery, there was sudden copious loss of blood from the drainage tubes that were positioned subdurally. Immediate cerebral computed tomography scan and angiography revealed a subarachnoid hemorrhage at the level of the basal cisterns from a ruptured basilar apex aneurysm. We discuss the cause-effect relationship between the surgery with its positioning of subdural drains and the rupture of a previously unrecognized cerebral aneurysm.

CONCLUSIONS

The rupture of an unknown, previous "unruptured" aneurysm after craniotomy with subdural positioning of drainage, must be considered a possible complication.

Chronic subdural hematoma after endoscopic third ventriculostomy: case report

Endoscopic third ventriculostomy (ETV) is an effective and rather safe treatment for noncommunicating hydrocephalus secondary to aqueductal stenosis and other obstructive pathologies. It has become a popular alternative to ventricular shunts for noncommunicating hydrocephalus. Although it is a safe procedure, several complications related to this procedure have been reported in the literature. We report a rare case of a large chronic subdural hematoma (ChSDH) after ETV in a patient with aqueductal stenosis. A 42-year-old female patient presented with acute symptoms of obstructive hydrocephalus, headaches and blurring of consciousness. A computerized tomogram (CT) of the patient's brain revealed marked triventricular supratentorial hydrocephalus and an external ventricular drainage (EVD) was performed first. After this procedure, magnetic resonance imaging (MRI) demonstrated hydrocephalus secondary to aqueductal stenosis. ETV was performed and the EVD removed uneventfully. The patient was discharged home after a few days without any complications. She then presented with headaches 4 weeks following ETV. A CT demonstrated chronic subdural hematoma on the contralateral side. This was treated with burr-hole evacuation. Postoperatively, her headaches improved. During the follow-up period, she remains symptom-free and has radiographic evidence of a patent ventriculostomy. This case confirms chronic subdural hematoma formation is a possible complication following endoscopic third ventriculostomy.

The role of exudation in chronic subdural hematomas

Object

Chronic subdural hematomas (SDHs) are a local inflammatory process that causes the formation of a granulation tissue often referred to as the external or outer membrane. This membrane has abnormally permeable macrocapillaries. Therefore, exudation from the macrocapillaries in the outer membrane of chronic SDH may play an important role in the enlargement of chronic SDH. In this study the authors investigated the role of exudation in chronic SDH.

Methods

The authors examined 24 patients (16 men and eight women; age range 38–86 years [mean age 61.4 years]) with 27 chronic SDHs. The clinical status of the patients was evaluated according to the classification described by Markwalder. The diagnosis was established on computed tomography (CT) scans in all cases. The authors also used the Nomura Classification for judging the lesion's appearance on CT scans. Immediately after the diagnosis, all patients were administered 20 mCi (740 mBq) technetium-99m human serum albumin. Four hours later, blood and SDH samples were taken and radioactivity levels were measured in each. The ratio of activity of the samples taken from chronic SDH to the radioactivity of blood was determined as a percentage and defined as the exudation rate. On the follow-up CT scan obtained on postoperative Day 20, subdural collections thicker than 5 mm were determined to be a reaccumulation.

Results

The correlations between the exudation rate and age of the patients, clinical grades, CT appearances, and amount of reaccumulation were investigated. In this series the average exudation rate was 13.24% (range 2.05–28.88%). The mean exudation rates according to the clinical grades assigned to patients were as follows: Grade 0, 8.67 ± 5.64% (three patients); Grade 1, 5.07 ± 1.43% (eight patients); Grade 2, 17.87 ± 3.73% (seven patients); and Grade 3, 19.65 ± 7.67% (six patients). Exudation rates in patients with Grades 2 and 3 were significantly higher than those in Grades 0 and 1 (p < 0.05).

The mean exudation rates according to the lesion's appearance on CT scans were found as follows: hypodense appearance, 6.55 ± 4.52% (eight patients); isodense appearance, 11.07 ± 6.32% (five patients); hyperdense appearance, 19.47 ± 13.61% (three patients); and mixed-density appearance, 17.40 ± 5.80% (nine patients). The differences among the groups were significant (p < 0.05). The average exudation rate was statistically higher in the patients with reaccumulation (16.30 ± 8.16%) than that in the patients without reaccumulation (9.96 ± 6.84%) (p < 0.05).

Conclusions

The exudation rate in chronic SDH is correlated with a higher clinical grade (Markwalder Grade 2 or 3), mixed-density CT appearance, and reaccumulation. Therefore, exudation from macrocapillaries in the outer membrane of chronic SDH probably plays an important role in the pathophysiology and the growth of chronic SDH.